Preferences of Young Black Gay, Bisexual, and Other Men Who Have Sex with Men Regarding Integration of HIV and Mental Health Care Services

Abstract

Optimization of mental health service use is critical to HIV care engagement among young Black gay, bisexual, and other men who have sex with men (YB-GBMSM). Clinic-level interventions to integrate HIV and mental health services have been proposed; however, patient perspectives on such care models are often lacking. We conducted a mixed-methods study consisting of surveys (N = 100) and qualitative in-depth interviews (n = 15) with YB-GBMSM recruited from two Ryan White-funded HIV clinics in Atlanta, Georgia. Most participants (70%) agreed that integration of HIV and mental health services was beneficial to them. Thirty-six percent (36%) desired a higher level of integration than what they perceived was currently available in their clinic setting, 51% believed their clinic was already optimally integrated, and 13% preferred less integration. In the qualitative interviews, participants discussed their support for potential integration strategies such as training HIV providers to prescribe antidepressants, closer in-clinic proximity of HIV and mental health providers, and use of patient navigators to help patients access mental health care and remind them of appointments. Perceived benefits of care integration included easier access to mental health services, enhanced overall well-being, and improved HIV care engagement. In summary, YB-GBMSM were supportive of integrating HIV and mental health services, with varying individual preferences regarding the degree and operationalization of this integration. Improving integration of mental health and HIV services, and tailoring modes of service delivery to individual preferences, has the potential to improve both general well-being and HIV care engagement in this high priority population.

Introduction

Young, Black gay, bisexual, and other men who have sex with men (YB-GBMSM) in the United States are disproportionately impacted by HIV,¹ and have lower rates of engagement across the HIV care continuum compared with other demographic groups.² Mental health conditions are frequently comorbid,^3,4 and often exacerbate challenges with HIV care engagement. Depressive symptoms, for example, are frequently found among YB-GBMSM living with HIV,^5,6 and are associated with suboptimal rates of medication adherence,^7–9 retention in care,¹⁰ and viral suppression.^5,9,11 A significant burden of trauma and anxiety has also been observed in studies that include YB-GBMSM.^7,12,13 Given the high burden of psychological distress and adverse impacts on HIV care, it would follow that engaging with professional mental health services could help improve HIV care engagement outcomes in this high-priority population.

However, YB-GBMSM are also at risk for low uptake of mental health services. A retrospective cohort study of YB-GBMSM engaged in HIV care found that only 20% of those with identified mental health concerns were referred, linked to, and remained engaged with professional mental health services.⁴ Black individuals, including youth living with HIV (YLH), may face unique barriers to mental health care access and utilization. For example, a multi-site clinical study of psychiatrically symptomatic YLH found that Black YLH were less likely than non-Black YLH to receive mental health care (37.4% vs. 48.6%).¹⁴ Similarly, a community-based study found that YB-GBMSM were less likely than other young GBMSM to access counseling or treatment (40.4% vs. 52.8%).¹⁵ Barriers to mental health care seeking include stigmatizing attitudes toward mental health treatment,^16,17 discrimination and mistrust within patient–provider relationships,^18,19 and logistical barriers such as difficulties with transportation or insurance.²⁰ Interventions to increase mental health service utilization are therefore urgently needed to improve well-being for YB-GBMSM and to improve engagement in HIV care for this population.

Integration of mental health and HIV care services has been proposed as a structural intervention to improve HIV and mental health care engagement among people living with HIV.²¹ Care integration is explicitly encouraged by the Ryan White HIV/AIDS Program (Ryan White), a federal program that funds HIV care for over half of people living with HIV in the United States, and has particular importance for underserved and underinsured populations.^22,23 Integration of primary care and mental health services is also a potential strategy for decreasing racial disparities in mental health care engagement.²⁴ Service integration, particularly when culturally centered, can reduce disparities by addressing barriers to mental health care use: decreasing logistical barriers, decreasing stigma, and prioritizing cultural competence.^24–27 However, real-world implementation of HIV-mental health care integration is highly variable and does not reliably result in improved outcomes across subpopulations. For example, one study reported significant gaps in mental health care engagement among YB-GBMSM receiving care at a Ryan White-funded HIV care center, despite both mental health and HIV care services being available in the same building.⁴ In another study, co-located mental health services increased viral suppression rates, but this effect was not realized among young or minority patients.²⁸

YB-GBMSM may not benefit from current integration strategies without consideration of their specific needs and preferences. Tailored strategies may be needed to more fully realize the potential of HIV-mental health integration for reducing disparities and improving care continuum outcomes for YB-GBMSM. To our knowledge, studies have not yet addressed the preferences of YB-GBMSM related to mental health care delivery or integration with HIV primary care. To address this gap, we sought to explore YB-GBMSM patient perspectives, attitudes, and preferences regarding mental health care delivery and integration.

