Intersection of Substance Abuse, Depression, Violence & HIV: Implications for Ending HIV (15883)

– [Jean] Good morning We are honored this morning to talk about the intersection of substance abuse, depression, violence and HIV and the implications that these conditions have for ending the HIV epidemic These are our disclosures The objectives for this presentation are to recognize the interrelationship of HIV, substance abuse, depression and violence, to describe the effect of these conditions on the course of HIV, and to identify challenges and potential strategies to address this syndemic I think everyone in this audience understands the importance of viral suppression Maximal and durable viral suppression have been associated with prevention and delay of the selection of drug resistance, improvement in immune function, reducing HIV associated morbidity, and prolonging duration and quality of life and preventing HIV transmission The current understanding is that persons living with HIV who take their HIV medications daily as prescribed and who achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to a negative partner And that’s the undetectable equals untransmissible public health messaging that you may see or U equals U This is data from the CDC looking at HIV viral suppression, which has been increasing over the years from 2010 on this slide to 2018, we started out at about 46% of patients with HIV being virally suppressed to now 65% This has also been associated, obviously with an improvement in the proportion of persons who know their HIV status 85% in 2017, and 80% of newly diagnosed individuals living with HIV were linked to care This is data from New York State looking at viral suppression among persons living with HIV who are in care by different demographics And what I’d point out is that women in the most recent data from 2018 have pretty high rates of viral suppression, 88% If you look by race on the lower panel of this slide, Black or African American individuals and Hispanic individuals have lower rates of viral suppression than white individuals And if you look at age categories, the lowest rates are among youth aged 13 to 19 And then this is data on viral suppression among women who are served under the Ryan White Program, again, from 2018 Looking at women, 86% overall with viral suppression, but again, looking by age, and you can see that younger women are less likely to be suppressed And if you look on the far side of this panel, those women who were infected prenatally, 71% had viral suppression and also lower rates than we would want among women living with unstable housing So in 1994, the syndemic of SAVA was conceptualized SAVA stands for substance abuse, violence and HIV AIDS And this was described as a set of closely intertwined and mutually enhancing epidemics fueled and sustained by social and economic inequities Each of these conditions contributes independently to the collective health burden on women, but they also act synergistically to negatively affect health outcomes And we have added depression because we think this is an important part and has an independent and interdependent role in this syndemic

So let’s look at some of the general statistics in the population We know that substance abuse is a national public health crisis Over 21 million Americans needed treatment for substance use disorder in 2018 but only 3.7 million actually received treatment In 2018, over 31 million Americans aged 12 or older, were current illicit drug users And drug overdose is currently the number one cause of injury related deaths in the US About a third of US women will experience physical violence by an intimate partner during their lifetimes and a higher number, about 47%, experience psychological aggression This burden falls higher on women with, from lower socioeconomic strata or on public assistance where 50 to 60% have been victims of domestic violence as adults And the costs of IPV are extreme, exceeding $5.8 billion each year Depression is also extremely common, about 7% of US adults have had at least one major depression episode in the past year and the lifetime prevalence is much higher If you look at sort of the interaction among IPV, mental health and substance abuse, we know that there are higher rates of trauma related mental health conditions among IPV survivors That they have nearly three times the risk for developing major depression or PTSD And women with a recent history of IPV had nearly six fold the risk of problematic alcohol use The prevalence rates of substance abuse or use among IPV survivors is variable but is as high as 72% And the prevalence rate of IPV among people using substances is also variable, but ranges from 31% to 90% So now if we look at the interrelationship of these problems with HIV, there is evidence that physical violence alone increases the risk of HIV in women by 28 to 52% There’s probably a lot of reasons for this, but one of those is that women in relationships with violence have about fourfold greater risk for contracting sexually transmitted infections than women in relationships without violence We know, of course, that substance abuse is a major risk factor for HIV transmission Injection drug use is the transmission category for up to 28% of women with newly diagnosed HIV and non injection drug use or alcohol abuse increase the risk through impaired judgment and disinhibition leading to increase in risky behaviors The syndemic effect of living with all three factors is associated with increased risk of depression among women A study of over 400 urban women who had experienced IPV, depression, HIV were 6.8 fold more likely than women who had none of these factors to have depression This is simply a graphic looking at the central role of intimate partner violence both the proximal and distal factors that increase risk of HIV So then, again, looking now further among the risk of these problems among HIV infected women We know that women with HIV experience more frequent and more severe IPV than HIV negative women In one study, over 55% of HIV positive women experienced intimate partner violence, that’s over two fold the national rate One third of that 1.2 million people living with HIV in the US drink alcohol in unhealthy amounts or use illicit drugs And depression is the most common psychiatric comorbidity among persons living with HIV It affects at least a third of infected adults, which is three fold greater than among the general population And it’s more common among women living with HIV than men by about two fold

