Innovations to Address Unmet Behavioral Health Needs in National Ending the HIV Epidemic Priority Jurisdictions

Abstract

People who have behavioral health disorders are disproportionately represented among people with HIV and those likely to be diagnosed with HIV. Despite repeated calls for the past decade for the integration of behavioral health into the HIV Care Continuum, findings from priority jurisdictions show these efforts lag. We present 5 examples of efforts to integrate behavioral health services into the HIV Care Continuum, across regions and populations in Ending the HIV Epidemic priority regions. Across diverse settings, care provision—screening, assessment, referrals, and treatments—remains insufficient. Consistent, ongoing actions are needed to address the compounded consequences of the HIV and behavioral health synergistic epidemics, or syndemic. The studies in this article involved local communities, provider groups, and people with lived experience of trauma, serious mental illness, neuropsychological disorder, substance use disorder, and HIV. These example studies reveal significant unmet needs for behavioral health care and/or HIV prevention and treatment in these priority communities. A common finding among these examples was that the success of interventions hinges on the extent to which interventions are tailored to local contexts and the specific needs of historically underserved populations, including Black women, the socioeconomically disadvantaged, LGBTQIA+ individuals, and people with serious mental illness and/or substance use disorders. We suggest recommendations for how Ending the HIV Epidemic efforts can be optimized to adapt and implement integrated HIV and behavioral health care to advance national goals.

INTRODUCTION

More than 1.1 million Americans are currently living with HIV, and an estimated 32,000 Americans are newly diagnosed with HIV each year.¹ The Ending the HIV Epidemic (EHE) initiative identifies priority geographic jurisdictions with the greatest disease burden and offers resources to tailor local plans to remove barriers to prevention and treatment. People who have behavioral health disorders— mental disorders, substance use disorders (SUDs), or neurocognitive impairment—are disproportionately represented among people with HIV (PWH) and those likely to be diagnosed with HIV. Compared with the general population, individuals who have a mental disorder are up to 10 times more likely to be diagnosed with HIV,² and PWH are twice as likely as the general population to have comorbid major depressive disorder or generalized anxiety disorder,³ and .15 times more likely to meet the criteria for post-traumatic stress disorder.⁴

Across the HIV Care Continuum, systemic barriers prevent people with behavioral health disorders from accessing prevention and treatment services and continue to fuel the epidemic. Traditional systems of health care require appointments or regularly scheduled visits, making services inaccessible to many PWH with complex behavioral health needs. Such systemic barriers have resulted in substantial unmet mental health care needs, particularly among PWH who inject drugs,⁵ and contribute to low uptake of pre-exposure prophylaxis (PrEP) among people with serious mental illnesses (eg, schizophrenia).⁶ The National HIV/AIDS Strategy⁷ highlights the need to increase PrEP uptake and other HIV prevention services among people with serious mental illnesses, such as schizophrenia and bipolar disorder. Lack of trauma-informed care also represents a significant barrier to accessing HIV prevention and care services among key populations,^8–10 and policy makers and EHE plans have highlighted a need for trauma-informed services.

Behavioral health disorders are associated with poor outcomes at every stage of the HIV Care Continuum,¹¹ including reduced adherence to PrEP¹² and antiretroviral therapy (ART)¹³ and decreased engagement in HIV care.¹⁴ Despite this known connection, insufficient attention is provided to identifying and addressing behavioral health across the HIV Care Continuum.¹⁵ For example, screening for PTSD is not typically conducted as part of routine HIV care,^16–18 and though more than half of PWH in the United States now are aged 50 years and older, cognitive impairment is not routinely assessed for among PWH.¹⁹

Rationale for This Article

As part of the national EHE plan, the National Institute of Allergy and Infectious Diseases and National Institute of Mental Health issue annual calls to Centers for AIDS Research and AIDS Research Centers for administrative supplements to fund projects that advance local EHE plans and priorities. Of the supplements awarded in 2022, 5 projects that focused on behavioral health along the HIV Care Continuum were identified by an editorial team from the Journal of Acquired Immune Deficiency Syndromes (JAIDS). Principal investigators of these supplements were invited to contribute to a special issue of JAIDS highlighting lessons learned from EHE supplements.

