Designing Health Care Policy and Systems to Reach and Retain Those with Severe Mental Illness in HIV Prevention and Care Efforts: Insights from Ten US States

Abstract

People with severe mental illness (SMI) have a higher risk of HIV infection than the general US population. Despite this increased prevalence, robust efforts to engage this population in routine HIV testing, timely linkage to and ongoing engagement in care, and treatment adherence have been challenging. We sought to identify solutions at the health care delivery system level, as well as policies at the state and local level, that might affect HIV-related health outcomes for this key population, particularly those that featured integrated care models. We recruited key stakeholders in 10 states within the United States, based on HIV prevalence and approaches to HIV and mental health services. From June 2018 to May 2021, we conducted 64 in-depth interviews with key informants which lasted 45-90 minutes. Interviews were recorded and transcribed. Informants included state and county-level public administrators in HIV and/or behavioral health; HIV and behavioral health clinic administrators, medical providers, and case managers; service providers at non-profit agencies serving those with SMI and/or HIV; and academics. Interview topics included HIV testing policies and systems, HIV linkage and treatment policies and organization of SMI and HIV health care systems, funding streams, recent care integration efforts, and electronic data sharing. Transcripts were coded for broad themes, and segments were further reduced for key content. Key factors leading to improvements in HIV-related outcomes for those with SMI include state and local efforts to integrate physical and mental health services, funding requirements for grantees to perform HIV testing, shared electronic health records, ability to combine funding streams, expansion of telehealth services to deliver psychiatric and behavioral health care, and charismatic leaders at the state or local level championing care integration. Fragmented and decentralized physical and behavioral health care systems that disincentivized care integration, policies that limited data sharing, stigma, a depleted workforce, and a lack of collegial working relationships between behavioral health and infectious disease leaders were perceived barriers to improved HIV outcomes for those with SMI. Scaling up facilitators of implementation and addressing the present challenges has the potential to promote successful implementation of integrated care models and positively impact the health and well-being of individuals living with HIV and SMI.

Keywords: Behavioral health; HIV; Health care delivery; Integrated care; Severe mental illness; Telehealth; Workforce burnout.