Deadly trio: mental health – HIV - drugs Integrating Substance Abuse Treatment into HIV Services Across the Treatment Cascade Deadly trio: mental health – HIV - drugs L Michel, MD, PhD Pierre Nicole Center Inserm CESP/U 1018 French Red Cross Paris, France

Conflict of Interest No conflicts of interest to declare

Mental health among people who use drugs (PWUD) PWUD are particularly exposed to the burden of mental health disorders Up to 40% among people who inject drugs When HIV, mental illness and substance use disorder occur at the same time: major impact on quality of life, stigma, treatment outcomes, burden of illness and risky behaviours mainly anxiety and depressive disorders, suicide

Mental health among key populations Stimulants: frequent psychiatric complications (psychotic syndrome particularly) and associated with increased sexual risk behaviours Psychiatric disorders worsens the prognosis of substance use disorders and vice-versa  Prognosis worsens for the 3 illnesses, with poorer treatment outcomes and higher risk of transmission  All outcomes have to be considered at the same time mainly anxiety and depressive disorders, suicide

One major recommandation  Consider a comprehensive, multidisciplinary, integrated approach, including mental health assessment and care for populations exposed to HIV (Altice 2010, Patel 2016) but keep in mind that: Around 50% of people with severe mental health disorder in the general population are untreated (Kreyenbuhl 2009): screening and inclusion in treatment strategies are necessary Once in treatment, dropout rate is around 50% (Hasin 2015, Hunsley 2013): retention in treatment strategies also necessary

Strategies in France? Integrated approach: Consultation and treatment for substance use disorder are totally free: no ID or medical insurance requested, can be anonymous Once HIV-infection screened, all HIV consultation and treatment are free Access to mental health services is also free Around 500 drug/alcohol use disorder treatment centers in the community + hospital-based services One place treatment for those with the trio “mental health disorder-HIV-substance use disorder” promoted  Active networking to coordinate interventions

Situation in Vietnam Access to psychiatric care is limited, complex and not cost-free even with health insurance Treatment of substance use disorder is limited to methadone provision In Haiphong, doctors in methadone clinics never prescribe any psychotropic drugs Same situation for HIV clinics

DRIVE project in Haiphong, Viet Nam NIDA RO1 DA041978 / ANRS 12353 DRIVE study 188 people who inject drugs assessed for psychiatric disorders (MINI-DSM 4 criteria) after 12 months follow-up including CBO-based interventions 2 died from suicide and 2 from overdose during 12 months follow-up 11.4% reported a past suicide attempt Only 17.4% had a medical insurance Increasing rate of methamphetamine use, associated with sexual risk behaviours

DRIVE project in Haiphong, Viet Nam NIDA RO1 DA041978 / ANRS 12353 DRIVE study 25.5% presented at least 1 psychiatric disorder and more than 10%, 2 or more 10.1% a lifetime psychotic syndrome (methamphetamine use) 12.2 a current major depressive episode 80% of the 49 PWID referred to a psychiatrist “on-site” met him But none came-back or acceded to a treatment  Main reasons: cost of the treatment and stigmatization associated with care in a mental health department

What about the young drug users? 584 YWUD,16-24, recruited in Hanoi, HCMC and Haiphong through CBOs Prevalence of HIV: 6.3%, of HCV: 9.4% 16-19 using mostly cannabis/Met, no HIV/HCV (<1%) 20-24 polydrug users, Met, Heroin, Ecstasy, Ketamine, injecting (23%), concerned with HIV (10%) and HCV (15%) 51% with mild to severe depression

Perspectives-conclusions ? Develop comprehensive approaches to face this deadly trio simultaneously Different interventions at the same place and at the same time Develop pilot projects to explore adapted strategies CBO empowerment Screening, treatment as prevention, quick access to opioid agonists, harm reduction strategies targeting methamphetamines users are crucial Consider also alcohol use disorders