Methods

This analysis is derived from a pre-implementation study of mental health and HIV care integration at two Ryan White-funded clinical programs in Atlanta, Georgia, conducted between November 2019 and July 2020. One clinic (Clinic A) is associated with a public safety net health system and serves >600 YB-GBMSM living with HIV, whereas the other (Clinic B) is located in an academic hospital setting and serves ∼120 YB-GBMSM living with HIV. Both clinics offer both HIV and mental health services on site: at Clinic A, a team of full-time psychiatrists, psychologists, and licensed therapists is housed on a separate floor, but within the same building as the other services. At Clinic B, there were two part-time licensed therapists at the time of this study; however, they are physically more integrated into the same area where HIV/primary care providers work. At both clinics, there is a formal referral process (via the electronic medical record) from HIV/primary care or social work to mental health services; however, informal referrals and self-referrals are possible as well.

We used a convergent parallel mixed-methods design, in which quantitative and qualitative data were collected concurrently but analyzed independently.²⁹ We conducted cross-sectional surveys with N = 100 participants, and qualitative in-depth interviews with a subset of those participants (N = 15) across the two clinics. Patients were eligible to participate if they were: (1) between 18 and 30 years of age, (2) self-identified as Black/African American, (3) self-identified as gay, bisexual, or had a self-reported history of consensual sex with a male ever, (4) self-identified as male, (5) received HIV care at either participating clinic, and (6) were able and willing to provide informed consent. Institutional Review Board approval was obtained for the conduct of this research.

Procedures

Potential participants were identified and recruited through three mechanisms: (1) Direct recruitment from clinics involving review of daily clinic schedules to identify and approach eligible individuals after their appointments and offer study participation; (2) provider referrals of eligible patients in the two clinics who were subsequently contacted via phone to offer participation; and (3) utilization of an existing research database to identify and telephone eligible individuals who had participated in prior studies and expressed interest in being contacted for future research opportunities. Participants self-administered the survey online using REDCap,³⁰ a HIPAA-compliant web-based software system: surveys took ∼30 min to complete. Survey self-administrated occurred in person for those recruited in the clinic, or remotely for those who were recruited through phone.

The full survey examined topics including mental health symptoms (e.g., depression, anxiety), perceptions of mental health services, as well as other topics such as drug use, religiosity, and experiences with discrimination. For the current analysis, we focused on a subset of survey questions in which participants were asked about their experiences and preferences regarding care integration. We showed participants a schematic depicting the SAMHSA/HRSA Center for Integrated Health Solutions (CIHS) “Six Levels of Collaboration/Integration” (Table 1). Participants were asked to choose the level that they thought described their clinic's collaborative style, and also to choose an ideal level of collaboration/integration. Consistent with the CIHS model levels, answers ranged from 1 to 6, with 1 being minimal collaboration and 6 being full collaboration.

Table 1.

Levels of Integration of Mental and HIV Health Care

Level 1	Level 2	Level 3	Level 4	Level 5	Level 6
Minimal collaboration	Basic collaboration at a distance	Basic collaboration onsite	Close collaboration	Closer collaboration	Full collaboration
◊Mental health and HIV care providers work in different buildings	◊Mental health and HIV care providers work in different buildings	◊Mental health and HIV care providers work in the same building but in different spaces	◊Mental health and HIV care providers work in the same building and same office space	◊Mental health and HIV care providers work in the same building and share some office space	◊Mental health and HIV care providers share all clinic space
◊Mental health and HIV care providers rarely communicate with each other	◊Mental health and HIV care providers communicate every once in a while about patient cases	◊Mental health and HIV care providers communicate regularly about shared patients by phone or e-mail	◊Mental health and HIV care providers share medical records of scheduling systems	◊Mental health and HIV care providers actively seek solutions together	◊Mental health and HIV care providers actively seek solutions together
◊Mental health and HIV care providers don't understand each other's roles	◊Mental health and HIV care providers appreciate each other's roles	◊Mental health and HIV care providers sometimes meet to discuss patients in person	◊Mental health and HIV care providers communicate in person to talk about patients	◊Mental health and HIV care providers communicate frequently in person and have regular team meetings	◊Mental health and HIV care providers communicate frequently in person and have regular team meetings
		◊Mental health and HIV care providers feel like part of a team	◊Mental health and HIV care providers have a basic understanding about each other's roles	◊Mental health and HIV care providers have in-depth understanding of each other's role	◊Mental health and HIV care providers roles blur/blend together

Adapted from HRSA/SAMHSA CIHS Model.

