Psychology, HIV/AIDS and Opportunities in Integrated Care
About the experts:
Eugene Farber, PhD, is a professor of psychiatry and behavioral sciences in the Emory University School of Medicine. For over 25 years, Dr. Farber has conducted clinical activities, teaching/training and research focusing on the psychological aspects of HIV. Among his professional interests is the integration of behavioral health services in HIV primary care settings.
Fayth Parks, PhD, is an associate professor of counseling and licensed psychologist in the department of Leadership, Technology and Human Development at Georgia Southern University. She focuses on rural HIV-related phenomena within healthcare contexts and the social environment when contrasted with urban frames of reference. Dr. Parks serves as 2017 chair of APA’s Ad Hoc Committee on Psychology and AIDS (COPA). Twitter: @faythparks
Leah E. Squires, PhD, is a clinical psychologist at the Washington, D.C., VA Medical Center (DCVAMC). She provides integrated HIV mental health services, as well as consultation for the care of individuals with HCV. She is coordinator of the National Liver Disease/ HIV Psychology Fellowship Program for the HIV, Hepatitis and Related Conditions Program of the VA Clinical Public Health/Office of Public Health. Dr. Squires’ postdoctoral training was supported by the Minority Fellowship Program of the American Psychological Association. She completed internship at the DCVAMC and attained her doctoral degree from Boston University.
Fayth Parks: In 1989, my older brother and only sibling died from AIDS. I was very confused, and angry, and sad about my brother’s death, and at the time I was working on my doctorate degree at the University of Illinois in counseling psych. I vowed to stay active in fighting the epidemic. All along in my career I’ve done something that related to HIV/AIDS.
Leah Squires: During my first career, which was as a performing artist living in New York City — that coincided with the early years of what we now call our highly active anti-retroviral therapies...I’ve always had an interest in HIV and health disparities, and found that to be kind of where my passion lies within psychology.
Eugene Farber: I remember we were reviewing a protocol for the combination anti-retrovirals, and the physician running the meeting — there was a bit of a kick to his description of these protocols... I turned to him and I said, “You seem to think there’s something here,” and he sort of smiled and said, “Yeah, I think so.” And within a year or so, the transformation occurred, and then we entered an era of holding our breaths, but also an era of new hope.
Hannah Calkins: The stories you just heard came from three psychologists who have dedicated their careers to providing mental health services to people with HIV.
I’m Hannah Calkins, and on this episode of Progress Notes, we’ll hear more from them about the work that they do; the role that psychologists can play in HIV care; and how that role can be replicated in integrated care environments across the health care spectrum.
Fayth Parks: HIV/AIDS poses many unique challenges which the science and practice of psychology are uniquely qualified to address.
Hannah Calkins: This is Dr. Fayth Parks, a licensed counseling psychologist and associate professor at Georgia Southern University in Statesboro, Georgia. She’s been involved in HIV prevention and outreach activities professionally and as a community volunteer for more than 20 years. She’s a founder and chair of the Rural HIV Research and Training Conference. This year, Dr. Parks is also serving as the chair of APA’s Ad Hoc Committee on Psychology and AIDS, or COPA.
Fayth Parks: One of the issues is HIV and psychiatric comorbidity. Research shows that HIV infection overlaps with major mental disorders such as major depression; depressive disorders; and other more serious mental illness issues. And of course the opioid epidemic is making the battle right now against HIV/AIDS much more difficult.
Leah Squires: You know, a lot of the mental health risks for people with HIV are the same as for people living without HIV.
My name is Dr. Leah Squires. I’m a clinical psychologist at the Washington, DC, VA Medical Center.
Hannah Calkins: Dr. Squires provides integrated mental health services and consultation for people living with HIV. She’s also the national coordinator of a VA psychology fellowship program for psychologists training in HIV, hepatitis, and related conditions, and she holds a faculty appointment in George Washington University’s department of psychology.
Leah Squires: We do see higher rates of depression among folks with HIV. The things I see most frequently in my office here are depression, stress management or anxiety, and then just a lot of complex trauma history. And at times that impacts engagement in care.
Eugene Farber: From a medical standpoint, HIV is very treatable.
I’m Eugene Farber, and I’m a clinical psychologist. I’m based primarily in an HIV primary care setting — a large urban HIV clinic.
