Karina K. Uldall

The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals.

Information regarding the prevalence of mental illness and substance use among HIV-infected patients and the effect of these problems on HIV treatment is needed. We conducted an observational study of patients in the University of Washington (UW) HIV Cohort to determine prevalence rates for mental illness and substance use. Cox regression analyses were used to examine the relationship between mental illness and substance use, pharmacologic treatment for depression/anxiety, and initiation of highly active antiretroviral therapy (HAART) within 9 months of becoming eligible for HAART. Among 1774 patients in the UW HIV cohort during 2004, 63% had a mental illness (including mood, anxiety, psychotic, or personality disorders), 45% had a substance use disorder, and 38% had both. There were 278 patients who met criteria for HAART eligibility. After controlling for other factors, patients with depression and/or anxiety were significantly less likely to initiate HAART compared with patients without a mental illness (hazard ratio [HR] 0.4, p = 0.02). However, patients with depression/anxiety who received antidepressant/antianxiety medications were equally likely to initiate HAART as patients without a mental illness (HR 0.9, p = 0.5). We found that patients with mental illness or substance use disorders receive HAART at lower CD4+ cell counts and higher HIV-1 RNA levels than patients without these disorders. However, HAART initiation among patients who receive treatment for depression/anxiety is associated with no delay. Screening for these disorders in primary care settings and access to appropriate treatment are increasingly important components of providing care to HIV-infected patients.

Adherence to antiretroviral medications and medical care in HIV-infected adults diagnosed with mental and substance abuse disorders

Abstract This paper examines factors associated with adherence to antiretroviral medications (ARVs) in an HIV-infected population at high risk for non-adherence: individuals living with psychiatric and substance abuse disorders. Data were examined from baseline interviews of a multisite cohort intervention study of 1138 HIV-infected adults with both a psychiatric and substance abuse disorder (based on a structured psychiatric research interview using DSM-IV criteria). The baseline interview documented mental illness and substance use in the past year, mental illness and substance abuse severity, demographics, service utilization in the past three months, general health and HIV-related conditions, self-reported spirituality and self-reported ARV medication use. Among the participants, 62% were prescribed ARVs at baseline (n = 542) and 45% of those on ARVs reported skipping medications in the past three days. Reports of non-adherence were significantly associated with having a detectable viral load (p<.01). The factors associated with non-adherence were current drug and alcohol abuse, increased psychological distress, less attendance at medical appointments, non-adherence to psychiatric medications and lower self-reported spirituality. Increased psychological distress was significantly associated with non-adherence, independent of substance abuse (p<.05). The data suggest that both mental illness and substance use must be addressed in HIV-infected adults living with these co-morbid illnesses to improve adherence to ARVs.

Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: a review of the literature

Adherence to antiretroviral medications is central to reducing morbidity and mortality among people living with HIV/AIDS. Relatively few studies published to date address HIV adherence among special populations. The purpose of this article is to review the existing literature on HIV antiretroviral adherence, with an emphasis on studies among the triply diagnosed population of people living with HIV/AIDS, mental illness, and chemical dependency. In order to reflect the most current information available, data from conference proceedings, federally funded studies in progress, and the academic literature are presented for consideration.

Lipoatrophy among HIV-infected patients is associated with higher levels of depression than lipohypertrophy

We sought to determine the association between body morphology abnormalities and depression, examining lipoatrophy and lipohypertrophy separately.

Association between Delirium and Death in AIDS Patients

The purpose of this study was to examine the relationship between delirium and death in AIDS patients. Forty-one patients admitted to a combination skilled nursing and assisted-living facility in 1994 were included in the retrospective chart review. Patients were grouped according to the presence versus absence of delirium during the first week of admission. Demographic characteristics and medical morbidity of the two groups were compared using the Chi-square statistic. Kaplan-Meier survival analysis was used to estimate survival functions during the study period for the delirious and nondelirious groups. Nine patients (22%) were found to have an episode of delirium in the first week of admission. There were no significant differences in demographic characteristics or medical morbidity between the delirious and nondelirious groups. Median days from admission to death for those with delirium (10 days) versus those without delirium (135 days) was significantly different (log rank = 19.03; p < 0.0001). Authors concluded that delirium is a marker for decreased survival in this sample of AIDS patients. Future research needs to demonstrate whether improved care of AIDS patients can prevent delirium or limit adverse outcomes associated with it.

