Physical and Mental Health Outcomes Among HIV Patients Receiving Integrated Care Treatment

Abstract

HIV literature suggests that up to 50% of HIV patients endorse psychiatric disorders (Soto, Bell & Pillen, 2004); furthermore, persons with mental illness and substance abuse have shown to exhibit poorer general health outcomes, higher treatment drop out, and poorer adherence to HIV medication (Sherbourne et al., 2014, Viswanathan, Anderson & Thomas, 2005, Tedaldi et al., 2014). Such findings suggest that integrated care interventions may potentially bolster health outcomes as well as retention and adherence. This 3 year long retrospective program evaluation demonstrated how a local HIV agency utilized integrated care interventions to significantly reduce a measure of disease progression and improve retention in care among HIV patients when compared to treatment as usual.

A 3-year Longitudinal Retrospective Study

The term integrated care is relatively new among heath care providers in the 21^st Century (Kodner & Spreeuwenberg, 2002), as such there is a lack of conceptual clarity surrounding the meaning of integrated care which may serve as a barrier to implementing effective treatment for complex patient populations. (Kodner & Spreeuwenberg, 2002). The definition of integration refers to “organic parts of a whole” which implies separate yet interactive components that play complementary roles (Kodner & Spreeuwenberg, 2002). This concept lies at the heart of systems theory (Kodner & Spreeuwenberg, 2002). In order for such parts to work as a system, a level of collaboration and cooperation is required. The Integrated Primary Care (IPC) model emphasizes a patient-centered, humanistic approach that aims for more comprehensive and coordinated care as well as enhanced access to services (Vogel, Kirkpatrick, Collings, Cederna-Meko & Grey, 2012). It is believed that integrated care will create more efficient, affordable, and effective treatments which incur less waste, better service provision and improved continuity of care (Kodner & Spreeuwenberg, 2002).

Integrated care is a multilayered model that operates on the macro, meso and micro level of society. Macro level integrated care is believed to improve overall quality of care, quality of life, and consumer satisfaction (Valentijn, Schepman, Opheij, & Bruijnzeels, 2013). This is accomplished through vertical and horizontal integration. Vertical integration refers to the treatment of illnesses at various levels of specialization (Valentijn et al., 2013). In contrast, horizontal integration refers to the improvement of the general health of people and the larger population, which is more holistic (Valentijn et al., 2013). Nonetheless, Valentijn et al., (2013) argue that both vertical and horizontal integration are required to offset the fragmented nature of the healthcare system.

Integrated care at the meso level is concerned with professional partnerships which allow for collaboration of care via shared competencies, responsibilities, and accountability to deliver care to a given population (Valentijn et al., 2013). This requires health care providers to bridge the gap between illness and social issues by acknowledging the connection between medical, psychological and interpersonal factors (Valentijn et al., 2013). On the micro level, integration refers to the person-centered delivery of care to the individual, which means involvement of the patient as co-creator in his or her own care. In contrast to traditional health care models, the patients’ perspectives, personal needs, and values are essential to the success of integrated care models. (Kodner & Spreeuwenberg, 2002, Valentijn et al., 2013) Valentijn et al., (2013) posit that integrated care should implement a person and population focused view over the previous, disease focused view, where health care providers translated the needs of the patient into biological components that existed apart from the individual (Valentijn et al., 2013).

A core component of the integrated care approach includes the intersection of multiple disciplines for the improvement of the overall well being of the patient. D’Amour and Oandasan (2005) refer to this concept as “interprofessionality” which they define as,

The process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population…It involves continuous interaction and knowledge of sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patients’ participation (p. 9).

The notion of patient centeredness is another hallmark of the integrated care model. The Institute of Medicine defines patient centeredness as, “Health care that establishes a partnership among practitioners, patients, and their families to ensure that decisions respect their patients’ needs and preferences and that patients have the education and support they need to make decisions and participate in their own care” (Hurtado, Swift & Corrigan, 2001, Lüdecke, 2014). The working relationship between practitioner and patient is based on respect and trust; therefore, in ideal integrated care models, mutual expectations are established between patients and health care providers (Lüdecke, 2014). These expectations are made explicit for both parties, which leads to the construction of mutual reliability. Integrated care networks are based on this reciprocal give and take dynamic such that one party relies on the resources controlled by another (Lüdecke, 2014). This dynamic extends to practitioners as well whereby interdisciplinary teams exchange information and professional abilities to their informed patients (Vogel et al., 2012).

