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GLASGOW, Scotland -- HIV clinicians need to be aware that mental health affects every stage of HIV diagnosis and treatment, and manage issues just as they would any other comorbid condition, experts said here.

The prevalence of mental health issues, mostly depression, in people living with HIV may be higher than either the general population or even others with long-term chronic health issues, and clinicians need to be screening for these on a more regular basis.

Chloe Orkin, MD, of Royal London Hospital and chair of the British HIV Association (BHIVA), suggested that in addition to the well-known 90-90-90 AIDS targets, a new "90" needed to be added: 90% good health-related quality of life.

"Often, we see the physical and psychological as distinct, but we need to be aware of people's mental health," she said at HIV Glasgow: The International Congress on HIV Drug Therapy. "As physicians, we need to become stigma-aware."

Fiona Lampe, MD, of University College London, went through a review of the literature on HIV and mental health issues. The results mainly focused on depression, because that was most frequently studied, she said.

One study examining undiagnosed depression via clinical interview found a prevalence of 21.2%. Yet a separate study found that only 8.5% of people living with HIV were receiving treatment for depression, Lampe said. In this study, more than a third of patients had evidence of depression, according to a symptom questionnaire, but 45% of them were not receiving treatment.

These mental health diagnoses often appeared to occur after patients were diagnosed with HIV, Lampe added, with one study finding this to be true in 70% of cases. Interestingly, when one study compared a group of HIV-positive individuals with an age-sex matched comparison cohort, there was a higher use of psychotropic drugs, as well as a higher prevalence of mental health problems in the HIV group, even prior to diagnosis.

Moreover, people living with HIV compared unfavorably with those who had other long-term health conditions, such as diabetes or rheumatoid arthritis. Several studies found a lower quality of life among people living with HIV, and those with HIV had the poorest mental health, even after adjustment for confounders.

"This gives some indication that HIV may have a different impact from other long-term health conditions in mental health, and factors such as stigma may be a big role here," Lampe said.

She also highlighted socioeconomic context as a potential factor, citing a more than fourfold increase in the prevalence of depression among "financial hardship" groups of people living with HIV in one study.

Orkin then went through the BHIVA's "mental health audit," which focused this year on whether or not clinics were asking patients about changes in mental health, as well as alcohol and recreational drug use, including chemsex among gay or bisexual men.

First, they asked the clinics themselves about these procedures, and about three-quarters of clinics said that they asked all adults with HIV about their mental health or psychological well-being, and alcohol and recreational drug use, though only 30% asked about chemsex. However, only a quarter of clinics said they used a standardized assessment tool or questionnaire in their mental health assessment.

Then the BHIVA examined 40 sets of notes from each clinic to see whether the pathways were actually working. Over the last 18 months, they found that 66% had asked about psychological well-being/mental health or documented this specifically. Among those asked, about 60% said they were "coping well," with about 17% saying they "had some need for info/support" and 5% likely having a psychiatric illness.

About half of HIV services had an identified clinical lead for psychological support, Orkin said, though she noted that these varied widely across clinics.

She closed the talk by reminding healthcare providers about stigma -- and pointing out that both mental health issues and HIV are two stigmatized conditions, and to be aware of language, as well as body language, around these patients.

"It's not an additive stigma, it's an exponential increase in stigma," Orkin said. "It's really important as healthcare professionals to be part of the solution rather than exacerbating the problem."

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