1. 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

2. Conflict of Interest
No conflicts of interest to declare

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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