According to Greenfield at al., (2014) there are several issues with the notion of “patient-centeredness” in integrated models of treatment. Greenfield and colleagues (2014) assert that taxonomies of integrated care never define what or whom care is being integrated around, instead, they mainly describe how the patient fits in with services that are integrated rather than describing how services are tailored to each individual’s experience. When reflecting on their experience of integrated care treatment, patients identified six major themes related to person-centeredness: holism[1], naming[2], heed[3], compassion, continuity of care[4], agency and empowerment[5] (Greenfield et al., 2014). Greenfield et al., (2014) outline very specific areas of interaction between patient and provider that require fortification within the integrated care model. The high rate of mental illness that accompanies patients seeking primary care may contribute to the difficulties of establishing more comprehensive person-centered humanistic treatment. For this reason, the inclusion of mental health professionals within integrated care models is essential.

Increased focus on patient centered care and the establishment of the Patient Protection and Affordable Care Act has led to the growth of patient centered medical homes (PCMH) within the United States (Protection, P., & Act, A. C., 2010). Stange et al., (2010) describe the Patient centered medical home as community based team that aims to promote wellness and healing for the patriots of their community. A central goal of the patient centered medical home involves optimizing the qualities of primary care and modifying larger healthcare reimbursement systems. The PCMH strives to treat people in a personal manner, while integrating care to improve overall health of communities. The PCMH typically includes a team of integrated health care professionals who deliver care in brief interactions of 15 to 30 minutes. Core features of the patient centered medical home include a personal physician[1], a physician lead team based care[2], whole person orientation[3], enhanced access to care[4], coordinated care[5], population based care[6], quality and safety[7], patient-centered care with shared decision making[8], and payment[9] (Nash, Cubic, Khatri & Baird, 3013).

Recent literature speaks to the need for behavioral health to become more integrated into the PCMH.  (Nash, Cubic, Khatri & Baird, 2013). Some specific reasons for the inclusion of behavioral health in the PCMH model include the high prevalence of mental health problems in primary care, unmet behavioral health needs in primary care, cost of unmet behavioral health needs, and better health outcomes (cite the packet of info). It is believed that if behavioral health becomes more integrated into the PCMH model, then healthcare systems will achieve “a sustainable person-driven long-term support system, in which people with disabilities and chronic conditions have choice, control and access to a full array of quality services that assume optimal outcomes, such as independence, health and quality of life” (Department of Health and Human Services Vision Statement).

To further complicate the notion of integrated care, various levels of integration may be implemented within the medical system. According to Heath, Wise, & Reynolds (2013) the more recent standard framework for levels of integration in health care consist of six different levels of collaboration and integration. Three main categories include coordinated, co-located and integrated care. The first level of coordinated care is called minimal collaboration, which describes behavioral health and primary care providers working at separate locations with separate systems. In this level of care, providers rarely communicate with one another about individual cases. Infrequent cases of communication may occur via e-mail or phone when a provider needs specific information about a mutual patient. Providers have a limited understanding of each others’ roles in helping the patient. The second stage of coordinate care is called basic collaboration at a distance. In this level of care, behavioral health and primary care providers still maintain separate facilities and separate systems, but providers view one another as resources and may communicate on occasion about mutual patients. This increase in communication and greater understanding for the other’s role is a key distinction between level 1 and level 2 coordinated care (Heath, Wise, & Reynolds, 2013).

The first level of co-located care is called basic collaboration onsite. In this level of care, behavioral health and primary care providers are both located within the same facility. Nonetheless, they may or may not use the same practice space. In basic collaboration onsite, providers employ separate systems but communication is more frequent due to close proximity. Occasional meetings may be held to discuss specific patients. Patients are likely to be more successful in their treatment because they are more readily moved between practices given that services are provided within the same location. Although providers who work in this level of care may feel like more of a team, there is no clear definition of how the team of providers interacts, thus the majority of decisions about the patient are made independently by providers (Heath, Wise, & Reynolds, 2013).

The second level of co-located care is called close collaboration with some system integration. In this level of care, behavioral health and primary care share the same practice space and integration begins to take place through shared systems. A typical model might consist of a primary care setting where behavioral health is embedded within the practice. In such a model, the primary care receptionists schedule all appointments and the behavioral health provider enters notes into the medical record of the patients. Consultation through personal communication between primary care providers and behavioral health will take place for more complex patients with multiple healthcare problems. This levels allows for stronger relationships and more trust to develop between providers (Heath, Wise, & Reynolds, 2013).