Approximately 50% of depression goes unrecognized, and about 50% of those among whom it’s recognized, go untreated If we look at specific substances in terms of substance use disorders among persons living with HIV, this slide, which is in over 10,000 individuals, notes that marijuana is the most common substance used, followed by alcohol at 19%, methamphetamines in 13%, cocaine, 11% and opiates at 4% PTSD is a closely related mental health disorder There’s a 10 to 20% prevalence of PTSD in the general population but prevalence and incidence is higher in the setting of HIV with a lifetime PTSD prevalence of 54% Women again, are two fold more likely to have PTSD than men And patients who have PTSD are two to three times more likely to have a substance use disorder This is a meta-analysis looking at the prevalence rates of traumatic events and PTSD in HIV positive women If you look simply at the third column, you will see that all of these traumatic events are at very high rates ranging from 30% with recent PTSD to over 70% with a history of lifetime physical abuse These are extremely prevalent issues in the lives of women living with HIV If you look at the relationship between psychosocial factors associated with SAVA, this is a study of over 500 HIV positive women of color, two thirds of whom were black, and about a quarter were Hispanic or Latino at nine different sites and they looked at the relationships among five psychosocial factors; poor mental health, substance use, binge drinking, IPV and sexual risk taking And they found as the number of these problems increase the likelihood of viral suppression decreased There was an additive effect up until three or more psychosocial problems at which point this relationship plateaued And this suggests that there’s a threshold beyond which an increasing proportion of women will have poor clinical outcomes In looking at the impact of substance abuse, IPV and depression on HIV outcomes, we know that depression in the setting of HIV is associated with negative health behaviors and outcomes It’s associated with reduced adherence to antiretroviral therapy, missed HIV primary care appointments, reduce viral suppression, and higher rates of AIDS related morbidity and mortality Women with a history of violence are also less likely to have viral suppression Experiencing physical or other types of IPV also increases the likelihood of not getting tested for HIV, as well as not accessing and staying in care and poor medication adherence among those who use drugs And childhood sexual abuse is a particularly strong risk factor for substance abuse, particularly injection drug use, as well as risky sexual behaviors and then failing to engage or be retained in HIV care and maintaining good medication adherence Several studies have shown an association between specific substance use and lack of viral suppression And we know that there is a relationship between psychological environmental factors with adherence to antiretroviral therapy And certainly depression is associated with decreased adherence and fewer depression symptoms is associated with better adherence In this cross sectional study of about 200 women, I’m sorry, this included men as well, from 2012 to 2014 These were individuals living with HIV who were on therapy,

antiretroviral therapy and who had a current substance use disorder They found that, in particular, the past 30 days of specific substance use or heavy drinking days, as well as the severity of the drug and alcohol dependence criteria in the previous year, based on DSM IV criteria were associated with poor ART adherence Approximately three quarters of this substance use cohort was able to achieve virologic controls So, again, these were individuals who were in care So it’s probably much lower among those who have these problems who are not diagnosed for sure, or for those who have been diagnosed but have not been able to be maintained in care Interestingly, the criteria for drug dependence rather than the specific substance was associated with lack of viral suppression So, what about treatment of these disorders? We know that treatment for depression can improve outcomes among persons living with HIV It not only reduces the depression symptoms, but it improves ART adherence and viral suppression Drug use is independently associated with poor outcomes along a depression treatment cascade And current drug users are more likely or most likely to need depression treatment, but are least likely to receive treatment A retrospective study of over 3300 patients found that 42% had a depression diagnosis, 15% were on SSRIs in addition to antiretroviral therapy, and they found that those patients who had depression who were adherent to their SSRIs had significantly greater ART adherence compared to those not on SSRIs Similarly, they were also more likely to have a viral load less than 500 copies per milliliter at 12 months, and improvement in immune function as measured by CD4 count In another study, retrospective chart review of patients who were referred to on location therapy, services for depression had both significant decreases in depression scores, as well as improvement in HIV RNA suppression and increases in CD4 count Viral suppression CD4 count increased and PHQ-9 screen for depression improved after initiating antidepressants In another study comparing the effectiveness of single versus dual acting antidepressants If you look at treatment of substance use disorders, this slide mentions three separate studies, one in San Francisco methadone clinic of 65 patients with HIV, women were more likely to attain viral load suppression than men, viral suppression was 14% higher for those who received HIV care at the same site as the methadone clinic versus those at a nearby HIV clinic Again, pointing out the advantages of one-stop shopping Another study from France found two to three fold better adherence to ART among those who had stopped injecting drugs, while prescribed methadone or buprenorphine, and the duration of the opioid agonist therapy was positively associated with viral suppression And then the third study from Canada, again, looking at methadone treatment was associated with improved adherence, viral suppression and CD4 count And this is simply from a study looking at medication assisted therapy for substance use disorders, and associations of that with the percent who were on antiretroviral therapy as well as viral suppression below 400 copies per milliliter We also know that brief behavioral interventions can reduce this syndemic risks for IPV and HIV among women who use drugs Both meta-analytic reviews and recent study suggests

