Twenty-one years ago, Glenn Treisman, director of the AIDS Psychiatry service at Johns Hopkins and the moving force behind one of the oldest and what continues to be one of the preeminent integrated HIV/mental health clinics in the country, came to the University of North Carolina at Chapel Hill to give a lecture about mental health and HIV to a broad entry-level HIV survey course. You think HIV is a neglected, stigmatized, and devastating disease? (according to the memory of the first author) he asked the lecture hall of hundreds of undergrads, premeds and at least one first-year epidemiology doctoral student. Let me tell you about mental illness among people with HIV. No one knows about this, no one is researching it, and it is killing my patients.

What has changed in these 21 years? We now have a deep and robust literature base convincingly demonstrating what Dr Treisman and many others already knew: depression in particular, and other mental health concerns generally, are overwhelmingly common among people with HIV, much more so than in the general population [1–3]; depression and other mental health concerns are consistently and strongly associated with worse medication adherence, falling out of care, disease progression, and early mortality in this population [4–6]; and treating depression and other mental health concerns reverses these negative effects and improves outcomes [7–9]. We know that combined treatment approaches that integrate mental health counseling with skill-building around medication adherence and HIV care are particularly impactful [9–11]. And now, thanks to the compelling, intricate, and elegant analysis by Koenig and colleagues in this issue, we know that comprehensively addressing depression among people with HIV in the United States would lead to a substantial and impactful improvement in national levels of HIV viral suppression, with consequent gains in health, longevity, and prevention of transmission [12].

A separate, equally robust line of research has provided the tools we need to address this need. STAR∗D demonstrated that primary care providers, with the right decision support, are equally as effective as psychiatrists in treating depression to remission with medication [13–15]; several studies have demonstrated the feasibility and effectiveness of integrating the STAR∗D decision support model into HIV care [16–18]. The closely related field of collaborative care has shown the impact of integrating stepped mental healthcare into chronic disease medical care [19]. In parallel, the global mental health field has demonstrated that in settings with few psychiatrists and psychologists, other cadres such as behavioral health providers, lay health workers, and even grandmothers in Zimbabwean villages – with the right training and ongoing support – can deliver behavioral activation, problem-solving therapy, and even cognitive behavioral therapy with safety, fidelity, and effectiveness [20–22]. A third critical tool in the toolbox is the robust evidence base around designing and delivering trauma-informed care [23], since the presenting mental health concerns of depression or substance use for many people with HIV are rooted in a history of traumatic life experiences [3,24] which can complicate their ability to engage in traditional medical care.

The HIV treatment field has been galvanized by the now-ubiquitous images of the HIV treatment cascade [25] and the resulting articulation of ‘90–90–90’ goals. These goals drive healthcare innovations through systematic and repeated measurement of the critical benchmarks of HIV diagnosis, antiretroviral treatment initiation, and viral suppression. This focus on measurement and feedback to drive care improvement has led to dramatic gains in HIV treatment coverage and outcomes in the US and around the world. Eleven years ago, this journal published what may have been the first estimated ‘depression treatment cascade’ among people engaged in HIV care (Fig. 1) [26]. Putting the depression treatment cascade next to the HIV treatment cascade is sobering. You think the HIV treatment cascade has gaps? we might reprise Dr Treisman's opening words today. Let me talk to you about the depression treatment cascade in HIV. Half of patients with depression go undiagnosed, half of those diagnosed go untreated, and very few of those treated are treated assertively to remission [26]. And it's killing these patients.

Fig. 1:

The Depression Treatment Cascade for HIV Patients.

Calls have been recently renewed to articulate ‘90–90–90’ goals for global mental health [27]. Let's define goals of 90% of patients in need of mental healthcare being identified, 90% of those identified starting mental health treatment, and 90% of those starting treatment achieving clinical remission. Let's invest in data systems to routinely measure these benchmarks and centralize the results to drive care improvement. Let's invest in placing depression care managers in HIV clinics to support routine depression screening and guide busy providers both in providing evidence-based antidepressant prescription and, critically, in completing systematic follow-up assessment of symptom response accompanied by any needed antidepressant dose adjustment. Let's invest in training and supporting behavioral health providers, peer navigators, and other healthcare extenders in providing evidence-based psychosocial counseling, building on the evidence generated in other resource-constrained settings. We don’t need a psychiatrist or clinical psychologist in every HIV clinic, but we do need to focus resources and attention on leveraging the lessons we’ve learned from STAR∗D, collaborative care, and the global mental health field about how to effectively and efficiently address mental health in general medical care.

We know what we need to know about the burden of mental illness and its consequences. We have the tools to evolve HIV care to address the large unmet mental health need even with limited access to mental health professionals. We have a roadmap for care improvement with the depression treatment cascade. We know that this investment will have a dramatic impact on the mental health and quality of life of people living with HIV. And thanks to Dr Koenig and colleagues [12], we have firm evidence that such an investment will also have a profound and measurable impact on the national HIV epidemic. It's time to act. Let's get it right.

Acknowledgements Conflicts of interest

There are no conflicts of interest.