The first level of integrated care is called close collaboration approaching integrated practice. Changing the operation of the practice is a key component of integrated care. In the close collaboration level of care, collaboration and integration between primary care and behavioral health is substantial. The providers communicate with one another frequently and they work as a team to seek solutions for barriers to patient care. Regular team meetings are scheduled to discuss overall care as well as specific issues. There is explicit understanding of the responsibilities of each provider and their role within the team, which enhances patient care. Logistical issues that arise in this level of care may include the lack of an integrated medical record (Heath, Wise, & Reynolds, 2013).

The second level of integrated care is called full collaboration in a transformed or merged practice. This is the most sophisticated level of integration within integrated healthcare. In this level of care, two or more separate systems combine into one merged practice which operates a single health system. As a result, no one system predominates and all providers are required to modify the way in which they practice. In full collaboration all members of the system maintain a shared concept of team care. There is an emphasis on the treatment of the whole person rather than disease specific elements of the patient (Heath, Wise, & Reynolds, 2013). Patient contact occurs through a physical handoff of the patient in the practice setting and verbal communications predominates over written communication. Sessions are brief and occur with flexibility and the practitioner orientation tends to be generalist in nature and employs a behavioral medicine scope (Blount, 1998).

An article by Vogel, Kirkpatrick, Collings, Cederna-Meko & Grey (2012) claims that integrated primary care (IPC) is a model that “normalizes mental health and behavioral health issues in primary care with the aim of improving health outcomes” (p. 271). Up to 70% of primary care visits are related to mental health issues for individuals with behavioral health disorders and 80% of the population with mental health issues will visit their primary care provider at least once per calendar year (Vogel et al., 2012). These statistics emphasize the importance of collaborating mental health treatment with primary care given the fact that primary care is the point of first contact for most patients (Valentijn et al., 2013). Psychologists who are trained in integrated primary care serve as consultants in the medical culture and help physicians to become more culturally competent through self-awareness, reducing bias, and modeling a multicultural approach (Vogel et al., 2012). Psychologists working in this model should be open to gaining knowledge relevant to the primary care setting, such as learning common medical terms and developing efficient communicative skills (Vogel et al., 2012).

Vogel and colleagues (2012) examined the impact of an integrated primary care model in four clinical sites during 2009. Prior to the initiation of the integrated care program, targeted areas of improvement included more accurate identification of of patients’ behavioral health issues, increased access to medical services, and increased rate of retention. Treatment was initiated with the physicians’ assessment of the patient which included identifying specific psychiatric issues impacting the patient’s general health. Patients were then asked more specific questions pertaining to their symptoms which allowed interventions to be implemented in the first visit. Patients were provided with psychoeducation and coping skills that were typically cognitive behavioral in nature. Next, the behavioral health consultant and the physician collaboratively constructed a treatment plan for the primary issues at hand.

Internal quality improvement data from this program suggested patients were triaged more effectively and the attrition rate dropped from 28% in 2008 to 10% in 2011. Depression and anxiety decreased from the moderate to severe range at intake to the mild range at follow up. Patient satisfaction ratings were overall positive. Physicians reported a greater sense of competence in managing mental health problems and increased satisfaction with care (Vogel et al., 2012). Vogel et al’s (2012) study suggests that individuals with behavioral health problems present an at risk population that may greatly benefit from integrated models of treatment. According to Bradford et al., (2013), Individuals with serious mental illness have higher rates of infectious disease, diabetes and cardiovascular disease than the general public. Additional risk factors such as smoking, alcohol consumption and obesity are highly prevalent in individuals with serious mental illness (Bradford et al., 2013). Primary obstacles to care frequently exhibited among mentally ill populations include poverty, homelessness and social isolation (Bradford et al., 2013).

Druss, Rohrbaugh, Levinson & Rosenheck, (2001) examined the effects of an integrated medical care program initiated for VA patients with serious psychiatric illness. The researchers randomly selected VA patients to receive an integrated care treatment versus general medical treatment. Patients who were hospitalized for serious chronic conditions within the last month were included. In the integrated care treatment group, the clinic emphasized patient education, preventative services, face to face contact with mental health care, and telephone appointment reminders for patients (Druss et al., 2001). Whenever possible, patients were scheduled immediately following their previous visit. One of the providers from the integrated clinic served as a liaison to the three mental health teams and attended team meetings. Mental health care providers were included in a discussion of patients’ medical status and attendance to appointments (Druss et al., 2001).