that trauma-focused or trauma-informed care that address all of these disorders in an integrated concurrent approach are more likely to succeed, they’re also more cost effective, and associated with increased medication adherence and they reduce the symptoms of PTSD Other trauma informed interventions for those who have HIV have also revealed significant effects in reducing substance use decreasing PTSD, as well as risky sexual behavior I’m going to turn over now to Alison for the next part of our presentation – [Alison] Hi, in looking at screening for substance abuse and depression There was a study in 2015 at a North Carolina clinic and the aim was to describe the prevalence of mental health and substance use and factors associated with poor adherence and examine those differences They looked at the patients in the waiting room and had been complete PHQ-9s And what they found was 12.2% had indications of moderate to severe depression that was associated with decreased adherence 19.1% had indications of problematic drinking and 8.2 had indications of problematic drug use Essentially, what they found was that patients were willing to disclose mental health distress, substance use and sub optimal medication adherence and that highlighting that we need to routinely assess these behaviors at clinic visits Next Another study was at an HIV clinic in Alberta, Canada, and essentially what they found was 46% of women in HIV had actually experienced IPV and only 22% of patients have been asked about violence in any other healthcare setting The patients were responsive to screening and 23% of patients disclosing IPV were connected to resources after screening And their recommendation was that universal IPV screening should be incorporated with regular HIV care If we don’t screen patients the we can’t initiate the interventions Next There was a Chicago HIV clinic and they actually tested a novel approach to screening, they used a couple of different scales At baseline, they used a battering scale, a three question ER, question for IPV A question measuring fear of partner and they were asked to identify level of safety and this was an acuity assessment that they then are repeated three months, six months One of the questions they answered at three months was how likely is it that you became infected with HIV as a result of being forced to have sex with someone who may have been infected? Their feeling was that disclosure of these various issues is facilitated by asking different questions over time, building trust and coming at things from different angles The results of the study, were that women reporting IPV were approximately eight times less likely to be virally suppressed 70.6 indicate a history of violence using the Composite Measure 35% identified a history of sexual assault and the acuity assessment identified 41% of participants as having a history of IPV and 26% identified having, feeling like they had contracted HIV through unwanted sexual attention Their baseline ER screening identified 37% of participants as having had a history of IPV So in terms of actually looking at screenings, next slide, sorry Depending, we’ve selected a few examples here, and all of these tools, a yes response constitutes a positive screen for IPV And these all contain questions about physical and psychological violence How well the screening works for you depends on your clinic and the circumstances of asking the questions they have their pros and cons in varying sensitivity and specificity and positive and negative predictive value In terms of actually, you know, implementing these screens, providers have identified various barriers The top barrier has been lack of time