Investigators applied findings from these 5 EHE supplements to develop this article. Our primary goals were to (1) provide examples of efforts to address unmet behavioral health care needs in EHE priority jurisdictions, (2) identify similarities and differences across these heterogeneous sites bound by the commonality of high HIV burden, and (3) synthesize findings to envision a path to propel EHE goals forward. Overall, our findings highlight some of the ongoing efforts to advance behavioral health care as a core component of the HIV Care Continuum. We provide details on each of our case examples to demonstrate the utility of evidencebased approaches in addressing behavioral health issues and identify common needs across these heterogeneous geographic regions, focus populations, and clinical settings. Key shared determinants of successfully integrated care are provided and recommendations for the path forward to progress EHE goals. An overview of key findings is provided in Table 1.

TABLE 1.

Summary of Examples to Address Unmet Behavioral Health Needs in Ending the HIV Epidemic Priority Jurisdictions

Location	Evidence-Based Approach	Setting	Focus population	Aims@@@@@& Design	Key Findings
Prevention
Baltimore MD	Trauma- and violence-(TVIC) informed PrEP initiation	Community and university-affiliated health centers	Black women	• Aim 1: Adapt a toolkit to address TVIC’s and Black women’s health. • Design: Hybrid type 2 effectiveness–implementation trial to assess feasibility and appropriateness	• Barriers: There was an identified need to acknowledge and address the sociohistorical context of trauma and Black women’s health. • Facilitators: Personnel being genuine, obtaining staff buy-in, building and maintaining capacity to address IPV, ensuring compatibility of toolkit within clinics. • Key takeaways: The adapted toolkit was associated with increases in self-efficacy and perceived feasibility and appropriateness of screening
Seattle King County WA	PrEP and other HIV prevention services	Behavioral health organizations	People with serious mental illness	• Aim 1: Determine current HIV-related services in community mental health organizations that can be scaled. • Aim 2: Identify barriers and facilitators to routine screening and linkage to PrEP or HIV care • Design: Explanatory sequential mixed methods (survey followed by interviews)	• Barriers: Lack of protocols to systematically identify need for HIV testing or PreP, no standardized approach to sexual health, lack of specific resources (point-of-care tests), limited personnel training and support, inability to bill for HIV prevention services • Facilitators: HIV prevention aligned with organizational mission to provide holistic care and harm reduction approach, personnel (nursing) and other resources, partnerships with primary care organizations. • Key takeaways: A quarter of sites provided on-site HIV testing, half provided referral for PrEP, none provided PrEP. Organizations were more likely to provide HIV prevention services if they primarily serve clients unable to access services elsewhere, have adequate nursing staffing, and had robust primary care partnerships
Status neutral
Suffolk County MA	Adapted, bundled evidence-based behavioral interventions to increase effective delivery of HIV treatment and prevention services	Community-based organizations (CBO) serving people who use drugs (PWUD) with and vulnerable to HIV	Nonclinician CBO personnel serving PWUD with and vulnerable to HIV	• Aim 1: Enhance capacity for nonclinician personnel to deliver HIV treatment and prevention efforts to PWUD with unmet behavioral health needs • Design: Iterative codesign, following principles of community engaged research	• Barriers: CBO personnel had limited knowledge of how best to serve PWUD with unmet behavioral health needs; PWUD have limited access to behavioral health care. • Facilitators: CBO personnel expressed strong interest in increasing their capacity to deliver HIV treatment and prevention services to PWUD with unmet behavioral health needs; CBO personnel easily identified specific training needs related to behavioral health. • Key takeaways: • Codesigning psychobehavioral training (ie, with nonclinical CBO personnel and clinical psychologists) determined to be feasible, acceptable, and beneficial. • Collaborative training can increase nonclinician CBO capacity to serve PWUD with unmet behavioral health needs and may improve HIV treatment and prevention efforts among this high-need population.20,21
Treatment
Memphis TN	Trauma-informed HIV care (TIC) for youth and young adults	Pediatric HIV clinic	Youth and young adults with HIV	• Aim 1: Determine current patient trauma services offered in the clinic. • Aim 2: Identify barriers and facilitators to providing trauma-informed care in clinic. • Design: Multimethod (process mapping followed by interviews)	• Barriers: Clinic personnel perceived HIV stigma as common among other hospital personnel (ie, outside the clinic) and noted a need for greater championship among leadership, and a need for more peer-to-peer support and protected time to engage with TIC activities. • Facilitators: Clinic personnel perceived the clinic had a culture with an equity focus in which TIC was seen as a priority and compatible with the culture. • Key takeaways: There are limited patient trauma services, methods for training personnel on TIC or efforts to integrate patient preferences, and no clinic-level cultural responsiveness efforts
Washington DC	Brain health assessments (BHA) (ie, neurocognitive/mental health screens)	Adult HIV care clinics	Older adults with HIV	• Aim 1: Determine current mental health and neuro services offered in clinics and build champions among providers and administrators for integration of BHAs into clinical practice • Aim 2: Determine perceived barriers and facilitators to adopt a BHA regimen as part of HIV care. • Design: Multimethods (semistructured interview and focus groups)	• Barriers: Social determinants of health (eg, scarcity of culturally competent mental health providers, affordability, literacy, and accessibility); lack of motivation among some physicians to implement. • Facilitators: The BHA was seen as critically important to enhancing adherence to treatment and promoting a better quality of life. • Key takeaways: Enhancements are needed to improve participant knowledge of/access to mental/neurologic health care, and the concept of BHA integration into the HIV Care Continuum was well received

