The American Psychological Association is reportedly on the verge of releasing a policy statement condeming HIV criminalization. The nation's largest scientific and professional organization for psychology, it represents over 122,500 members (researchers, educators, clinicians, consultants and students). The APA previously voiced concern over HIV criminalization in 2013 when it urged support for the Repeal Existing Policies that Encourage and Allow Legal (REPEAL) HIV Discrimination Act (H. R.1843), a bill that unfortunately never passed Congress.
At the time, APA argued, "Growing empirical evidence suggests that unduly punitive laws undermine efforts to prevent HIV transmission. Criminalizing behaviors that are perceived to cause HIV transmission produces negative consequences, including increased stigmatization and discrimination and the avoidance of voluntary testing (ignorance of HIV status is a primary defense against charges of intentional transmission)."
Now David Martin, Senior Director of APA's Office of AIDS, tells Plus that the organization is poised to adopt that sentiment as official organizational policy. That has the potential to have wide-ranging implications. APA's influence stretches far beyond its membership roster and mental health focus. As we've seen with sexual orientation and gender identity, changes in APA diagnoses and policies have had real world impacts on the lives of LGBT people.
In this exclusive interview, Plus talks with Martin about HIV criminalization laws, integrating mental health services into HIV care, how the APA’s Office of AIDS plays a role in the “conscience of the organization,” and why adherence issues aren’t limited to people living with HIV.
Plus magazine: First, why don’t you tell me about why the American Psychological Association has an Office of AIDS?
David Martin: The Office on AIDS was started in the late '80s. Originally, APA’s response to HIV was in the science directorate, and was spearheaded by two men, Walter Bachelor and Bill Bailey. It was largely through their efforts that the board of directors…put together resources for an Office on AIDS. I think it was in 1987 when the office was formally formed in the public interest directorate of the association.
What you need to understand about the American Psychological Association is that it has four directorates: [including] the practice directorate…[and] the education directorate, [which] is responsible for forming education policies, and it also houses the accreditation institution for accrediting APA accredited doctoral programs. Then there is the science directorate which is primarily concerned with the science of psychology: social psychology, cognitive psychology. And then finally there is the public interest directorate, which in many ways acts as the conscience of the organization. That’s why the Office of AIDS was put into the public interest directorate.
And what does the APA Office on AIDS do?
The Office on AIDS is charged with the responsibility of staffing the ad-hoc Committee on Psychology and AIDS (COPA) [and] with the responsibility of educating psychologists and the public about AIDS. [COPA] also advocates for policy within APA, and so, right now we have before counsel for the American Psychological Association, a resolution opposing HIV criminalization, and this document, if it becomes APA policy — which we believe that it will— will align APA’s policy on criminalization with that of the best practices documented by The Department of Justice and the CDC issued, in July of last year.
HIV criminalization is really disturbing, so it’s great to hear the APA might come out against it.
That’s why this has been one of the big projects for the Committee on Psychology and AIDS, this resolution opposing criminalization. We have every reason to believe that will become official APA policy. That’s kind of what we do in the Office on AIDS, and one of the other things that we advocate for is integrated care. In fact, we work with folks in the practice directorate as well, because one of the things that psychology has been trying to do in general has been to integrate mental and behavioral health into primary care.
Why is that important?
It’s important because — just to take the example of depression — almost half of the depression that is diagnosed in the United States is diagnosed in family practice settings. With HIV, as you might imagine, even with the improved treatments, there is still a high incidence of depression and anxiety, not to mention substance abuse within the HIV-positive population. Trying to provide medical care without addressing these other issues becomes a real [barrier to] overall treatment for HIV. If you have HIV and you’re engaged in substance abuse, for example, the chances that you will actually be able to adhere to your medical regiment are greatly diminished. So, having a practitioner available who can address that substance abuse, in the same setting in which the patient is getting his or her care.
I was recently talking to someone who is dealing with depression. He went to his doctor and said he was depressed, and the doctor’s response was kind of "Of course you’re depressed! You have HIV!" But, they didn’t really do anything more about dealing with his depression. Some medical doctors — maybe they’ll give you a prescription — but aside from that, they don’t even seem to know how to deal mental health issues.
Right. Before I came to APA, I actually ran an HIV mental health program. I was working in a large teaching hospital, and it had a whole [integrated program] and so, we were able then to have HIV mental health staff actually located in the medical health clinics when patients came in. So that when a doctor or nurse practitioner saw a patient with some sort of mental health or substance abuse issue, they could do what we call in the healthcare industry, a warm hand off, where the nurse practitioner or doc would come to whoever it was that was in the clinic on that day, and say ‘We have a patient who is depressed or is taking drugs or whatever, could you talk to him or her?’ And the mental health professional [would immediately] address some of the concerns that the patient might have.