and also discomfort with the topic Providers feel that there’s generally a lack of awareness of the problem and its prevalence, they are uncomfortable, feel like there’s a lack of privacy to screen If patients screen positive, what are the resources and the time taken to actually, you know, address the issue And there’s a perception that screening is not necessarily the clinicians role In terms of being able to identify patients with IPV, basically looking for evidence of physical trauma that are unexplained They found, a study found that 37% of women who presented to the ER and had physical injury had experienced that through a close partner Unexplained chronic GI, GU symptoms, reproductive tract symptoms, other explained chronic pain, concussion, repeated health consultations where there’s no clear diagnosis Another clue would be an intrusive partner who does not want to leave the room and the patient being nervous and agitated when the partner is present Other symptoms that crossover also with both depression as well Depression, anxiety, PTSD, sleep disorders The other thing to think about is patients who have not disclosed their HIV status, disclosing to their partner can increase their risk for IPV Our next slide Patients may also appear to be embarrassed, ashamed, frightened, disoriented or depressed They also may screen negative the first time as this studies show, you have to build some trust So repeated screening is very important Next slide In terms of clues for depression and substance use, there are many non specific symptoms, different chronic pain, symptoms that have no explanation And there’s a crossover between the depression symptoms and the substance use, same chronic pain, emotional lability, weight changes, chronic missed visits, financial problems, labile mood, weight changes, changes in hygiene and skin changes are just a few of the red flags The, a good method for screening for depression, the US Task Force recommends screening in adolescents and adults in clinical practice that have systems in place to ensure accurate diagnosis, effective treatment and follow up So one of the challenges with all of these is having a referral system in place The PHQ-2, PHQ-9 are assessments for depression The PHQ-2 has a 97% sensitivity and 67% specificity in adults If a patient screens positive for the PHQ-2, they then are tested with the PHQ-9, which has a 61% sensitivity and 94% specificity and that’s in adult For the PHQ-2, the questions are asking, over the last two weeks, how often have you been bothered by any of the following problems? The patient than answers the questions and they get a score And if the score is greater than two, it defaults to the PHQ-9 Again, one of the reasons why this should be done every, more frequently is that this only ask the patient about the previous two weeks And the two questions yielding, having, then defaulting to greater than two can vary So the PHQ-9, again, over the past two weeks, have you been bothered by the following problems? And it’s on the same scoring system Things like little interest or pleasure in doing things, feeling down, depressed or hopeless, addresses sleep issues, appetite, energy, feeling bad about themselves, concentration, other people’s perceptions of them And one of the final questions is thoughts that you’d be better off dead or hurting yourself in some way And I think it’s important to pay attention to this question You have the potential to score a negative for depression but still have a positive on the questions So pay attention if you’re conducting this test,

what the patient’s answer for that is The scoring system basically yields one to four being minimal depression, five to nine, mild, 10 to 14, moderate, 15 to 19, moderately severe and then 20 to 27, severe In their recommendations based on that as to what your intervention would be As part of screening for a patient, we can use the SBIRT, it’s an evidence based test to identify problematic use of substance use on a continuum One of the benefits of this is it looks at, doesn’t have the addictive, non-addictive framework It looks at patients at various levels and helps identify the level of service needed The screening determines if the patient is at risk for or may have an alcohol or substance use disorder There’s an intervention which explains the screening results, information on safe use and also very important assessment of readiness to change And then referral to treatment Patients with positive results are referred for more in depth assessment or, and or treatment and if they decline services, you could still give them the information and more information on readiness to change Next slide One of the screens is the Alcohol Screen Audit C and this is an example of three questions that are part of a full 10 item audit It addresses alcohol use, and in women a score of greater than three is considered a positive score and men greater than four I’m not sure if that is actually gonna be changing but essentially gives you a range of the impact on health and the things that the patient may be at risk for Next The drug use screen, it asks, in the past 12 months, have you used any illegal street drug including marijuana, and then it also addresses the use of prescription medication for a non-medical use and a positive response prompts additional questions, intervention or referral The rationale for SBIRT is basically that, it can be conducted in a very short period of time, it can identify people who are at high risk, who actually have current issues And you can help with assessment of readiness to change and with motivation Next slide The SBIRT has been shown to be very effective using Cochrane methodology, 69 Primary Care brief intervention trials for over 33,000 participants showed that there was a significantly reduced alcohol consumption compared to controls Essentially, SBIRT is associated with reduced healthcare costs, emergency room visits and hospitalizations And greater intervention intensity was associated with larger decreases in substance use and that’s with a cross site evaluation Then we look at the how often to screen So for intimate partner violence, the Maryland healthcare Coalition Against Domestic Violence suggest to screen every patient every visit As discussed, depending on where the patient is at, the circumstances surrounding asking the patient the questions screen them at every visit is important because that’s when you can potentially catch something you didn’t catch at the previous appointment Given the time of COVID, this is a little more complicated If you’re doing a virtual visit with a patient, you don’t know for sure that the abuser is not in the room And in terms of depression and substance abuse, there are no formal evidence-based screening guidelines But we do feel that screening every patient at every visit for both depression and substance use can help identify patients in need I’m going to turn over to Rose Ramroop as she talks about what we need, in terms of screening, what things we need to consider – [Rose] Hello, good morning Thank you, I’m glad to be here