Implementation Research Orientation

All EHE supplements were required to focus on EHE priority jurisdictions and to include an implementation research logic model.²² Therefore, investigators from all 5 case examples used methods informed by implementation theories, models, and/or frameworks.²³ There were differences in methods across the studies. Determinant frameworks were used in most studies to elicit barriers and facilitators of expanding or scaling effective (mental health or HIV prevention) services in the jurisdiction. Investigators applied a process model (process mapping), a hybrid type 2 trial design, and multiple qualitative methods or mixed (qualitative and quantitative) methods, using primarily The Consolidated Framework for Implementation Research (CFIR)^24,25 or the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework.²⁶

Aims in these studies were primarily focused on preimplementation stage research—to gather information to inform data- and context-driven implementation plans or adapt an intervention to the setting. Two of the studies showed preliminary feasibility and acceptability of adapted evidence-based intervention strategies. These studies span the HIV Care Continuum, with attention to prevention, a status neutral approach to services, and treatment. Although results identified unique implementation determinants for each setting, several generalizable findings emerged across these EHE priority settings. We present brief descriptions of our cases to orient readers to the generalizable indications for a strategical national approach to integrate behavioral health across the HIV Care Continuum.

Case 1: Trauma-Informed PrEP Implementation Among Community and University-Affiliated Health Care Clinics in Baltimore, MD

From 2017 to 2022, HIV diagnoses among women in Baltimore, Maryland (MD), consistently disproportionately affected Black women.²⁶ Despite this trend, Black women represented only 10% of PrEP users in Baltimore in 2022.²⁶ Black women face multiple forms of trauma,²⁷ which can not only increase the likelihood of HIV acquisition but also create additional barriers to access HIV prevention strategies such as PrEP.^28,29 Specifically, intimate partner violence (IPV), physical, sexual, and psychological abuse from a former or current romantic partner, can elevate heterosexual transmission of HIV through compromised psychological wellness, substance use, and unequal sexual power dynamics.^30,31 Furthermore, Black women have historically experienced gendered racism in health care through unethical medical practices and research that reinforces present-day discrimination from providers about Black women’s sexuality and sexual health.³² Navigating power dynamics and challenges within partner and patient–provider relationships can curb Black women’s access to PrEP.³³ These trends indicate that the disproportionate impact of HIV among Black women will likely remain stagnant until structural and interpersonal changes are made to increase PrEP initiation among Black women in Baltimore.

Therefore, we sought to adapt a trauma-informed PrEP Implementation Toolkit, by integrating trauma-informed principles at the system and patient levels,³⁴ to improve PrEP initiation among Black women in Baltimore, MD. We conducted a hybrid type 2 effectiveness–implementation trial to assess the feasibility of implementing the toolkit in health care settings. To adapt an existing toolkit,³³ we conducted one-on-one qualitative interviews with 20 Black women patients and 18 clinical personnel in Baltimore, MD. During this phase, qualitative themes described several barriers and recommendations for the toolkit’s implementation (Table 1).