CIHS, Center for Integrated Health Solutions.

From the 100 survey participants, 15 qualitative participants were purposively selected (based on their survey responses) to include YB-GBMSM who had utilized mental health services in the past, as well as those who had not. We asked all qualitative interview participants about their views on mental health service use, mental health-HIV care integration, and specific models for care integration and/or delivery: (1) primary HIV care providers prescribing antidepressants or doing therapy; (2) having a patient navigator to assist with scheduling and reminders; (3) having mental health and HIV care services on the same floor (as opposed to different floors in the same building); and (4) use of telehealth for mental health care. Although telehealth does not represent a care integration model per se, we included these questions given that telehealth has become increasingly salient in the setting of COVID-19, and is also another strategy for decreasing barriers to mental health care among those already engaged in HIV care. All interviews were conducted by trained interviewers, in a private room at either clinic or at Emory University. Interviews were recorded digitally and transcribed verbatim by a professional service. On average, each interview lasted ∼1 h. Participants received a $50 gift card as an incentive for participating in the survey, and another $50 if they completed the in-depth interview.

Statistical analysis

Survey data were entered into a REDCap database and exported into SAS (SAS Institute, Inc., Cary, NC, USA), version 9.4, for subsequent statistical analyses. Descriptive analyses were used to summarize demographic data, and to summarize participants' perceived and desired integration levels.

Qualitative analysis

Transcripts were uploaded in to MAXQDA20 (VERBI Software, Berlin, Germany). We used a thematic analysis approach³¹ to guide our inductive/deductive coding and subsequent identification of major themes. First, transcripts were coded utilizing a team-based approach to enhance reliability and internal validity. The research team discussed transcripts, recurring themes, codes, and definitions to iteratively develop and modify a codebook, using both deductive (based on the interview guide) and inductive (emergent from the data) codes. Study team members independently coded transcripts, then met routinely to rectify discrepancies and refine the codebook to maximize intercoder reliability. Research staff then wrote thick descriptions (detailed analytic memos) about each theme, exploring the depth, breadth, context, nuance, and relationships between codes.³² Thematic saturation was determined to have occurred when no new patterns or themes emerged in the data.

Results

The mean age of our 100 study participants was 25 (standard deviation = 3 years). Seventy-eight percent (78%) identified as gay, with the remainder self-identifying as bisexual or another orientation. Approximately half of the sample had a high school diploma or less, 42% were unemployed, and the majority earned <$20,000/year. By self-report, 51% had ever used mental health services in their lifetime. Additional demographics are listed in Table 2.

Table 2.

Demographic Characteristics of the Sample

Variable	N (%)
Age, years
18–25	51 (51.0)
26–30	49 (49.0)
Sexual orientation
Gay/homosexual/same gender loving	78 (78.0)
Bisexual/straight/other	22 (22.0)
Highest education level
High school diploma or less	52 (52.0)
Some college or tech school	33 (33.0)
Bachelor's degree or higher	15 (15.0)
Employment status
Full time	38 (38.0)
Part time	20 (20.0)
Unemployed	42 (42.0)
Annual income
Less than $10,000	39 (39.0)
$10,000–$19,999	16 (16.0)
$20,000–$29,999	20 (20.0)
$30,000 or more	25 (25.0)
Mental health service utilization
Ever used in lifetime	51 (51.0)

Integration of mental health with HIV care

Quantitative findings

Seventy percent of respondents indicated a preference for an integrated care model (close collaboration with at least some system integration or higher), with 43% of respondents indicating a preference for the highest level of integration possible. Thirty-six percent (36%) of respondents desired closer collaboration between mental health and HIV care providers than that currently occurring in their clinic; 51% were content with the level of collaboration in their clinic, whereas 13% preferred a lower level of collaboration than that currently occurring (Table 3).

Table 3.

Participant Opinions of Current Clinic Integration Level

Level of collaboration	Current level of integration as perceived by participants (%)	Ideal level of integration desired by participants (%)
Level 1: Minimal collaboration	11	8
Level 2: Basic collaboration at a distance	10	8
Level 3: Basic collaboration onsite	24	14
Level 4: Close collaboration onsite with some system integration	16	12
Level 5: Close collaboration approaching an integrated practice	7	15
Level 6: Full collaboration in a merged integrated practice	32	43

Qualitative findings

The overwhelming majority of participants agreed that integrating HIV health care services and mental health services in some manner was beneficial. This was generally related to these participants' favorable views of mental health care overall. Many participants reported that ensuring proper mental health was crucial to maintaining good HIV care. One common reason participants gave was the importance of good mental health in being able to adhere to their HIV medications.

