The Role of Community Health Workers (CHWs) in Redressing Syndemics of Mental Health, Substance Use and HIV Infection: A Study in an Ending the HIV Epidemic Priority State

Background and Purpose: Syndemics of mental health, substance use (MH-SU) and HIV infection present intractable barriers to advancing the goals of the Ending the HIV Epidemic (EHE) to optimize health outcomes for people living with HIV (PLWH). Missouri is a priority EHE state because of inequitable lags in progression along the HIV care continuum, from initial diagnosis to viral suppression. To meet the state’s goals, Missouri’s EHE plan calls for developing evidence-based treatment and prevention interventions that combat inequities and target communities disproportionately impacted by HIV. The shared lived experiences of Community Health Workers (CHWs) position them to navigate the social and structural forces that marginalize PLWH from access to MH-SU and HIV care as well as the multiple parallel systems (i.e. social services, health care, criminal justice) that complicate engagement in treatment. This analysis presents findings from an EHE initiative funded study highlighting the potential of CHWs to increase engagement along the HIV care continuum by enhancing engagement in MH-SU treatment.

Methods: In-depth interviews and focus groups were conducted with key informants (KI) from five groups that included community health workers/supervisors working in HIV service delivery (6), community leaders (5), people living with HIV (12), clinical providers (4) and front-line health care workers (12) guided by the Intersectionality-based policy analysis framework and the Consolidated Framework for Implementation Research. Rapid qualitative analysis methods were used to generate themes allowing for integration and synthesis findings across groups.

Results: PLWH reported experiencing intersecting stigmas including discrimination by health care professionals, fear of judgement by employers, stigma and anticipated stigma by intimate partners and health care professionals as well as symptoms of anxiety and depression related to their HIV diagnoses. Shared lived-experiences between CHWs and PLWH provided experiences of how systemic racism, discrimination, poverty, and marginalization from social determinants of health marginalize PLWH from receiving MH-SU and HIV care. CHWs helped find transportation for medication management, counseling for mental health issues, support groups, provided access to fentanyl test strips, services for people engaged in commercial sex work, assistance with obtaining suboxone, syringe exchange services and sexual health resources. Community health workers were identified as facilitating a referral system to credentialed professionals when mental health problems or recent release from incarceration was identified. Despite the utility of CHWs in coordinating services across systems of care, barriers persist to scaling up CHWs as a strategy of redressing the MH-SU, HIV syndemic. Training needs for CHWs include screening for MH-SU issues and knowledge of where to direct them to increase engagement in care. Lack of consistent funding under the Ryan White Program blocks sustained efforts to use CHWs as a strategy to redress the MH-SU and HIV syndemics.

Conclusions and Implications: Findings from this study underscore CHW potential to enhance engagement in MH-SU services including harm reduction for PLWH particularly from groups that are disproportionately marginalized from access to services. Increasing the capacity of community-based organizations to deploy CHWs is a promising workforce development strategy that requires greater investment in training, funding and organizational support.