Impact of HIV/AIDS Education on Health Care Provider Practice: Results from Nine Grantees of the Special Projects of National Significance Program

The study assessed the impact of health care provider HIV/AIDS education and training on patient care from nine Special Projects of National Significance. Telephone interviews were conducted with 218 health care providers within 8 months, on average, following completion of training. Respondents provided examples of how the SPNS trainings affected their provision of patient/client care. Transcribed comments reflecting change in patient/client care were classified by independent coders under 1 of 10 broad practice change categories. Eighty-two percent of the trainees identified at least one instance of change in patient/client care as a function of their training experience. Self-reported findings included changes in the number/types of patients seen, interpersonal interactions with patients/clients, HIV testing and counseling practices, patient/family education, infection control, advocacy, referrals and collaboration, documentation, and other service changes.

Use of hospital services by AIDS patients with psychiatric illness.

The purpose of this study was to assess the effect of psychiatric illness on length of stay and patterns of admission among AIDS patients hospitalized for medical illnesses. Medical records were abstracted for AIDS patients admitted to hospitals in Washington State from 1990 through 1992. Psychiatric comorbidity was defined by the presence of an International Classification of Disease-9 code reflecting psychiatric illness. Medical morbidity was addressed using CD4 count and AIDS-defining illnesses as markers of disease severity. Of 2834 admissions, 15% included one or more psychiatric diagnoses. Psychiatric illness (F 39.1; df 1,2830; p < 0.001) and discharge disposition (F 81.2; df 2,2830; p < 0.001) contributed significantly to the model, explaining increased length of stay (F 67.2; df 3,2830; p < 0.001). Future research needs to address the possible etiology of psychiatric comorbiditys contribution to length of stay and the effect on quality and cost of care.

Outcomes associated with delirium in acutely hospitalized acquired immune deficiency syndrome patients.

The study demonstrates that delirium in acquired immune deficiency syndrome (AIDS) patients is associated with mortality, the need for long-term care, and an increased length of hospitalization. Data were collected prospectively on human immunodeficiency virus (HIV)/AIDS patients admitted to a teaching hospital from January 1996 through December 1996. The data included demographic characteristics of the participants, medical diagnoses, CD4 cell count, Karnofsky functional assessment, mortality during admission, length of stay, and discharge placement. Participants were evaluated throughout their hospital stay for evidence of delirium. The presence of delirium was determined using DSM-IV diagnostic criteria. There were no significant differences between delirious and nondelirious patients with respect to demographic characteristics or markers of medical morbidity. Patients with delirium were more likely to die during admission (chi-square [chi2] = 39.1, df = 1, P<.0010), to stay longer in hospital (t = 3.50, df = 12.9, P<.0041), or to need long-term care if discharged alive (chi2 = 12.8, df = 2, P<.0021). Delirium is associated with adverse outcomes in hospitalized AIDS patients. More research is needed to characterize the nature of this association.

Rearrest: does HIV serostatus make a difference?

Correctional facilities have become collection and containment centres for HIV-seropositive individuals. This is due to factors that affect incarceration in general: past criminal behaviour, age and crime type. In addition, the sex trade industry, intravenous drug use and community instability are likely factors affecting this particular population. The objective of this study was to determine whether HIV-positive offenders have higher rates of rearrest than HIV-negative offenders. A sample of HIV-positive offenders ( n = 57) were seen for mental health evaluation at the King County Correctional Facility (KCCF) in Seattle Washington. They were compared to a historical sample ( n = 254) of HIV-negative individuals also from the KCCF. After three months, 50% of both samples had been rearrested. Using the log rank test in Kaplan-Meier survival analysis, statistical difference in the relative risk of rearrest occurred for the HIV-positive group (logrank = 0.03). Statistical adjustment for mental illness, age, race, ethnicity, substance abuse history and past criminal history did not affect rearrest significantly. Nonetheless, HIV-positive individuals who presented with mental health needs appeared to be significantly more vulnerable to rearrest after the first three months of release into the community.

Systems Change Resulting from HIV/AIDS Education and Training A Cross-Cutting Evaluation of Nine Innovative Projects

An evaluation of nine diverse HIV/AIDS training programs assessed the degree to which the programs produced changes in the ways that health care systems deliver HIV/AIDS care. Participants were interviewed an average of 8 months following completion of training and asked for specific examples of a resulting change in their health care system. More than half of the trainees gave at least one example of a systems change. The examples included the way patient referrals are made, the manner in which agency collaborations are organized, and the way care is delivered.