I feel like when you lose your mental, you lose your physical. Because I don't think that you can collectively keep up with taking medication with mental health issues. I really don't think that you're capable of keeping up on your regimen and your day to day basis of taking medication—27-year old, engaged in mental health care

Participants had varying opinions on different levels and types of integration. The main options that were discussed were HIV primary care providers taking on additional mental health duties, such as prescribing psychotropics and/or providing basic therapy, increasing collaboration between HIV and mental health care providers, utilizing patient navigators, and implementing new mental health care delivery methods.

Primary care provider prescribing and counseling

Most participants approved of the idea of their HIV providers prescribing antidepressants and/or providing basic therapy during their consults. They spoke about trusting their HIV care providers and knowing that their providers had their best interests at heart. Another reason for supporting this strategy was not having to retell their story to a new person and experience the accompanying discomfort:

It is still just having an appointment here or having an appointment there or having to go back to your primary doctor and tell them this, and go to your therapist and tell him that, so that's one of my big problems. I didn't like to meet anybody new because I hate telling the same story over and over again—25-year old, engaged in mental health care

Some participants also expressed that receiving mental health prescriptions directly from their HIV care providers would decrease the number of appointments they would be responsible for attending, making them more likely to adhere to medication while simultaneously addressing mental health concerns.

I think that would be great because that's what I actually have been trying to get myself on to as well as I happen to miss appointments and it makes me a step behind on where I'm trying to be at—25-year old, engaged in mental health care

Those who disagreed or who were hesitant cited fears that a provider who does not specialize in mental health may inappropriately prescribe antidepressant medications or not be able to diagnose mental health disorders as accurately as a psychiatrist could. Some participants also felt that HIV providers should be focused on HIV and not delve into subjects outside of their purview.

I don't think that would be good at all because our main focus needs to be making sure that you take your medicine so that you are healthy on the inside. I don't think she needs to be worried about doing anything cerebral whatsoever—27-year old, never engaged in mental health care

Consolidated services

Many participants mentioned liking the idea of a “one stop shop” in which they could see all of their health care providers (e.g., HIV, mental health), as well as obtain all of their prescriptions, without having to travel outside the building or make multiple appointments.

Doctor, mental, everybody the same day, with numbers, information, and anything that you need, it's right here in this building. Nobody should have to wait around for something to happen, to know that it's here. I think that everybody should be aware of everything from the time they step in this door, we offer everything that you need to make sure that you live a healthy life—27-year old, never engaged in mental health care

The main reason stated in support for this strategy was convenience, which would eliminate barriers such as time and transportation and thus allow participants to better engage in health care other than just their HIV care. Participants also stated that consolidating might serve to lessen the stigma associated with a center being known as an HIV/AIDS clinic.

As reflected in the quantitative findings shown in Table 3, a substantial minority of participants expressed a preference for only minimal or basic collaboration between mental health and HIV primary care providers. For example, one participant described a preference for keeping their physical and mental health concerns separate:

I like to keep my physical and mental health separately. I think there should be some kind of communication between the two, but ultimately I feel like they're two different dynamics as far as my health, and I don't really care for the idea of them being joined—Participant 173, 28-year old, never engaged in mental health care

Patient navigators

When asked about the possibility of a patient health navigator providing reminders for both HIV and mental health care appointments, the majority of participants expressed that such a service would be helpful and improve the likelihood of patients attending their appointments. However, some participants expressed concern about this strategy potentially resulting in reduced personal accountability of patients. Some participants stated that patients should use the patient health navigators as aids but aim to be internally motivated enough to make it to appointments without extra help. One participant disagreed wholly with the idea of patient navigators and felt that reminders were unnecessary and could come off as a “lecture” and make patients less likely to attend their appointments.

Telehealth

The overwhelming majority of participants thought that the option to have their mental health needs addressed through telemedicine, including video visits, would be beneficial. Several participants mentioned that video visits would be easier to attend from a time management standpoint, particularly if the participant also had a daytime job.

I think that would be perfect because people could walk down the street [on a video call] and get their act together [treat their mental health] at the same time. I think that would be perfect—Participant 164, 27-year old, never engaged in mental health care

Having a videoconferencing mental health appointment option could eliminate the barrier of finding transportation to get to appointments. It was also mentioned that the large shift to videoconferencing brought about by the COVID-19 pandemic could facilitate providers being willing to offer telemedicine appointments, especially as many of them were having to provide these services during the pandemic by necessity.