When we consider screening, things you need to have in place is a private place and whereas confidentiality is respected there So you want to have brochures and you want to have material in the waiting room And in the bathrooms, the reason I say the bathrooms is because if a woman is a victim of abuse, she may not want to pick up that literature from the waiting room, especially if the abuser is with her And also because of the embarrassment of being abused, so it’s easier for them to pick that literature up in the bathroom In every Institute, you have your own systematic protocols So I’m not going to go through the rest of this but it’s site specific, next Reporting IPV in Maryland, one thing you want to be careful with is that you don’t want to report a violence to the police without that patient’s consent, because you can put them in a higher level of danger So you want to inform them, you want to give them, tell them to call their local police or their state’s attorney and request to file charges And then also, whichever state you’re in, file a protective order You have to look at all your referrals for specific states regarding confidentiality and reporting Next This is just a graph, I’m not going to get into it, but it’s a graph that shows how everything with substance abuse, domestic violence, and alcohol abuse are all entwined together Next Responding to a positive screen One, you want to acknowledge and then you want to ask if that person, if she wants help You want to offer your support and referrals Encourage a safe plan for that IPV person because the fact that helping them identify ways of doing things and come up with code words like we use SAVA for patients That can help them but you have to do it according to what the patient needs and assess and determine what are the levels of danger, if it’s suicide ideation and provide the service as appropriate Identify relevant comorbidities Next Services of intervention and general considerations You want to ensure for cultural, culturally, we have a lot of African women and we also have a lot of Hispanic and Latino You want to make sure that you have services that can relate to their culture Especially, we have a lot of undocumented clients here, patients, so they may not be willing to talk about trauma because they feel like they may be deported So you have to consider all those things and build that relationship and report with them Using a peer, this is where using a peer support person really come in handy because they have more time than the doctor, than the providers do They can help build that rapport and trust with that patient They also can help find resources and help them navigate how to access those resources I always use 211.org, that is a statewide bureau that you can look out sources in there in your area Understand the specific factors that influence access to and adherence to care You need to provide privacy, we keep saying it all the time, privacy and confidentiality HIV disclosure consideration, this is very important If she’s or been a victim of domestic violence, disclosing her status to the partner may not be the best option because you will put her in a higher danger of violence

So you want to reevaluate, talk to her, get a sense of what her partner is like before disclosure, and then come up with a plan You need to establish a pathway, a referral pathway meaning get to know the referrals in your area And once you know the referrals for yourself, you can actually provide that for your client Next Now, with COVID-19, we’re all locked down, you know, so just imagine, it may be as hard for a person that We have heard of reports of increase of violence among, domestic violence among patients Depression and substance abuse and doing, um, all these stays at home So they may be locked down with their abuser So we have to think about that Accessing medication, insurance issues Do a visits to your medical doctors and psychiatrists, or even such treatment (mumbles) Providers should have a low threshold for considering these problems Screening is critical, especially confidentiality issues Extend medication referrals, which work really well with us because we give them a more supply of medication and then we have home deliveries So that may be a good thing for you to do in your area Consider an in-person visits if needed Next In conclusion, substance abuse, depression and IPV and HIV are closely intertwined, mutually enhance the epidemic These factors collectively associate with negative in HIV outcome And we’ve seen that in so many cases where with all the issues that they have, that they are less likely to come to their appointments or even take their medication, because they may not have disclosed and the abuser’s there So, instead of putting themselves at risk, these are the outcomes that happen Then we want to identify treatment and depression, and substance abuse, to that can improve the ARTs and suppress viral load and screening components for this syndemic should be a routine for the context of healthcare, HIV care And I would like to thank you for inviting us This is a resources and referrals we meant for violence and mental health in our area And now, we would like to take questions and thank you so much for inviting us