Getting to 90-90-90 requires attention to mental health
The Joint United Nations Programme on HIV and AIDS (UNAIDS) has established goals for countries trying to achieve progress in the prevention, care and treatment of HIV infection. Countries and regions are encouraged to strive to meet these goals by the year 2020. The goals can be summarized in the phrase 90-90-90, which stands for the following:
- 90% of all people living with HIV will know their HIV status
- 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART)
- 90% of all people receiving ART will have viral suppression (their viral load will be undetectable)
These are laudable and important goals. To enable them, opportunities for the offer of confidential HIV testing must be made more widely available. In cases of positive test results, after counselling patients, healthcare workers must swiftly refer them to care, where they can receive an offer of treatment. By starting treatment and taking it every day exactly as prescribed and directed—getting viral load to an undetectable level and keeping it there—clinical trials have found that ART users do not transmit HIV to their sexual partners and the overall health of their immune system improves.
However, to achieve and maintain an undetectable viral load in the blood requires a high degree of adherence—the ability to take ART every day exactly as prescribed and directed.
One barrier to achieving and maintaining an undetectable viral load is the ability to take ART exactly as prescribed and directed every day. For most people starting ART in high-income countries, there are entire treatments available in one or just a few pills taken once daily, which can overcome some barriers to adherence. However, not everyone can easily take ART every day exactly as prescribed and directed.
Mental health issues become important
People living with HIV can undergo stressful periods in their life. Much of this stress has its origins in other people’s negative attitudes and behaviour, which can result in stigma and discrimination. This can cause HIV-positive people to become socially isolated and oftentimes fearful of disclosing their health status. Some HIV-positive people who survived the early years of the epidemic have lost many friends and loved ones to AIDS. All of these factors can have an impact on a person’s psyche.
Although ART can significantly reduce the amount of HIV in the blood, it cannot penetrate all parts of the body—particularly lymph nodes, lymphatic tissues and the brain—in high concentrations. As a result, even in ART users, HIV continues to infect cells in the body on a small scale. What’s more, some of these infected cells travel to and reside in the brain. There, infected cells release chemical signals and HIV proteins that cause inflammation and have an unfavourable effect on brain cells, causing them to malfunction and in some cases die. Prolonged elevated levels of inflammation could, in theory, have a negative effect on brain health by increasing some people’s susceptibility to poor mental health.
Once HIV-positive people are in care, unless mental health issues are regularly screened for and detected—and, when present, treatment is offered and taken—such conditions can reduce quality of life and interfere with one’s ability to take ART and maintain an undetectable viral load. Ultimately, this can affect a person’s survival.
Studies have found that mental health conditions, including depression and problematic substance use, can, in some cases, increase the risk for non-adherence to ART (and other medicines). As more people take ART in an effort to reach the goals of 90-90-90, more effort will need to be paid to factors that interfere with adherence to sustain the third 90.
In this issue of TreatmentUpdate, we present information from studies that underscore the importance of screening for mental health and related issues in the lives of HIV-positive people.
—Sean R. Hosein
- Jallow A, Ljunggren G, Wändell P, et al. HIV-infection and psychiatric illnesses – A double-edged sword that threatens the vision of a contained epidemic: The Greater Stockholm HIV Cohort Study. Journal of Infection. 2016; in press.
- Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. New England Journal of Medicine. 2016;375:830–9. Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1600693
- Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316(2):171–81. Available from: http://jama.jamanetwork.com/article.aspx?articleid=2533066
- Trickey A, May MT, Vehreschild J, et al. Cause-specific mortality in HIV-positive patients who survived ten years after starting antiretroviral therapy. PLoS One. 2016 Aug 15;11(8):e0160460.
- Smith CJ, Ryom L, Weber R, et al. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort collaboration. Lancet. 2014 Jul 19;384(9939):241-8.
- Helleberg M, May MT, Ingle SM, et al. Smoking and life expectancy among HIV-infected individuals on antiretroviral therapy in Europe and North America. AIDS. 2015 Jan 14;29(2):221-9.
- Lorenzo-Redondo R, Fryer HR, Bedford T, et al. Persistent HIV-1 replication maintains the tissue reservoir during therapy. Nature. 2016 Feb 4;530(7588):51-6.
- Fletcher CV, Staskus K, Wietgrefe SW, et al. Persistent HIV-1 replication is associated with lower antiretroviral drug concentrations in lymphatic tissues. Proceedings of the National Academy of Sciences USA. 2014 Feb 11;111(6):2307-12.
- Ransohoff RM. How neuroinflammation contributes to neurodegeneration. Science. 2016 Aug 19;353(6301):777-83.
- Ferguson D, Clarke S, Berry N, Almond N. Attenuated SIV causes persisting neuroinflammation in the absence of a chronic viral load and neurotoxic antiretroviral therapy. AIDS. 2016 Oct 23;30(16):2439-2448.
- Lamers SL, Rose R, Maidji E, et al. HIV DNA is frequently present within pathologic tissues evaluated at autopsy from combined antiretroviral therapy–treated patients with undetectable viral loads. Journal of Virology. 2016 Sep 29;90(20):8968-83.
- Dou H, Morehead J, Bradley J, et al. Neuropathologic and neuroinflammatory activities of HIV-1-infected human astrocytes in murine brain. Glia. 2006 Aug 1;54(2):81-93.
- Kipnis J. Multifaceted interactions between adaptive immunity and the central nervous system. Science. 2016 Aug 19;353(6301):766-71.
- Garrido MM, Prigerson HG, Neupane S, et al. Mental illness and mental healthcare receipt among hospitalized veterans with serious physical illnesses. Journal of Palliative Medicine. 2016; in press.
- Moore CL, Grulich AE, Prestage G, et al. Hospitalization for anxiety and mood disorders in HIV-infected and -uninfected gay and bisexual men. Journal of Acquired Immune Deficiency Syndromes. 2016 Dec 15;73(5):589-597.