Francine Cournos

HIV seroprevalence among people with severe mental illness in the United States: a critical review.

The authors reviewed all studies in the peer-reviewed literature reporting HIV seroprevalence among people with severe mental illness in the United States, which varied from 4.0% to 22.9%. Findings across samples suggest that seroprevalence varies with geographic concentration of HIV and presence of comorbid psychoactive substance use disorders, but is consistently high. Unsafe sex, drug injection, and noninjected drug use were associated with infection, and in most studies women were as likely to be infected as men. Seroprevalence also varied with age and ethnicity, but not psychiatric diagnosis. The authors review questions and methodological issues important to future studies.

Schizophrenia and comorbid human Immunodeficiency Virus or Hepatitis C Virus

Patients with schizophrenia are at significantly increased risk for infection with human immunodeficiency virus (HIV), hepatitis C virus, or both. Several factors underlie this increased risk, including substance abuse and high-risk sexual behavior. Although being sexually active tends to be less common among patients with schizophrenia than among nonpsychotic individuals, patients with schizophrenia who are sexually active are more likely than nonpsychotic individuals to engage in high-risk behavior. Many patients with schizophrenia have inadequate knowledge about the risks of HIV, but delivering factual information is not likely, by itself, to bring about behavioral changes that reduce the risk of exposure and transmission. Comorbidity of schizophrenia and life-threatening viral illnesses incurs a worse prognosis for both conditions. Nevertheless, effective pharmacotherapy exists, and antipsychotics and highly active antiretroviral treatments for HIV can be used together successfully. The clinical challenge is to encourage adherence to treatment and to coordinate the clinical services needed to address the diverse psychiatric and medical problems that coexist in this population.

A Model for Adapting Evidence-based Behavioral Interventions to a New Culture: HIV Prevention for Psychiatric Patients in Rio de Janeiro, Brazil

As in other countries worldwide, adults with severe mental illness in Brazil have elevated rates of HIV infection relative to the general population. However, no HIV prevention interventions have been tested for efficacy with psychiatric patients in Brazil. We conducted participatory research with local providers, community leaders, patient advocates, and patients using an intervention adaptation process designed to balance fidelity to efficacious interventions developed elsewhere with fit to a new context and culture. Our process for adapting these interventions comprised four steps: (1) optimizing fidelity; (2) optimizing fit; (3) balancing fidelity and fit; and (4) pilot testing and refining the intervention. This paper describes how these steps were carried out to produce a Brazilian HIV prevention intervention for people with severe mental illness. Our process may serve as a model for adapting existing efficacious interventions to new groups and cultures, whether at a local, national, or international level.

HIV-1 infection at two public psychiatric hospitals in New York City.

Seroprevalence for HIV-1 was anonymously evaluated between November 1989 and July 1991 among severely mentally ill patients at two public psychiatric hospitals in New York City. The study population consisted of new admissions and long-stay patients aged 18-59. Of 1116 eligible patients, usable samples were obtained from routine blood drawings on 971 (87%). Seroprevalence was comparable among men (5.2%) and women (5.3%). Age did not predict seropositivity. Men with a recorded history of homosexual behaviour or injection drug use were, respectively, 1.8 and 2.0 times more likely to be seropositive than men without these histories. Women with a recorded history of injection drug use were 4.0 times more likely to be seropositive than women without such a history. Ethnicity was not predictive for men, but Black women were 2.4 times more likely to be HIV-1 positive than non-Black women. Severely mentally ill inpatients had a substantial rate of HIV-1 seropositivity, indicating a need for additional testing, education and counselling efforts for this population.

Research on HIV, AIDS, and severe mental illness: recommendations from the NIMH National Conference.

We summarize the recommendations for research that emerged from a NIMH-sponsored Conference on HIV, AIDS, and Severe Mental Illness. Recommendations are made in four areas, namely, epidemiology of HIV infection, epidemiology of sexual and drug-use risk behaviors, risk reduction and transmission prevention, and treatment of infected persons. This research is urgently needed to adequately respond to the AIDS epidemic among people with severe mental illness.

