infected with HIV have their infections under control, Valdiserri
called upon participants to ease the way for Americans to get
tested, connect with care and stay on antiretroviral therapy.
Permanent housing with intensive case management and peers
who can help patients navigate the health-care system and thus
get into care and stay there could help, he concluded.
HIV infection is often just one of the problems the HIV-positive
face, said psychologist David Holtgrave, PhD, chair of the
health, behavior and society department at the Johns Hopkins
Bloomberg School of Public Health.
Urban gay men, for example, also have very high rates of
distress, depression, attempted suicide, childhood sexual abuse,
substance abuse and partner violence. These issues complicate
and worsen the HIV crisis, said Holtgrave.
“If you look at recent sexual behavior that could put one
at risk of HIV transmission or infection, there’s a strong
relationship between risk behavior, HIV prevalence and a
number of psychosocial health issues,” he said.
Prevention efforts must simultaneously address all these
challenges while also taking a lifespan perspective, Holtgrave
said. Early life experiences, such as parental abuse, homophobia
and school bullying can make people more vulnerable to HIV
later in life, he said.
That said, Holtgrave added, most people with multiple
psychosocial challenges don’t contract HIV.
“When we’re thinking about developing interventions, we
need to build on strengths and learn lessons from those who
have addressed a number of these challenges,” he said.
In addition to supporting behavioral changes people are
already making, prevention efforts should also remove barriers
that keep people from making changes they want to make
and achieving resilience. In one Washington, D.C., project, for
instance, women were motivated to use female condoms but
couldn’t until they were trained how.
But it’s not enough to change individuals’ behavior: The health-care system must also keep up with emerging science about the
psychological factors that influence disease, said psychologist
Robert M. Kaplan, PhD, director of the Office of Behavioral and
Social Sciences Research at NIH.
One hundred years ago, he said, the idea that germs caused
almost all disease dominated the health-care system, which
responded by building hospitals and training residents to fight
germs. In the 1960s, epidemiological advances revealed that risk
factors such as high blood pressure or cholesterol could also
cause problems, and the health-care system oriented itself to
identify factors that cause chronic disease.
“Science has moved on again,” said Kaplan. Now, there’s
a new understanding that social and environmental factors
also play a critical role in determining health outcomes. “The
difficulty is that we’re still running a health-care system that
doesn’t recognize that quite yet,” said Kaplan.
The nation also needs to invest much more heavily in public
health, said Kaplan. Despite the increased life expectancy that
past public health initiatives have brought, he said, the public
health system is now severely underfunded. A 2012 Institute
of Medicine report, “For the Public’s Health: Investing in a
Healthier Future,” offers one potential solution: taxing health-care transactions.
“That’s a remarkably gutsy thing to say in an era when
people say that anything that involves the word ‘tax’ is dead on
arrival,” said Kaplan.
The conference’s second half was devoted to small-group
discussions aimed at developing recommendations for the D.C.
Department of Health, D.C. Department of Mental Health,
District of Columbia Development Center for AIDS Research,
Center for AIDS Research at NIH and others.
Recommendations included expanding prevention messages
and testing to older adults and others who aren’t traditionally
considered high risk; focusing more on helping people who test
negative to stay that way; investing resources in housing, mental
health services and substance abuse treatment to help people
stay in care; and developing “red carpet care” in which peers
would offer advice, accompany patients to appointments or even
provide intensive case management. Participants also called for
developing a website that would bring together information on
all types of services — HIV/AIDS, housing and mental health
programs, for example — all in one place.
Participants also urged their colleagues to find ways to
overcome the stigma associated with HIV. One possibility is
establishing “ubiquitous care,” which would allow patients to
pick up their medications at drop-in centers or other places
besides HIV clinics, said psychologist Ellen Stover, PhD, a senior
policy leader at the National Institute of Mental Health.
“It doesn’t say HIV or infectious disease, so there’s not the
stigma,” said Stover.
Another strategy would be to start treating HIV like other
chronic diseases by incorporating exercise and good nutrition
into treatment regimens, she said.
The D.C. Department of Health will consider all the
recommendations, said Director Mohammad N. Akhter, MD,
adding that some efforts are already under way.
For example, the city is developing patient-centered
medical homes for HIV, which will bring HIV, mental health,
substance abuse, social services and other programs together
on one campus, he said. Other priorities include exploring
ways technology can improve prevention efforts and treatment
adherence and improving cultural competence among health-care providers. n
Rebecca A. Clay is a writer in Washington, D.C.
MONITOR ON PSYCHOLOGY • JULY/AUGUST 2012