Results indicated similar rates of attrition at both clinics. However, patients in the integrated care clinic were significantly more likely to schedule a primary care visit a year after the referral and less likely to have an ER visit during the year after the referral compared to general medical patients. Patients in the integrated care clinic reported significantly fewer complaints with satisfaction of care, particularly pertaining to continuation of care (Druss et al., 2001). Physical health outcomes, measured with the physical component summary score of the SF-36, revealed a 4.7 point increase in physical functioning for the integrated care group compared to a .3 point increase for the general medical group over 1 year (Druss et al., 2001). It is noteworthy that while physical health improved substantially in the integrated care group, emotional health did not (Druss et al., 2001). This article demonstrates some areas where integrated care can be effective for mentally ill populations, while the struggle to mitigate mental health symptoms remains a challenge.

Lemmens, Molema, Versnel, Baan, & De Bruin, (2015) conducted a meta-analysis of integrated care programs for patients with psychological comorbidity. Wagner’s Chronic Care Model was used to conceptualize the framework of integrated care models (Lemmens et al., 2015). The tenants of this model include: 1. A healthcare system that provides care for chronic disease and supports improvement for chronic care at all levels 2. Community resources and policies to enhance health care for chronically ill patients 3. Self-management support to encourage patients and families to cope with the obstacles of living with disease 4. Change in the delivery system by working in collaborative teams 5. Decision support by implementing evidence based guidelines 6. Construction of clinical information systems a tool for the care team such as reminder systems (Lemmens et al., 2015).

Results from the 15 studies included in the meta-analysis revealed that patients in integrated care programs were significantly more likely to experience 50% reduction in depression symptoms compared to patients in general medical care. Two studies showed improvement in Health Related Quality of Life (HrQOL) and three studies demonstrated larger improvements in emotional well being for patients enrolled in integrated care than those in general medical care. The authors concluded that there was insufficient evidence for a beneficial effect of integrated care programs on HrQOL and moderate evidence for a beneficial effect of integrated care programs on emotional well being. Insufficient evidence was found for a beneficial effect of medication adherence and moderate evidence was reported for a beneficial effect on patient satisfaction (Lemmens et al., 2015).

Although 15 studies were included in the analysis, only one study reported follow up measures up to 24 months as compared to 12 months or less. The integrated care programs included treatment for diabetes and mental illness, a combination of different somatic diseases, patients with cancer and depression, patients with epilepsy and depression and one with a focus on non-specified chronic medical conditions and depression (Lemmens et al., 2015). It is noteworthy that while several chronic conditions were examined, no study was included that addressed HIV positive populations. There are numerous reasons why integrated care for HIV patients may be sparse in the literature. PLWHIV tend to be a very heterogeneous sample with high rates of drug and alcohol comorbidity (Brown, Stepleman & Bottonari, 2012). Concurrent drug use often gets in the way of adherence to medication and overall treatment (Tedaldi et al., 2014). Additionally, there are higher rates of homelessness associated with PLWHIV compared to other chronic illnesses (Tedaldi et al., 2014). These factors all contribute to the complexity of treatment for people living with HIV; nonetheless, these variables provide more evidence for why coordination and continuation of care is essential to effective treatment of HIV infected individuals.

Coleman, Austin, Brach, & Wagner, (2009) state that there is increasing need to elaborate more specific frameworks of the integrated care model, specifically among complex diseases such as HIV. The biopsychosocial complexities of people living with HIV (PLWHIV) make it a particularly difficult disease to treat effectively. Studies from 2001 report that as many as 50% of a nationally representative sample of PLWHIV screened positive for a psychiatric disorder (Coleman et al., 2009). Previously published literature only includes a sparse number of detailed model descriptions for implementing mental health programs within HIV care. For example, (Feingold & Slammon, 1993) used a “Whole Life Model” which referred to a women-centered, family focused project that integrates mental health services with primary HIV medical care, obstetrical and gynecological care, and case management within one site. Nonetheless, this program served a very specific subset of HIV infected people, namely, women of color who may be pregnant. It is evident that additional studies on integrated care programs for people living with HIV are required.