Qualitative findings were used to guide adaptations for a context-tailored, trauma-informed PrEP Implementation Toolkit. Five clinics were randomized to receive the toolkit as an ongoing stepped wedge trial with 2-month steps. The toolkit comprised many sections, including an intense trauma and PrEP training for personnel, patient materials that centered Black women, and changes to clinic flow such as IPV screening protocols. After conducting the personnel training component of the toolkit, we observed significant preliminary changes in personnel outcomes such as increases in self-efficacy to discuss PrEP with Black women patients experiencing IPV, and increases in implementation outcomes such as feasibility and appropriateness to screen for IPV and refer Black women patients to community resources.

Case 2: Building Capacity for HIV Prevention Services in Behavioral Health Organizations in Seattle King County WA

In 2015, Seattle King County Washington (WA) became the first urban area in the United States to achieve the WHO 90-90-90 objective,³⁵ but this success has been difficult to sustain and accompanied by troubling disparities. Interactions between the multiple health threats of serious mental illness, substance use, and social vulnerabilities (eg, housing instability, poverty) perpetuate the HIV epidemic in King County. To date, efforts have focused on optimizing HIV prevention strategies in medical settings, but people with complex behavioral health disorders often face structural barriers to accessing medical care and prevention services in traditional medical settings. There is little evidence to inform optimal implementation of HIV prevention services in community mental health settings. In this study, we aimed to identify best practices for HIV prevention services in King County Behavioral Health organizations and barriers and facilitators to implementing a status neutral approach to HIV services in these settings. We used an explanatory sequential mixed methods study approach.

First, quantitative data were collected from an inventory of services and resources completed by executive directors of 24 member organizations of the King County Behavioral Health Provider Association. An online survey was built and administered through Research Electronic Data Capture (REDCap); the survey included questions about organizational characteristics and the resources and processes of care required to implement rapid HIV testing and linkage to PrEP or HIV treatment services. Executive directors of these organizations were asked to identify a member of the leadership team who was engaged in both administration and clinical programs to complete the survey, and the 1 elected individual completed the survey for the organization. Sixteen organizations completed the survey, with substantial heterogeneity across organizations with respect to size, personnel, and services offered. Findings indicated only a quarter provided on-site HIV testing, and while none provided PrEP on site, half provided referral for PrEP.

Based on survey responses, we identified 3 organizations that reported that HIV prevention was a high priority for their organization and obtained qualitative data through indepth interviews of 18 purposively sampled individuals, including administrators, psychiatric providers, nursing personnel, and frontline personnel and supervisors. Interviews aimed to identify barriers and facilitators to implementing routine HIV testing and linkage to prevention or treatment services. We used a rapid deductive qualitative analysis³⁶ informed by CFIR 2.0.²⁵ Implementation facilitators included perception that HIV prevention is within the scope of behavioral health providers, with a particular benefit for clients who are unable to consistently access medical care in other settings. Provision of HIV prevention services was seen as aligned with organizational missions to promote recovery and provide holistic care and was viewed as part of a harm reduction approach, but most organizations viewed screening for Hepatitis C and sexually transmitted infections as relatively higher health priorities. Participants emphasized the importance of formal partnerships with primary care organizations to provide specific services (eg, HIV and HCV testing, prescription of PrEP) on site that are not currently feasible for the behavioral health organization to provide. Implementation barriers included (1) a lack of protocols to systematically identify need for HIV testing or PrEP, (2) a lack of capacity to bill for prevention services, (3) need for additional resources (eg, point-of-care tests), and (4) weak or unclear referral pathways for prevention and treatment services. All participants identified a need for additional training for personnel to take on new tasks related to HIV testing and linkage to PrEP or care.

There is a need to scale and disseminate PrEP to people living with serious and complex mental disorders. Behavioral health organizations are uniquely positioned to reach these populations and address their needs and should be more systematically included in EHE plans.