References 1. Bing EG, Burnam MA, Longshore D, Fleishman JA, Sherbourne CD, London AS, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry 2001; 58:721–728. 2. Do AN, Rosenberg ES, Sullivan PS, Beer L, Strine TW, Schulden JD, et al. Excess burden of depression among HIV-infected persons receiving medical care in the united states: data from the medical monitoring project and the behavioral risk factor surveillance system. PLoS One 2014; 9:e92842. 3. Machtinger EL, Wilson TC, Haberer JE, Weiss DS. Psychological trauma and PTSD in HIV-positive women: a meta-analysis. AIDS and behavior 2012; 16:2091–2100. 4. Pence BW, Mills JC, Bengtson AM, Gaynes BN, Breger TL, Cook RL, et al. Association of increased chronicity of depression with HIV appointment attendance, treatment failure, and mortality among HIV-infected adults in the United States. JAMA Psychiatry 2018; 75:379–385. 5. Rooks-Peck CR, Adegbite AH, Wichser ME, Ramshaw R, Mullins MM, Higa D, et al. Mental health and retention in HIV care: a systematic review and meta-analysis. Health Psychol 2018; 37:574–585. 6. Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr 2011; 58:181–187. 7. Sin NL, DiMatteo MR. Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis. Ann Behav Med 2014; 47:259–269. 8. Tsai AC, Weiser SD, Petersen ML, Ragland K, Kushel MB, Bangsberg DR. A marginal structural model to estimate the causal effect of antidepressant medication treatment on viral suppression among homeless and marginally housed persons with HIV. Arch Gen Psychiatry 2010; 67:1282–1290. 9. Safren SA, Gonzalez JS, Wexler DJ, Psaros C, Delahanty LM, Blashill AJ, et al. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes. Diabetes care 2014; 37:625–633. 10. Safren SA, O’Cleirigh C, Tan JY, Raminani SR, Reilly LC, Otto MW, et al. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals. Health Psychol 2009; 28:1–10. 11. Safren SA, O’Cleirigh CM, Bullis JR, Otto MW, Stein MD, Pollack MH. Cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected injection drug users: a randomized controlled trial. J Consult Clin Psychol 2012; 80:404–415. 12. Koenig L. Closing the gaps in the continuum of depression care for persons with HIV: modeling the impact on viral suppression in the United States. AIDS 2023; 37:1147–1156. 13. Gaynes BN, Rush AJ, Trivedi MH, Wisniewski SR, Balasubramani GK, McGrath PJ, et al. Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR∗D. J Gen Intern Med 2008; 23:551–560. 14. Gaynes BN, Warden D, Trivedi MH, Wisniewski SR, Fava M, Rush AJ. What did STAR∗D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatr Serv 2009; 60:1439–1445. 15. Xiao L, Qi H, Zheng W, Xiang YT, Carmody TJ, Mayes TL, et al. The effectiveness of enhanced evidence-based care for depressive disorders: a meta-analysis of randomized controlled trials. Transl Psychiatry 2021; 11:531. 16. Pyne JM, Fortney JC, Curran GM, Tripathi S, Atkinson JH, Kilbourne AM, et al. Effectiveness of collaborative care for depression in human immunodeficiency virus clinics. Arch Intern Med 2011; 171:23–31. 17. Adams JL, Gaynes BN, McGuinness T, Modi R, Willig J, Pence BW. Treating depression within the HIV ‘medical home’: a guided algorithm for antidepressant management by HIV clinicians. AIDS patient care and STDs 2012; 26:647–654. 18. Pence BW, Gaynes BN, Adams JL, Thielman NM, Heine AD, Mugavero MJ, et al. The effect of antidepressant treatment on HIV and depression outcomes: results from a randomized trial. AIDS 2015; 29:1975–1986. 19. Bauer MS, Weaver K, Kim B, Miller C, Lew R, Stolzmann K, et al. The collaborative chronic care model for mental health conditions: from evidence synthesis to policy impact to scale-up and spread. Med Care 2019; 57: (Suppl 3): S221–S227. 20. Singla DR, Kohrt BA, Murray LK, Anand A, Chorpita BF, Patel V. Psychological treatments for the world: lessons from low- and middle-income countries. Annu Rev Clin Psychol 2017; 13:149–181. 21. Chibanda D, Weiss HA, Verhey R, et al. Effect of a primary care-based psychological intervention on symptoms of common mental disorders in Zimbabwe: a randomized clinical trial. JAMA 2016; 316:2618–2626. 22. Murray LK, Dorsey S, Haroz E, Simms V, Munjoma R, Rusakaniko S, et al. A common elements treatment approach for adult mental health problems in low- and middle-income countries. Cogn Behav Pract 2014; 21:111–123. 23. Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg LS. From treatment to healing: the promise of trauma-informed primary care. Womens Health Issues 2015; 25:193–197. 24. Pence BW, Mugavero MJ, Carter TJ, Leserman J, Thielman NM, Raper JL, et al. Childhood trauma and health outcomes in HIV-infected patients: an exploration of causal pathways. J Acquir Immune Defic Syndr 2012; 59:409–416. 25. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis 2011; 52:793–800. 26. Pence BW, O’Donnell JK, Gaynes BN. Falling through the cracks: the gaps between depression prevalence, diagnosis, treatment, and response in HIV care. AIDS 2012; 26:656–658. 27. Wagenaar BH, Turner M, Cumbe VFJ. Toward 90-90-90 goals for global mental health. JAMA Psychiatry 2022; 79:1151–1152.