Hannah Calkins: Dr. Farber is the director of behavioral health services at the Grady Infectious Disease Program in Atlanta. He’s also a professor in Emory University’s department of Psychiatry and Behavioral Sciences, where he directs the department’s internship in health services psychology.
Eugene Farber: People who get on therapy at the right time — their life expectancies are similar to people who aren’t living with the illness, assuming they don’t have certain comorbidities. But that doesn’t mean that people aren’t still dying, and there are regional disparities in this.
Hannah Calkins: According to the Centers for Disease Control and Prevention (PDF, 285KB), the southern United States (including Washington, D.C.) has the highest rates of HIV infection, illness and deaths in the country.
Dr. Farber’s clinic in Atlanta is largely funded through the Ryan White Program. This program provides a range of core and support services, including mental health care. Dr. Farber says that while of course it’s critical to treat mental health problems in people with HIV, like depression, anxiety, and serious mental illness, it’s also important to provide broader support to ensure that patients are retained in care and adherent to their medication regimens. Patients who don’t have mental health issues can benefit from this support, too.
Eugene Farber: In this era of HIV as a chronic illness, we want to focus on behavioral interventions that promote health and wellbeing. So, for instance, our program at my clinic, we provide comprehensive mental health care, but we also have a wellness track. So that somebody who is living with HIV but doesn’t have a mental health disorder, they can still attend programs that are focused on helping to promote health and wellbeing, and self-care, those sorts of things.
Leah Squires: A lot of the folks who receive care here are what we would consider to be a population that’s experiencing health disparities.
Hannah Calkins: Dr. Squires at the VA Medical Center in Washington, D.C., observes a challenging confluence of factors influence her patients’ engagement in care.
Leah Squires: We serve a predominantly African American population here. Within the VA a lot of our veterans have great access, in terms of access to all the FDA-approved medications, often at very low to no cost; really passionate providers — you know, the VA is the largest provider of HIV care across the country and so I think individuals receiving care here may look very different from individuals receiving care in the community, in the sense of some of the access concerns. At the same time, we have a lot of individuals who still have difficulty because of some structural inequalities or inequities, where it requires multiple busses to get here for their medical appointments, and it requires taking time that they may not have as paid leave from their jobs. And so there are still challenges to engagement in care for some of the veterans that we serve here.
Hannah Calkins: There are other challenges, too — not all of them veteran-specific.
Leah Squires: The word that keeps coming my mind is the stigma of HIV. And for some of the veterans I work with, the stigma of their sexual orientation. The racism and discrimination they’ve experienced as people of color. And how those experiences may influence their engagement in care, influence their quality of life outside of the medical center.
Hannah Calkins: Both Dr. Squires and Dr. Farber say that it’s important for clinicians to be mindful of structural factors without generalizing or making assumptions about their patients’ lives and experiences.
Leah Squires: What I try to do in my clinical work is spend a lot of time gaining an understanding of the individual’s experience of themselves and also their experience of living with HIV. Something I’ve observed in just working in this VA is that depending on whether a veteran was diagnosed during their military service or afterwards; the era of service; all of those factors can kind of influence how they experience becoming HIV positive.
Eugene Farber: It’s very important to understand the individual who is in front of me, in terms of the multiple and multi-layered factors that have influenced their experience. All of these are things that I need to understand because they influence perceptions of all kinds of things, including the clinic that they walk into, where they are asked to entrust care providers with their lives; their experience of me; their attitudes about coming in for mental health care, if that’s what they’re there to see me for; their attitudes about medical care systems and what they have to offer; and the degree to which medical care systems can be trusted.
Hannah Calkins: Dr. Farber is referring to the long and difficult history of marginalization, fear, and uncertainty that many people with HIV have experienced, particularly during the earlier years of the HIV/AIDS epidemic. For the same reason, Dr. Squires has this advice for her trainees and colleagues interested in working with people with HIV:
Leah Squires: Get to know the community and know the history of HIV and HIV care. Being familiar with some of the history of HIV and HIV activism perhaps or HIV policies or laws and thinking about how that might have impacted a person who is sitting with you in the office. You may not be necessarily need to explicitly discuss it but being able to have that context so they don’t have to explain it all you, similar to any other area where you may not have a lived experience but that could be very relevant to someone’s mental health, trying to be able to gain enough knowledge so you can communicate about it intelligently and empathically but also not jumping to conclusions.
