It is currently not possible to carry out most of the AIDSTAR-One recommendations in most parts of the world, and the vast majority of people who inject drugs are not in treatment for their addictive or nonaddictive mental illnesses. While mental disorders are common, accounting for 13% of the total global burden of disease, adequate treatment is often not available [14
]. In high-income countries, there is a 35–50% treatment gap for mental disorders. In low- and middle-income countries the gap is even more pronounced, with between 76–85% of those in need of services not receiving treatment for mental disorders [14
]. Low- and middle-income countries have not only the largest treatment gap for mental disorders, but also the highest burden of HIV/AIDS, with sub-Saharan Africa alone accounting for 69% of the entire population of people living with HIV/AIDS [55
]. Still another barrier to treatment is that drug use disorders are often criminalized rather than treated [56
]. With the clear association between mental disorders and HIV/AIDS and the enormous gap in mental health treatment services, especially in low- and middle-income countries, there is an obvious need for improved HIV and mental health interventions.
In addition, virtually every funding stream for people with HIV/AIDS spends very little money on the treatment of mental disorders. Factors that explain this include the lack of recognition and the stigma of mental illnesses and the low priority given to these disorders by country leadership (both public and private), including in the USA, and by the HIV experts and scientists who drive the HIV treatment and research agenda. They may share a common misperception that mental health services are costly, derived from basing their estimates on per capita costs of psychiatric care, even though many services are now provided by community workers through an approach called task-shifting [57
Another concern in relation to the specific needs of people who inject drugs is the availability and legality of opioid substitution therapy (OST). Of the five countries that have megaepidemics of HIV among PWID—Russia, China, Ukraine, Vietnam, and Malaysia—OST is available in all but Russia. In Russia, methadone and buprenorphine remain illegal for use in addiction treatment [58
]. However, even in those countries where opioid substitution therapy is legal, OST is offered to less than 5% of patients that are in need of drug treatment. While these percentages are very low, they are on the rise and countries, particularly those with megaepidemics, with the exception of Russia, are increasing the number of people receiving OST [58
In high-income countries, OST is generally more available. By 2000, all but two European Union countries (Cyprus and Estonia) had introduced opioid substitution therapy, providing drug treatment for approximately one third of the PWID. It is estimated that between 1998 and 2004, 15% to 25% of addicted opioid users were receiving opioid substitution therapy [59
While availability of OST is often the first step to treating PWID, maintaining drug treatment is also important. In the Mackesy-Amiti et al. [18
] US-based study of PWID, while 68% had received some form of substance abuse treatment in the past, only 5% were currently in treatment and only 10% reported current 12-step program attendance.
Beyond the treatment of opioid addiction with OST and the provision of clean injection equipment, it is difficult to identify effective and tested treatment models for HIV positive PWID with the common psychiatric comorbidities that we have discussed. Our own search through the Columbia University Libraries article database and PubMed revealed a dearth of peer-reviewed articles on models for providing care for both opioid addiction and other mental illnesses regardless of HIV status. Rarer still are articles that concern non-Western countries, as other reviewers have noted [17
]. Even fairly comprehensive articles on the subject of illicit drugs and HIV treatment seem to handle mental illness as merely another comorbidity that includes its own set of prescription drugs with specific interactions, rather than addressing the absence of systems to deliver mental health care [60
We therefore also searched the gray literature in the hopes of finding studies, technical reports, and other publications that could aid the search for information about active treatments in the field. Some of the largest organizations with the greatest reach financially and logistically do not include much information on mental health in their reports. Organizations and programs like UNAIDS, the World Health Organization, and the US Government's President's Emergency Plan for AIDS Relief (PEPFAR) often mention mental health briefly and in terms of the broader psychosocial aspects without going into psychiatric diagnoses and the options to treat them [10
Some smaller organizations have been making strides in treatment for HIV positive PWID and in reporting on methods of treatment. For example reports from the Global Initiative on Psychiatry are often in-depth and discuss the treatment options, or lack thereof, with a focus on mental health and HIV globally, in such places as Eastern Europe [66
], Kazakhstan [67
], and Tajikistan [68
]. If there is to be any progress in the integration of mental health treatment options for HIV positive PWID, it will take a concerted effort on the part of all organizations to include and incorporate the screening for and treatment of mental disorders into their activities.
Extrapolating from the existing literature on treating comorbid substance use and nonaddictive mental disorders, a number of recommendations can be made for meeting the mental health needs of people who inject drugs. To the extent possible it works best to have one-stop care where all services are integrated within the same program and team meetings take place with all providers present [69
]. This would include the integration of medical care for those programs that serve HIV positive populations. Use of a shared electronic record in this setting further enhances integration because providers can rapidly see one another's interventions. Mental health services that can be provided in integrated settings include comprehensive assessment and differential diagnosis; medications for both psychiatric and substance use disorders; psychotherapies, especially motivational interviewing and cognitive behavioral therapy; psychosocial support and social services; a thorough assessment of drug interactions and toxicities; and a comprehensive way to monitor people with multiple chronic relapsing disorders.
Other possibilities to achieve at least some degree of integration of services, in descending order of the likelihood of success, are programs colocated at the same site even though they are not integrated, case managers who escort patients from one service to other unrelated services, and having clinicians in unrelated settings share information and clinical decision making. Because buprenorphine treatment is more realistic to provide than methadone in medical settings, use of this agent for opioid substitution therapy can also facilitate integration of services. Screening consenting clients for common mental illnesses in methadone maintenance programs and those that offer clean injection equipment could help facilitate comprehensive care if such programs are linked with and make referrals to mental health services.
Achieving integrated services will require more successful strategies for funding the treatment of mental disorders, especially in low and middle-income countries; new approaches to overcoming systemic barriers to integration, such as the tendency seen in the United States to separately fund and operate services for addictive and nonaddictive mental disorders [70
]; and a commitment by the largest global health care organizations to include the diagnosis and treatment of mental disorders in HIV/AIDS and other treatment guidelines and programming.