Journal Article Annotations
2020, 2nd Quarter
Annotations by John Grimaldi, MD, Mary Ann Cohen, MD, FACLP, Kelly Cozza, MD, DFAPA, FACLP and Luis Pereira, MD
June 25, 2020
PUBLICATION #1 — HIV Psychiatry
This study investigated access to HIV prevention and treatment services for people with serious mental illness receiving psychiatric care at licensed community health centers across New York State. Surveys were distributed to agency directors and data were compared to similar surveys conducted in 1997 and 2004. HIV prevalence was significant, evidenced by a large majority of programs reporting clients with HIV or AIDS and nearly a quarter reporting more than 100 HIV-infected clients. Although 60% of programs assessed HIV risk at intake, only 33% of programs offered on site HIV testing when risk was identified. Condoms were available at 61% of programs. Proportions of programs offering HIV pre-exposure prophylaxis (PrEP) education and PrEP prescriptions were 32% and 20%, respectively. 69% of programs rated HIV services as either “essential” or “very important.” One-half of all programs were unable to estimate the number of clients receiving antiretroviral therapy and only 18% were “fully integrated.” Barriers to provision of HIV services comprised limited training and time, client resistance, and providers feeling overwhelmed by other comorbid conditions. Nearly all programs served clients with comorbid substance related conditions. Significant differences in results were found between this study and findings from the 1997 and 2004 studies. This recent study found a higher proportion of rural programs, programs with any HIV-infected clients, and more programs serving more than 100 clients with HIV or AIDS. There was a significant decline in some aspects of HIV treatment and prevention. Proportionally fewer programs supplied condoms and were able to estimate HIV testing rates and antiretroviral initiation.
Strengths and limitations
This study expands our understanding of the understudied intersection between HIV treatment and prevention and treatment services for people living with serious mental illness. Additionally, the study’s design comparing multiple “snapshots” over a 20-year period may offer insights that could guide future research and anticipate evolving resource needs. HIV medical care integrated in a psychiatric service setting could inform development of service models that integrate primary care and other medical specialties located within mental health centers. The inclusion of rural and suburban geographic locations fills a gap in knowledge about unique psychiatric and HIV treatment needs of people with serious mental illness. A 31% response rate is regarded acceptable for online surveys. The generalizability of findings to other states in the U.S. is limited. The quality of the survey data may vary among agencies and across the 20-year study period. Program characteristics also changed over time further limiting comparisons among the reporting periods. The degree to which the study accurately represents a broader group of programs and clients, and thus generalizability, is limited. An analysis of the differences between the respondent and non-respondent groups was not possible.
Higher than expected HIV seroprevalence rates among psychiatric patients in general, and among specific diagnostic groups including those encompassing serious mental illness, is well documented. Less is known about HIV treatment and prevention service needs in outpatient psychiatric settings. This study suggests that a majority of outpatient mental health centers across New York State recognize the importance of addressing HIV-related needs of clients. Despite this recognition, there is much work to be done to optimize care. Study findings point to relatively low cost interventions that may improve prevention outcomes. For example wider condom distribution, provider and client education about PrEP, provider, or referral to a provider, who prescribes PrEP, and on site HIV testing are achievable measures in the short-term. Leveraging electronic health records to identify HIV-infected clients and track antiretroviral medication uptake and adherence may be feasible and with high enough yield to justify piloting in some settings. Innovation at a systems level across multiple sites may also improve overall outcomes. Development of a nursing service staffed by R.N.s and nurse practitioners with training in HIV medicine, metabolic disorders, and other disorders commonly seen in serious mental illness may be a model for further integration of care. These improvements may have a significant outcome effect on the country’s plan to end HIV in the next decade.
Type of study
This was a survey-based study at 3 sampling points across a 20-year study period.
Patients with dementia often receive antipsychotics in combination with other psychotropic medications. This study compared mortality for antipsychotics combined with benzodiazepines or antidepressants with that for antipsychotic monotherapy. As the HIV population has aged, our understanding of the pathogenesis of HIV-associated neurocognitive disorders (HAND) and of the overlap with and vulnerability to other neurodegenerative disorders is evolving. This article reminds us to consider both HIV-associated as well as other causes of neurocognitive decline in people living with HIV and the potential risks of benzodiazepines including worsening of cognitive impairment, superimposed delirium, and falls.