A few participants agreed with making a telehealth option available but expressed that they personally preferred seeking mental health care in person. These participants discussed missing the connection that arises from talking with someone face-to-face, and about the ability to simply log off of a virtual session if it became uncomfortable, both of which could lead to patients being less able to open up. The potential loss of privacy that comes about with videoconferencing technology was also mentioned, which could also lead to reluctance to share personal details about themselves.

Discussion

The majority of participants were supportive of integrating HIV and mental health services, with varying individual preferences regarding the degree and operationalization of this integration. Over one-third of our participants desired a higher level of collaboration between HIV and mental health care providers than what they perceived to be currently occurring in their clinics, and almost one half of participants indicating that their clinics should strive for the highest level of integration possible. Specific integration strategies that participants discussed favorably included having HIV care providers undertake more mental health care responsibilities, co-locating HIV and mental health care services on the same floor, and using patient navigators to coordinate and affirm engagement in both HIV and mental health care. Those who were hesitant about integration primarily expressed concerns about the expertise of their providers to cross into other “lanes” (i.e., HIV providers crossing into mental health management or vice versa).

Our study adds to the literature owing to the focus on exploring patient perspectives on HIV mental health care integration, with specific focus on YB-GBMSM in a US setting. Prior studies and position papers have invoked calls to action to improve integration of mental health and HIV care services,^33–36 and/or examined clinical effectiveness and cost-effectiveness of implementing such approaches.^37–41 Additional studies have examined care provider perspectives, primarily in sub-Saharan Africa;^42–45 however, the patient perspective remains relatively understudied to date. We did identify one study from Uganda that included qualitative investigation of both provider and patient perspectives on a specific care integration strategy,⁴⁶ as well as a study from South Africa investigating patient preferences regarding integration of mental health and chronic disease (including HIV) care more generally.⁴⁷ In both these studies, patients were generally supportive of care integration, citing high unmet need for mental health care as well as the importance of convenience for patients and collaboration between providers.

In addition to rating their desired levels of care integration, our participants also discussed benefits of different strategies for care delivery and integration. Co-location of services and telehealth can eliminate the need for multiple visits and decrease potential for anticipated or internalized stigma, care navigation can assist with scheduling impediments, and provision of basic mental health services (i.e., prescribing antidepressants) by HIV providers can help to alleviate barriers associated with patient anxiety about establishing new patient–provider relationships. These findings were consistent with prior studies that found telehealth and patient navigation generally acceptable among people living with HIV.^48,49 Of importance, however, all participants did not need or want these types of services—for example, some preferred to see mental health and HIV providers separately, or did not want to work with navigators or utilize telehealth. Although some systematic changes could not be individually tailored (i.e., having mental health and HIV providers available on the same floor), our results indicate a benefit to allowing YB-GBMSM to curate their own HIV mental health care experience where possible. The incorporation of patient preference into implementation of integration strategies has potential to diminish barriers to care and increase rates of retention and viral suppression among YB-GBMSM living with HIV, consistent with the goals of the ending the HIV epidemic initiative.⁵⁰ Future implementation studies and programming efforts should continue to examine patient preferences and include opportunities for care differentiation within the larger umbrella of integration HIV and mental health care.

Limitations

This analysis focused on patient perspectives of theoretical integration of HIV and mental health care. Further research conducted during and after actual implementation of such integration strategies will help to ascertain benefits or barriers that YB-GBMSM patients might face as these clinical changes are implemented. In addition, this study reflected patients' perceptions of integration—however, it is also likely that they are mostly unaware of the degree of communication between HIV and mental health care providers in the respective clinics. There are also numerous additional mental health care delivery models that were not specifically discussed—strategies such as integrating substance use treatment with mental and HIV health care^51,52 training mental health providers on HIV-specific care,⁵³ or a more extensive case management approach (wherein the case manager coordinates care between providers and tracks medication adherence)⁵⁴ that have been proposed in other settings. We limited our inquiry to integration strategies that we deemed most feasible in our two clinic settings. Future research could explore alternative care integration models as well.

YB-GBMSM living with HIV generally support efforts to maintain or enhance integration between mental health and HIV care services. Integration of mental health and HIV care—whether through closer collaboration between providers, mental health training for HIV care providers, closer co-location of services, and/or utilizing navigators or case managers—has the potential to improve both mental health and HIV outcomes among this high priority population.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by the National Institutes of Health through a supplement to the Emory Center for AIDS Research (P30 AI050409).