A Lifetime Alcohol or Other Drug Use Disorder and Specific Psychiatric Symptoms Predict Sexual Risk for HIV Infection Among People With Severe Mental Illness

To clarify the relative contributions of psychiatric and alcohol or other drug (AOD) use disorders on sexual risk for HIV infection among people with severe mental illness, we interviewed 195 psychiatric patients. In the prior 6 months the 100 (51%) sexually active patients had a mean of 3.9 sex partners and 27.5 sex episodes; 49% had known high-risk sex partners; 34% used AOD during sex; 28% traded sex; and 59% never used condoms. The likelihood of being sexually active decreased with age and cognitive symptoms, increased with excited symptoms, and was more than twice as high for African-American patients as others. The likelihood of trading sex increased with cognitive symptoms. The likelihood of having a sexually transmitted disease history (reported by 32% of all patients) increased with depressed/anxious symptoms, a lifetime AOD use diagnosis (obtained for 57% of patients), and was more than twice as high for African-American patients as others. HIV prevention interventions that address specific psychiatric conditions and developmental and cultural issues of psychiatric patients should be developed and tested.

HIV risk behaviors among outpatients with severe mental illness in Rio de Janeiro, Brazil

We conducted the first study to examine rates of sexual activity, sexual risk behaviors, sexual protective behaviors, injection drug use (IDU), needle sharing, and knowledge about HIV/AIDS among outpatients with severe mental illness (SMI) in Rio de Janeiro, Brazil. Using a measure with demonstrated reliability, we found that 42% of 98 patients engaged in vaginal or anal sex within the past three months. Comorbid substance use disorder was significantly associated with sexual activity. Only 22% of sexually active patients used condoms consistently, despite having better HIV knowledge than those who were sexually abstinent. Overall, 45% of patients reported not engaging in any HIV protective behaviors. There were no reports of drug injection. Adults with SMI in Brazil are in need of efficacious HIV prevention programs and policies that can sustain these programs within mental health treatment settings.

HIV prevention with severely mentally ill men: A randomised controlled trial

Abstract We conducted a randomised clinical trial to test the efficacy of an enhanced version of an intervention previously shown to reduce HIV sexual risk behaviours among men with severe mental illness. One-hundred-and-forty-nine subjects aged 18–59 years were randomly assigned to the experimental or control conditions. Sexual risk behaviours were assessed every three months for 12-months. The primary analysis compared experimental and control groups with respect to sexual risk behaviours with casual partners as measured by the Vaginal Episodes Equivalent (VEE) score. Additional analyses included comparison of VEE scores of those men sexually active in the three months prior to baseline and the proportion of condom-protected sexual acts with casual partners. There were no significant differences in sexual risk behaviours with casual partners between experimental and control subjects. Additional analyses demonstrated a trend toward sexual risk reduction at six months post-intervention (p=0.06) but not at 12 months. These results may reflect a lack of efficacy or a true reduction in risk that the trial was underpowered to detect at the 0.05-level. If there was a true reduction in risk, it was not maintained after the initial six months.

HIV seroprevalence and clinical characteristics of severe inpatient mentally Ill homeless

Two related studies were carried out at a state psychiatric center unit designed for the long-term hospitalization of homeless mentally ill people removed from the streets of New York City and taken to hospitals for psychiatric treatment. The first study, a chart review of 102 patients, documented high rates of severe psychiatric illness, alcohol and other substance use, and untreated medical problems. Patient histories showed significant social disadvantages, including high rates of criminal activity and inability to complete high school or establish long-term relationships. Our second study anonymously tested 87 patients between the ages of 18 and 59 for the presence of HIV antibodies. An overall seroprevalence rate of 5.8% is reported. Men and women in this population are likely to have similar rates of HIV infection. Being young, and Black, or Hispanic appears to be associated with increased risk. This disenfranchised population urgently needs a broad array of social, medical, and psychiatric services. Assertive community outreach programs are necessary to assure delivery of services to this population.

Why the Treatment of Mental Disorders Is an Important Component of HIV Prevention among People Who Inject Drugs

People who inject drugs are more likely to be HIV positive and to have a mental disorder than the general population. We explore how the detection and treatment of mental illness among people who are injecting drugs are essential to primary and secondary prevention of HIV infection in this population. Aside from opioid addiction, few studies have been conducted on the links between mental disorders and injection-drug use. However, independent of the injection-drug use literature, a growing number of studies demonstrate that untreated mental illness, especially depression and alcohol/substance use disorders, is associated with HIV-related risk behaviors, acquiring HIV infection, failure to access HIV care and treatment, failure to adhere to HIV care and treatment, and increased morbidity and mortality from HIV-related diseases and comorbidities. In our review of both the published literature and gray literature we found a dearth of information on models for providing care for both opioid addiction and other mental illnesses regardless of HIV status, particularly in low- and middle-income countries. We therefore make recommendations on how to address the mental health needs of HIV-positive people who inject drugs, which include the provision of opioid substitution therapy and integrated mental health, substance abuse, and HIV services.