Coleman et al., (2009) initiated the Alafia Project, a SAMHSA funded grant for underserved PLWHIV. This program implemented a comprehensive range of mental health and medical services (Coleman et al., 2009). A client centered framework was emphasized, such that care included the clients’ perspective on problems and solutions, considered the clients’ values, and worked collaboratively with the client to foster a shared understanding between client and treating clinician. Clinicians frequently ask clients for feedback about their experience in treatment and their assessment of how effective the treatment has been (Coleman et al., 2009). Furthermore, the Alafia Program strived to understand how a client’s personal identity may impact their perceptions, beliefs, and attitudes regarding their illness and expectations for treatment. This program is one of the few mentioned studies which implemented a comprehensive patient-centered approach to care. The program staff included a psychologist, a psychiatrist, three mental health clinicians and a case manager. All services were collocated onsite, which was imperative for the collaboration of the medical, psychiatric and social work teams. Professional development for the staff, such as peer supervision and team meetings, were essential in preventing burn out. Additionally, shared social activities outside of the workplace greatly contributed to sustaining positive relationships among health care teams. The central focus of treatment included the clients’ strengths and resources with the goal of helping clients reach levels of autonomy, competence, and confidence (Coleman et al., 2009).

Despite the comprehensiveness of the Alafia Project, the authors noted several challenges in implementing this integrated care model. Patients living with HIV were often reluctant to seek mental health treatment due to stigma related obstacles. There was limited space to accommodate clients who arrived late to appointments given that all treatment took place within a hospital setting, and cross disciplinary teams had to be careful not to duplicate services (Coleman et al., 2009). Although the Alafia project encountered some difficulty in implementing its program, this relatively recent model of care for PLWHIV sets the groundwork for the layers of care required to effectively treat this deeply in need population.

Chapter 2

Within the health care and mental health care arenas, individuals diagnosed with HIV represent a population of grave concern. Literature points to the fact that patients with HIV frequently present with a combination of complicating medical conditions including mental illness, substance abuse and additional chronic health problems (Treisman & Angelino, 2004; Grumbach, 2003). The presence of HIV among mentally ill populations is estimated to be nearly seven times greater than the general population (Weiser, Wolfe, & Bangsberg, 2004). Literature suggests that up to 50% of patients with HIV present with psychiatric disorders (Soto, Bell & Pillen, 2004). Individuals with mental illness have shown to have poorer health outcomes as indicated by health related quality of life measures (Sherbourne et al., 2014). This suggests that an integrated care approach to HIV treatment has the potential to improve physical health outcomes among HIV populations. For the purpose of this dissertation, integrated care can be defined as a systemic collaboration of primary healthcare with either mental health treatment and/or substance abuse treatment used to improve overall health outcomes and life quality for individuals with multiple health conditions (U.S. Department for Health and Human Services, n.d.). Previous literature on the relationship between integrated care for HIV patients and physical health outcomes is limited and the findings are inconsistent, suggesting a need for further research in this area.

Soto, Bell and Pillen (2004) conducted a review of the publications on HIV integrated care and identified several holes in the literature. They found that the majority of the studies on integrated care focused on retention and engagement with treatment. Soto, Bell and Pillen (2004) stated that, “The formative state of integrated care will be enhanced when local programs conduct internal monitoring and evaluation that captures….physical health, mental health and substance abuse outcomes” (p. 50-51). Their review therefore elucidates the need for additional HIV program evaluations that specifically examine mental health, substance use, and physical health outcomes.

Three different studies from the last 15 years directly examine the area of integrated care, and included physical health, mental health and clinical outcomes for interventions involving HIV treatment. Of note, these three studies’ findings conflict with one another. A study by Call et al. (2000) investigated the relationship between CD4 count (a type of white blood cells called T-cells, which fight viruses such as HIV. A higher CD4 count can hold off further complications and symptoms of HIV) and psychological and physical health outcomes measured on the 36 item Short Form (SF-36)  (Call et al., 2000). Although viral load has been associated with disease progression, little is known about the relationship between viral load and patient based outcome measures. Call et al., (2000) found that patients with lower CD4 cell count reported a decline in perceived physical health as indicated by lower physical component summary scores (PCS) on the SF-36. As expected, patients with higher viral load also endorsed more physical health decline. Meanwhile, viral load and CD4  were not associated with mental health symptoms as measured by the mental component summary scores (MCS) . After controlling for the effect of CD4 cell count on HRQOL, Call et al., (2000) discovered that viral load was an independent predictor of PSC scores, suggesting that CD4 and viral load may affect quality of life in separate and distinct ways.