You keep mentioning substance abuse. Obviously some people really see substance abuse more than a moral failing, others see it sort of as an attempt to self-medicate or a physical dependency. You’re including it into behavioral and mental health issues. What APA’s official view on what substance abuse is or what causes it?
Historically, APA has defined substance abuse in much the same way that the American Psychiatric Association has, or other medical associations have. I don’t think that most psychologists, and certainly not most psychologists that I know, would view it as a moral failing. I think that there are reasons people take drugs. I think that most psychologists recognize that, and there is growing evidence to suggest that childhood experiences — certain childhood experiences— can increase the risk for taking drugs, and also, by the way, increase the risk of engaging in behavior that places them at risk for HIV.
So, for example, childhood sexual abuse is greatly overrepresented among people with HIV, and there are reasons to believe that this is in fact a risk factor for HIV, and it also happens to be a risk factor for substance abuse, and there are probably, just among gay men, about 15 studies out that have noted that. But, it’s not restricted to gay men; it’s also a risk factor in women. It’s a risk factor in heterosexual men; it’s just generally a risk factor for those things. So, we wouldn’t call [substance abuse] a moral failing, we would say that it is problem behavior when it starts getting in the way of carrying on a productive life. And, in order to get on with your life and take your medications as prescribed — if you’re in treatment for HIV, or for that matter, any other illness — then it really needs to be addressed in order that you can go on living a productive life.
Absolutely. We're definitely hearing more about the complex relationship between depression, substance abuse, and HIV. [Editor's note: Read more about this in Plus magazine’s special report on depression and HIV here.]
Yes. And, you know, people come in with multiple problems. The idea of co-location of care was that if patients could be handed off to a mental health practitioner while they were in to see their HIV doc, the likelihood that they would be able to follow through with their mental health care would be improved. In general that has been my experience…and I think that there is growing evidence to suggest that integration of mental health and behavioral health in medical care works across different medical settings.
So, what does a good integration treatment program look like for people with HIV?
The ideal integrated care team would have a psychologist, a social worker, and some kind of physician and nurse practitioner. We would have the team of providers…working out of one room, sitting around a table. Some of these mental health issues would come up. The psychologist might hear things that the provider wasn’t aware of, and so he or she then could step in and say, "I think we could help you with that."
A common example has to deal with treatment adherence, because, it’s very hard. Most people — when they’re prescribed an antibiotic that they’re supposed to take for 10 days — don’t take the full dose. They stop taking it when they feel better. People who are hypertensive, and are on anti-hypertensives — many don’t take their medications, because hypertension doesn’t have any overt symptoms. You don’t feel like you’re wired or anything with hypertension, you just have high blood pressure [and] you’re at risk for stroke and other issues. The hypertension example is particularly relevant here, because taking anti-hypertensives is a lifelong commitment, as is taking antiretroviral medication. It’s important that patients understand that they have to take their medications consistently, for the rest of their lives.
Some people I know struggle with taking their meds because doing so is a constant reminder that they have HIV.
Yeah. That’s been common since the beginning of the epidemic. Absolutely.
Are there, barriers to integrated care? Why is it that every program doesn’t just automatically do this? Is it about money?
It is about money. It is interesting to me that before the healthcare industry started talking about integrated care, the first Ryan White Care Act was passed. And the framers of the Ryan White Care Act — because it was actually written outside of Congress and taken to Representatives and Senators by a national coalition of advocates — took the position that what was needed to treat people with HIV, and to keep them in care, was a whole host of stuff. So when you look at the stuff that’s funded by Ryan White, you see housing, you see substance abuse treatment, you see mental health. [Local-level providers were] required to have a plan for integration for all of those services, wherever HIV care was paid for by Ryan White funds.
I used to live in Los Angeles. If you go to any of the county hospitals there, that’s what happens. If you go to AIDS Healthcare Foundation, they have a mental health component. If you go to AltaMed, they have a mental health component. Now, things are a little different in the private sector, because there are insurance reimbursement issues. [But] if you’ve got a doc who specializes in HIV, who works in a major urban area where there is a high prevalence of HIV, he or she is likely to be aware of the need for those kinds of services; they just might not have them on site.
What makes on-site better than referrals?
Because it’s right there, and it increases the likelihood that the patient will follow up. Depressed patients, as a specific example— as it is a very common diagnosis among people with HIV — one of the symptoms of depression is low energy, and not wanting to get out of bed in the morning. If you’re depressed, and you just get a referral to see a mental health provider….you might not go just because you’re too depressed to go. So, it’s important to have somebody who can address that right there in the clinic and help put stuff together so that [you] can go get follow up treatment.
This interview was conducted as part of the 2015 Equal Voice Fellowship for journalists, in partnership with New America Media and the Marguerite Casey Foundation.