Hannah Calkins: The mission of APA’s ad hoc Committee on Psychology and AIDS, or COPA, includes facilitating links between APA, researchers, and other organizations to help coordinate and improve HIV-related mental health services.
Dr. Parks, who is chair of COPA, says the committee started out as a task force in 1987, and in 1989 it became an ad hoc committee that’s been reauthorized every five years since.
Fayth Parks: The six-member COPA committee is comprised of the practitioners, educators, advocates, early career, midcareer and senior career psychologists who have an interest and a focus on HIV/AIDS. And the committee has existed for 25-plus years. And COPA continues to fulfill its goals of the strategic plan, which of course includes continuing to provide direction and oversight to APA on HIV/AIDS advocacy and policy issues. Also, I wanted to make sure to be clear about the relationship in regard to practice, because certainly we’re dealing with evolving challenges around the epidemic. Behavioral and biomedical integration into HIV prevention and treatment is also a focus of the committee.
Hannah Calkins: At the 2017 APA Convention in Washington, D.C., Dr. Parks co-chaired a symposium titled “Past, Present and Future of HIV/AIDS Science and Practice in Psychology.” Dr. Farber also presented his work as part of this symposium. Drawing on his experience working in an HIV primary care clinic, he explained that psychology has many contributions to make in health care settings across the board.
Eugene Farber: My main objective was to say, psychology has increasingly defined itself as a health service discipline as opposed to a mental health discipline, so it’s broadened its conceptualization, and that psychology has something to bring to the whole spectrum of health and illness. The whole objective was to say, this is what we’ve learned from actually doing this in HIV, and this is how it can apply more broadly to psychology as a health service discipline. So what I described as ways of thinking about psychology in HIV is broadly applicable in primary care, and cancer care, and diabetes care, surgical — all of it. That is, we have opportunities as clinicians to address the kinds of behavioral health problems that make it less likely for people to get what they need and follow through with their health care, and that’s the clinical side, but then that we also have a very powerful role as consultants to medical care providers to help them deal with the behavioral aspects of the work that they do. We also, to the extent that we’re trained or have learned to do administration, our backgrounds allow us to think about things like, how do we create a culturally responsive care environment as administrators? How do we set up environments of care so that people want to come and want to get their care and stay in care? How do we influence messaging around staying adherent to treatments that increases the likelihood that people will take things as they’re prescribed and do it consistently? We’re really the only behavioral health discipline that’s explicitly trained in research as part of our training. And so when it comes to evaluating medical systems, when it comes to researching systems of care or models of care, we’re in a good positive to inform that as well.
Hannah Calkins: Dr. Parks agrees, and emphasizes the responsibilities and opportunities that psychologists have in HIV prevention and intervention efforts.
Fayth Parks: So it’s not just about biomedical care. There is the behavioral intervention piece where psychologists play a vital role as partners to help advance care over the course of a lifetime, because we’re now talking lifetime.
Hannah Calkins: Dr. Parks, Dr. Squires and Dr. Farber provide three different but convergent examples of how psychologists can partner with clinics, institutions and organizations to serve people with HIV, improve patient outcomes and support further integration of mental health services into primary care.
Eugene Farber: You know, I fell into it, and I’m glad I fell into because it’s been incredibly rewarding and meaningful and both the people I’ve met that I’ve had the good fortune to be a provider for and also the people that work in HIV are pretty inspiring. It’s a very rewarding area of psychology to be in.
Leah Squires: I love my job. I can honestly say that every day I do something that is really interesting, and inspiring, and challenging, and that I wouldn’t keep doing it if I didn’t love it. So I guess I’ll keep doing it for now!
Hannah Calkins: Thanks for listening to Progress Notes. This episode was produced by me, Hannah Calkins, with help from Jewel Edwards-Ashman. Tune in to our next episode for an exclusive interview with APA CEO, Dr. Arthur Evans.
Arthur Evans, PhD: And I think the question for us is: are we going to continue to practice narrowly, or are we going to use the full breadth of our skills?
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