Although this study did not reveal any relationship between disease progression and mental health outcomes, a study by Weinfurt, Willke, Glick, Freimuth & Schulman (2000) which included over 1,000 HIV infected participants with CD4 counts below 300 cells/uL revealed an association between both CD4 and viral load and overall health related quality of life. Specifically, they discovered that lower baseline viral load and increases in CD4 count were correlated with improvements in mental and physical health components on the Medical Outcomes Study HIV Health Survery (MOS-HIV) (Weinfurt et al., 2000). Of note, the authors discovered that changes in CD4 were more strongly correlated with improvements in quality of life than viral suppression. In contrast, a study by Badia, Podzamczer, Garcia, Lopez-Lavid & Consiglio (1999) explored psychometric performance of two Health Related Quality of Life measures; MOS-HIVand the QOL-HIV, among 558 HIV positive patients. While their results demonstrated a strong correlation of HRQOL with symptoms, they found no association between viral load and health related quality of life on either physical health or mental health measurements. Taken together, these inconsistent findings highlight the need for more research investigating the potential relationship between physical and mental health outcomes and viral load.

Viswanathan, Anderson and Thomas (2005) examined mental health and physical health outcomes for low-income adults receiving treatment from an HIV service center. The researchers aimed to compare Health Related Quality of Life (HRQOL) within an HIV population to general United States’ population norms as well as other health-affected patients with chronic conditions such as diabetes and hypertension. Immune status was measured with CD4 cell count and HIV RNA viral load. Health Related QOL was obtained using the SF-12, which was broken down into two parts, physical component summary (PCS) and mental component summary (MCS). A total of 86 surveys were included in the analysis. Results showed that average summary scores for HIV positive males were significantly lower than the general population. When compared to patients with diabetes, hypertension, and depression, HIV positive patients reported similar PCS-12 scores. HIV positive patients reported lower MCS-12 scores compared to patients with hypertension and diabetes, pointing to a greater need for mental health treatment for persons diagnosed with HIV. Clinical variables such as CD4 count revealed no association with PCS-12 scores; however, poor adherence to antiviral therapy was associated with lower MSC-12 scores, suggesting that medication adherence may be associated with mental health symptoms.

Although Viswanathan, Anderson and Thomas’ (2005) results imply a potential relationship between mental health outcomes and medication adherence, the directionality of this relationship could not be fully determined within their study. Unlike Call et al., (2001), Viswanathan, Anderson and Thomas (2005) were unable to find a relationship between physical health outcomes and disease progression. Nonetheless, they found that poorer adherence to HAART medication was associated with poorer mental health outcome measures. It is suspected that improved medication adherence leads to lower CD4 count (Wood, Hogg, Yip, Harrigan, O’Shaughnessy & Montaner, 2004); therefore, this study implies an indirect relationship between disease progression and mental health, which may be moderated by medication adherence. The variation in findings between these two studies further emphasizes the need for more research in this area.

A study by Whetten et al., (2006) looked at the effects of integrated care interventions for triply diagnosed populations presenting with HIV, substance abuse, and mental illness. This subgroup of HIV positive individuals is thought to be particularly vulnerable to negative HIV treatment outcomes due to the severity of their disease comobrbidity (Whetten at al., 2006). The study included a total of 141 participants who received integrated treatment for mental health and substance abuse for 12 months. Behavioral health interventions included individual counseling, group counseling and psychiatric treatment. Psychiatric symptoms of depression and anxiety were measured with the Brief Psychiatric Rating Scale( BPRS), while general functioning and emotional distress were measured with the SF-36.

The findings revealed that by 6 and 12 months there were significant reductions in global psychological distress as measured by the SF-36. More specifically, there were statistically significant reductions in depressive and anxiety symptoms as well as a decrease in substance use. Compared to medication status at baseline, patients were more likely to be using HIV and psychotropic medications at 6 months; however, these changes did not reach a level of statistical significance. By 9 months into treatment, patients reported fewer emergency room visits and a reduction in inpatient stays when compared to baseline. It was estimated that this saved the government approximately 1.28 million dollars in ER visits.

Despite such findings, the integrated care intervention evaluated by Whetten et al., (2006) did not yeild improvement in physical health outcomes among this population. The researchers propose that physical health outcomes may take longer to improve compared to mental health outcomes. Overall, the results of this study suggest that while an integrated care approach may be an effective intervention for HIV positive populations with complicating mental illness, one year of treatment may not be sufficient to improve both mental and physical health outcomes. Unlike the two previous studies, Whetten et al. (2006) did not include viral load or CD4 outcome measures. Although the findings of this study suggest that integrated care interventions can potentially improve disease progression, the researchers did not use a quantifiable measurement of disease progression such as viral load or CD4. Rather, they looked at hospital visits as a representation of clinical outcomes.

Taken together, these three studies highlight the complexity of the relationship between disease progression and physical and mental health outcomes among HIV populations. The inconsistency in their findings provide grounds for further investigation of this relationship and additional factors that may be mediating or moderating the relationship between physical health, mental health and disease outcomes. Since much of the data is also cross-sectional and correlational, there is a need for the examination of longitudinal data to better ascertain how and in what ways some of these relationships co-vary or have a causal basis.

