HIV Psychiatry

Annotated Abstracts of Journal Articles
2014, 1st Quarter

HIV Psychiatry

Annotations by Oliver Freudenreich, MD, FAPM and Mary Ann Cohen, MD, FAPM
March 2014

  1. A Multisite Study of the Prevalence of HIV With Rapid Testing in Mental Health Settings
  2. Pain in people living with HIV/AIDS: a systematic review

PUBLICATION #1 — HIV Psychiatry
A Multisite Study of the Prevalence of HIV With Rapid Testing in Mental Health Settings

Blank MB, Himelhoch SS, Balaji AB, Metzger DS, Dixon LB, Rose CE, et al
Am J Public Health 2014 Feb 13 [Epub ahead of print]

ANNOTATION (Freudenreich & Cohen)

The Finding: Over 1000 patients in 3 different psychiatric treatment settings in Maryland were tested for HIV. Overall, 4.8% of patients were HIV infected which is over four-fold greater than the general population.

Strength and Weaknesses: This is a fairly large study in real-world settings. However, only 3 sites in 1 state were examined which limits generalizability.

Relevance: Psychiatrists need to strongly consider screening patients in their psychiatric practice settings to detect undiagnosed infected patients with HIV and bring them into treatment (which would prevent new infections: treatment as prevention). Such action by psychiatrists would be consistent with the CDC’s recommendation for routine HIV screening in all (not just non-psychiatric) settings; after all, this study shows that this is where infected patients get care. (Of note, this recommendation was first made in 2006 but remains woefully underappreciated.) In this way, psychiatrists would do their part in reducing the number of new infections or bringing patients to treatment earlier so they do not present with AIDS.


Objectives: We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011.

Methods: We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n=287), intensive case-management programs (n=273), and community mental health centers (n=501).

Results: Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI=3.7%, 9.4%) for inpatient units, 5.1% (95% CI=3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI=2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection.

Conclusions: HIV prevalence for individuals receiving mental health services was more than 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.

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PUBLICATION #2 — HIV Psychiatry
Pain in people living with HIV/AIDS: a systematic review
Parker R, Stein DJ, Jelsma J
J Int AIDS Soc 2014 Feb 18; 17:18719

ANNOTATION (Freudenreich & Cohen)

The Finding: In this systematic literature review of pain in HIV patients, the point prevalence of pain ranged from 54% (based on 1-week recall) to 83% (based on 3-month recall). Pain was often at least moderate, interfered with life, and was undertreated.

Strength and Weaknesses: The review was comprehensive but limited to cross-sectional assessments and an overall low quality of data.

Relevance: In HIV patients, pain remains a major quality-of-life issue that seems to not have gone away, despite very different treatment today compared to several decades ago (suggesting that treatment of HIV alone might not be sufficient). To complicate matters clinically, pain management is often complicated by current or past substance use disorders. Unfortunately, very little work regarding the best interventions has been undertaken.


Introduction: Pain is one of the most commonly reported symptoms in people living with HIV/AIDS (PLWHA). However, wide ranges of pain prevalence have been reported, making it difficult to determine the relative impact of pain in PLWHA. A systematic review of the literature was conducted to establish the prevalence and characteristics of pain and to explore pain management in PLWHA.

Methods: Studies that included cross-sectional data were included in the search, which was conducted in April 2012. Databases searched using a time limit of March 1982 to March 2012 included PubMed, Scopus, Africa-wide: NIPAD, CINAHL, PsychARTICLES, PSYCINFO, PSYCHIATRYONLINE, ScienceDirect and Web of Science. Search terms selected were “pain” and “HIV” or “acquired immune deficiency syndrome.” Two reviewers independently screened all citation abstracts for inclusion. Methodological quality was evaluated using a standardized 11-item critical appraisal tool.

Results: After full text review, 61 studies fulfilled the inclusion criteria. Prevalence of pain ranged from a point prevalence of 54% (95%CI 51.14-56.09) to 83% (95%CI 76-88) using a three-month recall period. The reported pain was of moderate-to-severe intensity, and pain was reported in one to two and a half different anatomical sites. Moderate levels of pain interference with function were reported. All nine studies reporting on the adequacy of pain management recorded marked under-treatment of pain.

Discussion: The studies reviewed reported that pain commonly presents at multiple pain sites with a range of severity suggesting that there are several differing pathological processes contributing to pain at one time. The interplay of variables associated with pain suggests that the biopsychosocial model of pain is an appropriate paradigm from which to view pain in PLWHA and from which to approach the problem, explore causes and establish effective treatment.

Conclusions: The results highlight that pain is common in PLWHA at all stages of the disease. The prevalence rates for pain in PLWHA do not appear to have diminished over the 30 years spanning the studies reviewed. The body of work available in the literature thus far, while emphasizing the problem of pain, has not had an impact on its management.

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