Implementation Research in HRSA Ryan White Clinics: Screening and Treatment for Mental Illnesses to further the National “Ending the HIV Epidemic” (EtHE) Goals
Dianne Rausch, Ph.D.
Division of AIDS Research
The goal of this initiative is to enhance screening and treatment for mental illnesses in HRSA Ryan White clinics through implementation research, to advance the goals of the “Ending the HIV Epidemic” (EtHE) initiative. The EtHE initiative, coordinated by the HHS Office of the Assistant Secretary of Health, focuses on four key strategies – Diagnose, Treat, Protect, and Respond – that together can end the HIV epidemic in the U.S. Success of the EtHE initiative depends on trusted partnerships among local and state health departments, communities, service providers, and research institutions. This initiative seeks to strengthen the research/service delivery collaboration between NIH grantees and HRSA-funded HIV care clinics, while increasing retention in HIV care and viral suppression through implementation of evidence-based mental illness screening and treatment.
Mental illnesses are prevalent among populations at risk for HIV acquisition and transmission, as well as people living with HIV (PLHIV). Depression is the most common, but other disorders among PLHIV include mood (e.g., bipolar), anxiety (e.g., generalized or posttraumatic stress), substance use (e.g., drug abuse) and psychotic (e.g., schizophrenia). These disorders are known barriers to early linkage and HIV care retention, treatment adherence, and viral suppression. Moreover, socioecological factors such as stigma, violence, unstable housing, and poverty produce additive or multiplicative effects on the association between mental health and HIV. Unfortunately, mental disorders remain under-diagnosed and under-treated in many settings in the U.S., particularly in the hardest-hit counties, regions and states. Treating mental illnesses among PLHIV may help to improve HIV care continuum outcomes, ultimately helping the U.S. to reach the EtHE goals.
In the context of HRSA Ryan White care programs, high rates of HIV suppression are evident overall – yet gaps remain among groups like youth, transgender individuals, and racial/ethnic minorities who experience intersectional stigma and other structural barriers to care and treatment outcomes. Attention to mental health care and psychosocial support could help to close these gaps.
There are evidence-based treatments for mental illnesses, but their deployment depends upon a number of factors, which includes routine screening and addressing the challenges of integrating new or modified protocols in busy clinic settings that are needed for effective implementation. Targeted implementation science can help to address these key needs and produce generalizable knowledge regarding feasible and scalable approaches. These approaches require strong partnerships between researchers and service delivery stakeholders to ensure that the research questions are also locally derived and meaningful, and sustainable beyond the research enterprise.
Studies are encouraged to consider approaches previously utilized to screen and treat mental illnesses in other clinic and community settings, including but not limited to:
- Task shifting and/or sharing and use of paraprofessionals
- Differentiated care/stepped care approaches
- Collaborative care to support the integrated care delivery
- Use of digital health/mobile technologies to support care delivery
- Use of transdiagnostic approaches to address multiple mental illnesses in the same interventions