Given the limited literature on physical and mental health outcomes in HIV care, another line of research has focused on broader quality of life (QOL) measurements as an attempt to understand the link between behavioral health interventions and general health outcome measures. This type of research attempts to demonstrate how physical and mental health symptoms relate to the complex construct ‘quality of life’ and has often focused on sociodemographic variables as predictors. Kowal et al., (2008) conducted a study examining pain related quality of life, depressive symptoms, and coping styles among 97 individuals living with HIV. More specifically, the researchers sought to identify sociodemographic, behavioral and psychological variables associated with overall quality of life among patients in an outpatient clinic. It was hypothesized that smoking and physical activity would be significantly associated with overall quality of life. Additionally, the researchers hypothesized that a diagnosis of depression would mediate the relationship between an individuals’ coping style and their quality of life. Quality of life was measured with the Medical Outcome Study Healthy Survey Short Form-36 (SF-36), which assesses both physical and mental quality of life and is frequently used to assess QOL among patients with chronic health conditions.

Findings revealed that symptoms of depression accounted for 15% and 5% of the variance respectively in mental health and bodily pain subscales on the SF-36. Task oriented coping was significantly associated with depression symptoms and bodily pain and depression symptoms mediated this relationship. Poorer physical health related quality of life was associated with worse disease outcomes indicated by lower CD4 count. Overall, the results of this study report two separate findings. The first being that HIV positive individuals with symptoms of depression experience poorer mental health related quality of life as well as greater levels of physical pain. The second finding reveals that lower general physical health quality of life is associated with worse disease outcomes. However, this study was unable to identify any relationship between mental health and disease outcome.

In contrast to the previous study, Brown, Stepleman and Bottonari, (2012) conducted an archival review of data from a clinic that provided medical and psychiatric services to HIV positive individuals. The researchers aimed to review the long-term effects of mental health treatment on medical outcomes among HIV positive individuals. Data was reviewed from 94 patients after two years of psychiatric treatment, which included therapy and or psychotropic medication. Medical outcomes included the total number of medical conditions, use of HIV medication, physician report of medication adherence, number of medications prescribed, AIDS diagnoses (met by CD4 count less than 200) and viral load. Findings revealed that patients with a history of physical abuse, sexual abuse or psychotic disorders were more likely to be retained in treatment. Patients with psychotic disorders were less likely to have multiple health problems and more likely to show better medication adherence. In general, patients receiving any form of psychiatric intervention were less likely to have comorbid health conditions. Overall, consistent use of psychotropic medications over the course of 2 years was associated with numerous positive health outcomes such as fewer additional health problems, greater use of HIV medications, fewer adherence concerns, and more likely to have an undetectable viral load. These findings imply that psychiatric services combined with primary care services may greatly improve physical health outcomes among HIV patients. However, it should be noted that the most psychologically distressed individuals showed better medication adherence and fewer physical health problems. It is possible that such patients were more closely monitored by integrated care teams due to more severe diagnoses and that patient-physician contact accounted for these positive treatment gains.

Overall, the results from the previous studies capture the varied and conflicting results surrounding integrated care interventions and their relationship to physical health, mental health and clinical outcomes. An additional concern within HIV treatment is the high rate of treatment drop out and poor medication adherence. Medication adherence refers to the accuracy with which a patient follows their prescribed medication regimen. Retention refers to the percentage of patients who are maintained in treatment. Retention and adherence can serve as additional outcome measures for patients receiving treatment for HIV because individuals who regularly attend their appointments and maintain their medication regimens are more likely to show decreased viral load and increased longevity (Gabriel & Solomon, 2014; Giordano et al., 2007; Tripathi, Youmans, Gibson, & Duffus, 2011). Retention and adherence may therefore be conceptualized as moderators when considering the effects of integrated care interventions on health outcomes, and thus, literature investigating these constructs is relevant to the examination of integrated care. The use of more recent Highly Active Anti-Retroviral Treatment (HAART) has allowed for increased longevity among people living with HIV (Konkle-Parker, Erlen, Dubbert, & May, 2012); therefore, factors such as physical and mental health outcomes are of growing concern to improving overall functioning and health among HIV positive individuals.