Case 3: Status Neutral Psychobehavioral Capacity Building Intervention for People Who Use Drugs in Suffolk County, MA

Untreated behavioral health disorders and psychosocial challenges (eg, internalized and anticipated stigma) are barriers to engaging people who use drugs (PWUD) in HIV prevention and care.^3,37 PWUD often face limited access to behavioral health care attributable to financial and structural barriers, resulting in too few PWUD with and vulnerable to HIV benefitting from evidence-based behavioral health interventions.³ In addition to increasing access to behavioral health care, to facilitate increased engagement in HIV prevention and care among PWUD, efforts are needed to increase nonclinical personnel’s capacity to better serve PWUD with unmet behavioral health needs and more effectively provide HIV treatment and prevention services. The goals of this study were to identify, create, disseminate, and evaluate a pilot training to increase nonclinician personnel’s capacity to deliver HIV treatment and prevention efforts to PWUD and have unmet behavioral health needs in low- threshold programs (eg, drop-in spaces, mobile units, low- threshold housing, and syringe service programs).³⁸ Over this project, clinical psychologist researchers and personnel from Victory Programs, one of the largest community-based organization (CBO) in Suffolk County, Massachusetts (MA) serving PWUD with and vulnerable to HIV, codesigned, delivered, and evaluated the evidence-informed capacity building training.

Consistent with the EPIS model,³⁹ we explored and identified 4 prioritized behavioral health needs through a series of focus groups with personnel (including peer navigators and program managers) and clients from low- threshold programs (n = 9). Four priority areas were identified: (1) safety training for personnel and clients, with a focus on psychosis; (2) trauma-informed care; (3) behavioral strategies to increase health engagement, with a focus on psychiatric care; and (4) personnel well-being to reduce burnout. Next, we iteratively and collaboratively selected and adapted evidence-based content^40–45 related to each of these priorities to increase the capacity of nonclinician personnel. This resulted in preparing a curriculum to be implemented through an in-person and a virtually delivered personnel training that was subsequently made available to all personnel through resource webpage as needed (including videos from the training, slides outlining the content, and related resources). The resource website was integrated into Victory Programs’ personnel intraweb to enable ongoing maintenance and sustained access to the collaboratively produced content. We evaluated acceptability, feasibility, accessibility, and utility of the training and resource webpage to inform future refinement, sustainability, and the possibility of sharing curriculum and web-based content with other CBOs across the Suffolk County EHE priority area and more broadly to end the HIV epidemic.

In this project, nonclinical personnel reported strong interest in trainings to increase their capacity to work with PWUD with unmet behavioral health needs. Collaborative training development with nonclinical low-threshold personnel and clinical psychologists was perceived to be feasible, acceptable, and beneficial in increasing capacity for effectively delivering HIV treatment and prevention efforts to PWUD with behavioral health needs. We learned the following takeaways: (1) training is critically needed for nonclinicians to better serve PWH and PWUD who are likely to be diagnosed with HIV and have unmet behavioral health needs, (2) adapting coselected evidence-based content for a training with and for nonclinician personnel was very well received, and (3) implementing this type of training would not replace the need for additional clinical person in low-threshold programs but could increase capacity to meet people with unmet behavioral health needs where they are and improve HIV treatment and prevention efforts among this high need population.

Case 4: Trauma-Informed Care for Youth With HIV in Memphis, TN

Shelby County, Tennessee (TN; Memphis), has the second highest HIV incidence nationally. Viral suppression rates in the region lag at a steady 63.8%, with youth aged 13–24 years accounting for 1 in 3 new infections⁴⁶ and experiencing a 40% increase in incidence between 2018 and 2023.³³ Psychological trauma remains a primary, underaddressed driver of these HIV-related disparities, with PWH in TN experiencing high rates of post-traumatic stress disorder (PTSD) (47%–64%)^4,47 and complex PTSD (C-PTSD) (23%).⁴⁸

We applied a multimethod approach to explore standards of care related to trauma-informed care (TIC) and potential implementation determinants of TIC in a pediatric, youth, and young adult-focused, HIV clinic in Memphis. Trauma-informed care is an evidence-based approach for improving HIV outcomes by way of building in screenings, assessments, and treatment for psychological trauma into standard HIV care workflow. A process map of the clinic was drafted through participatory discussions to elucidate standards of care related to screening, assessing, and treating patient psychological trauma, followed by semistructured interviews with clinic personnel. Iterative group discussions were conducted to validate the process map, and the CFIR³¹ was applied to analyze personnel interviews through thematic analysis.

A total of 43 personnel and 8 patient representatives participated in process map discussion groups, with patient representatives reflecting the patient population (ie, primarily same-gender-loving young men or women of color either living with HIV or those at an increased likelihood for HIV diagnosis). Twenty clinic personnel were interviewed. Findings indicated there were limited and nonsystematic patient trauma screenings, assessments, and interventions; limited efforts to promote professional quality of life and elicit and integrate patient experiences and preferences for care; no ongoing efforts to train and prepare workforce for traumasensitive or trauma-responsive care; and no clinic-specific efforts to promote cultural responsiveness. Barriers included a perceived disconnect/culture difference between the HIV clinic and larger hospital (eg, feared HIV stigma in hospital spaces), and sustainability concerns if efforts were not anchored into institutional policies. Future efforts would need to (1) enhance championship among leaders, (2) develop protocols for universal mental health screening/assessment/ treatment, (2) provide cultural responsiveness training for personnel, (3) expand opportunities for more peer-to-peer support, (4) develop mechanisms for routinely eliciting and integrating patient experiences to improve clinic services, and (5) design procedures to ensure personnel to have protected time to engage in TIC and research activities. Facilitators to TIC implementation included a clinic culture with an equity focus and positive learning environment and an identified need for/prioritization and compatibility of TIC for improving patient and personnel wellness outcomes. In conclusion, trauma services were not yet adequately integrated into HIV care, despite a perceived need for and prioritization of this integration in the clinic.

Case 5: Introducing BHAs as a Routine Component of HIV Care in Clinics in the Washington, DC, Metro Area

The success of modern HIV treatment leaves more people aging with HIV, 60% of whom have developed involvement of the nervous system, leading to HIV-associated neurocognitive disorder (HAND).¹⁹ Prolonged social isolation during the COVID-19 pandemic, combined with ongoing opioid and HIV epidemics in America’s cities, highlights the critical attention needed for mental health and HAND within the EHE efforts. The objective of this study was to investigate the feasibility of integrating a Brain Health Assessment (BHA) regimen, using evidence-based screening tools for mental health disorders, HAND, and neuropathology into the HIV Care Continuum throughout Washington DC The overall aim was to codesign a BHA regimen based on an education campaign for different sites and from different perspectives. At this preimplementation stage, we sought to determine perceived barriers and facilitators to implementation of such a regimen and elicit recommendations for how best to enhance the BHA’s efficiency and acceptability for implementation. In 1 phase of the study, semistructured interviews with providers and administrators were conducted. In another phase, PWH who were patients at various clinics in the DC region participated in focus groups. Focus groups and semistructured interviews were guided by CFIR constructs²⁴ and analyzed with rapid thematic analysis.

Before study recruitment, the research team developed and shared BHA educational materials (brochure, standardized PowerPoint presentations, video) through information sessions with providers and administrators. Subsequently, ;90-minute interviews were conducted with 12 providers from 5 different locations, spanning community health clinics and academic health centers. For input from PWH who were actively under medical care, focus groups lasting 2 hours each were held. Forty-seven percent of patient participants identified as transgender or nonbinary, and 85% were Black.

Clinical personnel interviewees expressed the need to involve practice and clinical managers, directors, and patients in the decision to locally adopt a BHA. Active actionable mental health/neurology referral systems were deemed a necessary part of any implementation strategy. Educational tools were codesigned with a primary focus of reinforcing that brain health should be assessed, especially among individuals with increased likelihood for HIV-related neurocognitive disorders. These educational tools were designed to be directed to providers, patients, and administrators about the needs and benefit of the BHA through an idealized 4-minute video to be most efficient. Potential barriers to the adoption of the BHA regimen were perceived to be time constraints (as the primary concern), followed by Social Determinants of Health, including the scarcity of culturally competent mental health providers, along with affordability, literacy, travel time, and what were perceived to be dangerous travel conditions across the city. Some physicians expressed a lack of motivation to implement the BHA if it was not required by insurers or funders. Although participants overall reported that the BHA is critically important to enhance adherence to treatment and promote a better quality of life for PWH, many did not know how to access mental/neurologic health care even though they experienced symptoms such as brain fog, apathy, depression, and unsteady gait (all strong indicators of HIV-related neurocognitive disorder).