Despite increased longevity with HAART treatment, recent publications address persistent concerns regarding poor medication adherence and retention in care among persons diagnosed with HIV. Recent data proposes that up to 50% of HIV patients within the U.S. are not retained in care (Konkle-Parker et al., 2012). Several studies have attempted to understand the factors associated with retention in HIV treatment as well as specific interventions aimed to improve retention. Several of these interventions incorporate aspects of the integrated care model by employing mental health treatment as well as social supports to foster greater adherence and treatment follow-up.

Within the HIV literature, numerous studies have established a baseline rate of retention and adherence among various populations and settings.  Fleishman, Yehia, Moore, Korthuis, Gebo, & HIV Research Network, (2012) completed a longitudinal study to examine the rate of establishment, retention, and treatment follow up over time. The sample included 12 sites within the U.S. and a total of 22,984 participants over the course of 8 years. Twenty-one percent of the participants never established HIV treatment, meaning they allowed 6 months or less between initiating and ending treatment. 32% of the sample was lost to follow up, meaning they missed outpatient visits for 12 consistent months or longer. Only 20% of the total sample was continuously maintained in HIV care, meaning they attended regular clinic visits. The recency of this study as well as its large sample size reflect the importance of the issue of retention among HIV patients. Fleishman et al.’s (2012) findings imply that only a minority of HIV positive patients are being adequately retained in care.

While very few studies have examined humanistic outcomes related to attrition (Hill and Kavookjian, 2012), a vast portion of the literature has looked at sociodemographic characteristics associated with adherence and retention. Haltkins, Palamar, and Mukherjee (2008) evaluated person and treatment characteristics related to HIV medication adherence among 300 HIV positive men. This study assessed participants over 12 months for adherence to medication treatment and examined behavioral and sociodemographic factors associated with adherence. They found that being black, younger, and having a history of substance abuse were all associated with poorer adherence. Additionally, they found that adherence rates decreased steadily and progressively over the study, with approximately 65% adherence to medication over the course of 12 months, suggesting that as patients improve they are less likely to follow their treatment regimen with precision.

A study by Tedaldi et al., (2014) looked at retention in HIV care within one year of initiating ART treatment. The researchers aimed to identify health and sociodemographic factors associated with retention in HIV treatment. It was predicted that baseline CD4 count, baseline viral load, insurance status and drug injection history would be associated with retention in HIV care. The sample included patients from eight different clinics in the United States. Of the 1,441 patients included in the study, 85% were retained in care during the first year. Retention was higher for individuals with baseline CD4 counts and non IV drug users, while having public insurance and missing baseline CD4 count predicted poorer retention. The results from this study imply that there is a potential relationship between disease outcomes and retention; however, the directionality of this relationship cannot be fully determined by the results.

Konkle-Parker, et al’s (2012) pilot study looked at adherence to HIV medication among patients within a public health clinic who were treated with a Motivational Interviewing technique that was designed to improve medication adherence. Adherence was defined as having taken at least 90% of prescribed medications within the last three to four weeks. When compared to treatment as usual, the study found that medication adherence increased to approximately 82% compared to 50% -70% which is the average in most published literature (Hill & Kavookjian, 2012; Bova et al., 2005). However, given the small sample size of only 56 subjects, there were no significant effects of medication adherence for the Motivational Interviewing versus control group. Of note, the researchers found that there were higher rates of treatment drop out for depressed participants. In general, there were small to moderate effect sizes of the intervention for the majority of the outcome measures including the number of missed medical visits and change in CD4 count as well as viral load. Taken together, these findings suggest that Motivational Interviewing techniques may help to bolster medication adherence, however, this intervention may not yield significant improvements in adherence and retention among individuals diagnosed with mental illness.

While numerous studies have attempted to understand the factors associated with HIV retention and treatment adherence, several issues exist within the literature. Firstly, each study defines “retention” and “adherence” in its own terms, making it difficult to assess globally. Secondly, the directionality of the relationship between medication adherence, retention, clinical outcomes and sociodemographic factors has not been clearly defined because these variables appear to have complex interactions with one another. The dynamic interplay between HIV, mental illness, medication adherence, retention and physical health outcomes leave much to be understood about how best to treat this population. Additional research is needed to demonstrate how integrated care interventions effectively treat HIV patients.

The purpose of this archival study was to further contribute to the existing literature evaluating integrated care approaches to HIV treatment in community based settings. More specifically, this study examined data from 204 HIV positive patients treated at two integrated care clinics run by the same agency. Intake and follow-up data was available for participants from the last three years. For the purpose of this study, integrated care was defined as simultaneous medical health, mental health, psychiatric treatment, dental care and social support within an HIV clinic.

---