In urban settings, access to mental/neurologic health screenings and referrals is lacking or insufficient. Education about the mental health needs of patients is necessary for providers in infectious disease clinics and implementation of a BHA regimen will rely on efforts of many champions, including administrators and funders/insurers.

Commonalities Across EHE Priority Contexts

These 5 implementation pilot projects spanned diverse settings across the HIV Care Continuum, including low threshold spaces/mobile units with syringe exchange, community-based organizations, community and university health care clinics, a pediatric HIV primary care clinic, and HIV care settings that serve older PWH. Studies varied with respect to design (eg, exploratory, cross-sectional mixed- and multimethods, randomized controlled trial), approaches, and strategies (key informant interviews, process mapping, learning collaborative, evidence-based intervention adaptation), and the implementation science framework used.

Despite substantial heterogeneity, we observed common needs related to enhancing integration of behavioral health and HIV prevention or care across the studies. We identified 3 commonalities: (1) additional resources and more efficient services (ie, standardized or systematic approaches) are needed to enhance screening, assessment, referral, and treatment; (2) training, supervision, and support are needed for personnel to take on new tasks and to improve quality of work life and mitigate burnout; and (3) tailoring of integrated care interventions to specific care settings will enable interventions to be contextually appropriate and positioned to be most useful.

Our studies represent innovative, integrated approaches to the complex intersection of behavioral health issues across the HIV Care Continuum. Several implementation determinants and strategies emerged as essential to success across these diverse settings and populations, including structural components of integrated care models (additional staff and resources, funding mechanisms, partners) and processes (task sharing and integrated workflows (Fig. 1).³³

FIGURE 1.

Recommendations for integrating behavioral health care into the HIV Care Continuum.

DISCUSSION

Given the prevalence of behavioral health disorders among those with and likely to be diagnosed with HIV,^2,32 there is a critical need to integrate behavioral health care across the HIV Care Continuum. The call for integration has been previously documented,⁴⁵ and efforts to optimize such integration are underway.⁴⁹ As our case studies demonstrate, greater effort is needed in EHE priority jurisdictions across care settings, including primary care clinics, community mental health settings, and community-based organizations that address HIV and/or subsistence needs (eg, mobile care units, communal meal programs, syringe service providers).

Across the 5 presented projects, specific needs identified emphasize the importance of culturally and contextually tailored adaptations and implementation of effective interventions or programs. All projects highlighted interrelated external barriers to both HIV treatment and/or prevention and behavioral health support including trauma exposure and structural barriers to optimal care (eg, poverty, lack of affordable housing, stigma, discrimination). The identified commonalities across these 5 distinct projects further underscore that despite repeated calls for integrating behavioral health support across the HIV Care Continuum, behavioral health care likely remains underaddressed in many priority jurisdictions.

Presented case examples demonstrate how innovative solutions (eg, low-barrier and mobile units or task sharing and task shifting that assign new tasks related to integrated care services to existing staff)⁴⁷ can expand integration of community-adapted, evidence-based, and evidence-informed approaches to improve outcomes at each stage of the treatment cascade. But more work is needed to reach individuals with HIV and those likely to be diagnosed with HIV who could benefit from such interventions. There is a need for future research on integrated care to focus on several key issues.

First, there is need to more widely adopt evidencebased approaches to prevent and treat behavioral health disorders as syndemic conditions with HIV. Second, evidence-based approaches need to be tailored to populations of interest. Differences in culture, language, age, and socioeconomic status of a population can pose obstacles to adoption or effectiveness if an intervention has not been validated with the needs of the population.^49–51 Indeed, literature suggests that intervention adaptations with diverse populations can improve intervention effectiveness, compared with unadapted interventions. Such adaptation processes ideally engage focus populations to cocreate products to ensure they are built on local knowledge, tailored to the specific context.^52–56 Most evidence-based behavioral health interventions are not designed or assessed for populations disproportionately affected by HIV (eg, racial and ethnic minorities, sexual and gender minorities, or PWUD).⁵⁷ Third, behavioral health workforce shortages⁵⁷ can limit efforts to implement and scale effective treatments. Therefore, there is a need for scalable interventions that involve task shifting to nonspecialists. Flexible and innovative strategies are needed to promote behavioral health equity and optimal HIV treatment and prevention, which may be accomplished by providing services in nontraditional settings. For example, the capacity building project in Suffolk County and the Brain Health Assessment implementation project in Washington DC identified a need for flexibly delivering evidence- informed services at community-based organizations that serve PWUD or PWH. The project in Seattle highlights potential roles in HIV prevention services for personnel of community mental health centers. Originally popularized in global HIV/AIDS work,^58,59 such task shifting has the potential to improve care in underserved settings in high-income countries. The term “task sharing”⁶⁰ has been used more recently to more accurately describe that care must be shared within a team of providers, and this approach may be particularly important to expand the workforce to better serve people with and vulnerable to HIV who have behavioral health needs.

In addition, PWH and health care providers and administrators identify a need for ongoing 360-degree education of constituents within the care continuum on how comprehensive HIV care necessitates attention and treatment of mental/behavioral health problems and neurocognitive disorders. Whereas some primary care clinics integrate evidence-based assessments for anxiety and depression into their intake process, many do not, and even fewer assess PTSD or neurocognitive disorder. Furthermore, once a need for mental/neuro health care is identified, navigating referrals to psychotherapy or neurologic care is a challenge, and culturally sensitive and responsive mental health care remains an even greater challenge. Overall, enhanced education and championship among leaders are critical components to moving forward with integration of mental health assessments into all phases of the HIV Care Continuum.

Inequitable access to services that will mitigate the negative impacts of social determinants of health perpetuates suboptimal engagement in HIV treatment and prevention efforts,^61–63 and these associations are often exacerbated by unmet behavioral health needs.⁶⁴ The Washington DC case study demonstrates that efforts are needed to systematically address other structural factors that contribute to behavioral health needs, including the perpetuation of discrimination, stigma, violence, and inequitable access to basic needs, including culturally responsive care. Case examples in Tennessee and Baltimore also underscore the need to address social determinants of trauma as part of TIC implementation across the HIV Care Continuum. Both discrimination and anticipated stigma have been found to exacerbate mental health challenges among Black women with HIV,^65,66 and this is also true too for people who inject drugs⁶⁷ and people with serious mental illnesses.^68,69 In addition, housing instability has been significantly associated with loss to care along the HIV treatment cascade for both people who have schizophrenia⁷⁰ and people who use drugs,⁷¹ who are also disproportionately affected by mental health disorders.⁷² Thus, efforts to expand access to resources related to social determinants ( housing, food security, employment opportunities, quality education, etc.) and culturally appropriate behavioral health support have potential to improve the effectiveness of HIV treatment and prevention efforts.

To scale the integration of HIV care and behavioral health care, the behavioral health workforce will need to be expanded, and personnel already working in these spaces will need additional support and training. Compensation is low for many nonclinician personnel in social service settings serving people along the HIV Care Continuum, with personnel shortages and turnover as major factors limiting implementation of new programs. Moreover, personnel (particularly nonclinical personnel) in these settings experience high rates of burnout.⁵¹ Burnout and other decrements in professional quality of life were identified as a primary challenge to scaling behavioral health care across the HIV Care Continuum in the presented case examples (Tennessee, Massachusetts, and Washington states) with several barriers presenting that exacerbated these reductions in professional quality of life (e.g., personnel retention in nonclinical settings, such as low threshold drop in spaces for PWUD with lower compensation rates, as well as in a clinic-based setting situated in a high-demand, low-resource region.^73,74 To improve access and outcomes of integrated HIV and behavioral health services, increased training, personnel support, and increased compensation may be required to retain the needed workforce.

CONCLUSIONS

An investment in expanded efforts to facilitate integrated behavioral and HIV treatment and prevention has the potential to contribute to reductions in HIV transmission and increased engagement across the HIV Care Continuum for the next 5 years and beyond. Systematic expansion of this integrated care will likely require multifaceted strategies, including increasing service access, task-sharing efforts to expand psychobehavioral support capacity, and adaptations to existing evidence-based approaches to meet the specific needs of various populations.