Community mental health's role in the AIDS crisis

Characteristics and Trends in HIV Testing Among Medicaid Enrollees Diagnosed as Having Schizophrenia

OBJECTIVE

People with schizophrenia have more HIV risk factors and higher rates of HIV infection than the general U.S. population. The authors aimed to examine HIV testing patterns in this population nationally and by demographic characteristics and presence of high-risk comorbid conditions.

METHODS

This retrospective longitudinal study compared HIV testing between Medicaid-only enrollees with schizophrenia and without schizophrenia during 2002-2012 (N=6,849,351). Interrupted time series were used to analyze the impacts of the 2006 federal policy change recommending expanded HIV testing. Among enrollees with schizophrenia, multivariable logistic regression was used to estimate associations between testing and both demographic characteristics and comorbid conditions. Sensitivity analyses were also conducted.

RESULTS

Enrollees diagnosed as having schizophrenia had consistently higher HIV testing rates than those without schizophrenia. When those with comorbid substance use disorders or sexually transmitted infections were excluded, testing was higher for individuals without schizophrenia (p<0.001). The federal policy change likely increased testing for both groups (p<0.001), but the net change was greater for those without schizophrenia (3.1 vs. 2.2 percentage points). Among enrollees with schizophrenia, testing rates doubled during 2002-2012 (3.9% to 7.2%), varied across states (range 17 percentage points), and tripled for those with at least one annual nonpsychiatric medical visit (vs. no visit; adjusted OR=3.10, 95% CI=2.99-3.22).

CONCLUSIONS

Nationally, <10% of enrollees with schizophrenia had annual HIV testing. Increases appear to be driven by high-risk comorbid conditions and nonpsychiatric encounters, rather than by efforts to target people with schizophrenia. Psychiatric guidelines for schizophrenia care should consider HIV testing alongside annual metabolic screening.

Case managers discovering what recovery means through an HIV prevention intervention

Following a randomized trial of case manager delivered HIV prevention intervention to persons with severe mental illness (SMI), this study sought to document changes within the service environment and with case managers themselves as a result of their experience and skills training. Utilizing qualitative methods, researchers conducted focus groups and in-depth interviews with 22 case managers and 3 administrators at an urban community mental health center. Beyond confirming previously established barriers to case manager delivery of HIV prevention interventions for persons with SMI, most noteworthy was the finding that case managers were generally unskilled in conducting assessments and tended to focus on "spoiled identity" and illness parts of their consumers. Experimental case managers revealed that they had been transformed by the training experience in a manner permitting them to both understand and work from a recovery model. Implications and directions for further study are discussed.

The social organization of HIV/AIDS care in treatment programmes for adults with serious mental illness

As the HIV epidemic expands within the mental health system, mental health professionals (MHPs) are under increased pressure to provide more HIV-related care to clients in treatment for serious mental illness. Scientific understanding of MHPs' readiness to provide these services, however, is limited. This paper examines the distribution of HIV care experience, HIV care-related knowledge, and related attitudes among 524 MHPs employed in three CMHCs and two state psychiatric hospitals in central Indiana. The results indicate that both clinical experience and subjective readiness to provide HIV care are concentrated among a few MHPs--primarily gay, lesbian, or bisexual (g/l/b) staff--within each facility. This informal system for organizing HIV care highlights the unique contributions g/l/b staff members make both in providing direct HIV care and in making sure that HIV-related issues are addressed in mental health settings. The implications of g/l/b staff members' "gate making" function for improving the provision of HIV-related mental health services are discussed.

Early HIV detection: a community mental health role

This paper documents the changing need for early detection of human immunodeficiency virus (HIV) infection and proposes a role for community mental health centers (CMHCs). Ignorance of HIV infection status can result in greater risk of medical complications and denies the individual the opportunity to take the steps necessary to prolong life and prevent further transmission of the virus. Individuals who know they are infected can obtain good medical care, avoid infection, avoid becoming pregnant, behave responsibly and plan their lives appropriately. Advances in specific therapeutics now make it important for infected individuals to know their HIV status well before becoming overly ill. The social history, sexual history, drug use history, and physical and mental status of each client will provide important clues regarding infection status. Reluctance to refer for testing because of concerns about level of stress, liability and confidentiality should be tempered by a policy of referring for testing whenever any indication of infection arises.

Training HIV specialists for community mental health

There is a critical need for trained HIV mental health specialists who possess the knowledge and attitudes necessary to meet the challenges of the HIV epidemic. A model for an intensive and experimental continuing education tutorial is briefly described, and evaluative data are presented. Upon completion of the three-day workshop, participants show an increase in HIV-related knowledge and a positive shift in attitudes regarding working with people affected by HIV disease.

The HIV mental health spectrum

The growing mental health needs that are related to HIV are immense and diverse. The HIV mental health spectrum is a model that identifies and characterizes populations in need of HIV-related services which can be offered by Community Mental Health Centers. The spectrum describes the specialized service requirements for each of these populations, the challenges in providing these services, and staff training needs. The authors propose this as a useful model for clinicians, researchers, educators, and administrators in planning to meet the needs of this expanding epidemic.

Suicide among AIDS patients

I studied 25 cases of suicide in people diagnosed as having the acquired immunodeficiency syndrome (AIDS) or who thought that they had that disorder, during 1985-1989. Case reports are presented. A discussion ensues concerning the occurrence of this phenomenon and the medical examiner's role in AIDS' public health situation in general.

AIDS education for patients with chronic mental illness

Despite the AIDS epidemic's impact, development of prevention and risk-reduction programs has been slow, especially for patients with chronic mental illness. These patients may be at particular risk for HIV transmission and acquisition due to characteristics of their illness. Despite a paucity of such program descriptions in the literature and widespread concern that exposure of such patients to educational material related to sexuality or AIDS would be overstimulating, an effective and safe curriculum to teach risk-reduction can be designed. This paper describes such a program at the Massachusetts Mental Health Center, in Boston.

Mental health and substance abuse staff: HIV/AIDS knowledge and attitudes

Mental health and substance abuse treatment staff completed a set of measures assessing their attitudes, knowledge, and beliefs concerning AIDS. Results indicated that while most staff were aware of basic information about the disease, approximately one-third were not aware of the neuropsychological and psycho-behavioural concomitants of the disorder. Those surveyed were aware of the main transmission routes, but overgeneralized their concern to casual contact. Most staff indicated willingness to work with HIV-infected individuals, although 29% stated they would try to avoid working with them. Interestingly, mental health staff expressed greater hesitancy than substance abuse staff. These and other results are interpreted to suggest that some desensitization of concern may have already occurred among those who have worked with HIV-positive clients. Individuals who had worked with an HIV-positive client had greater knowledge, less discomfort, and were less likely to want to avoid those who are HIV-positive. Questions attempting to identify sources of discomfort in working with AIDS or HIV-positive clients suggested that fear of contagion may be the primary concern, followed by discomfort of working with the terminally ill, and then discomfort with IV drug users and homosexuals. The implications of these results for continuing education activities and staff readiness are discussed.

The HIV clinical tutorial for community mental health professionals

HIV disease is an emerging community mental health concern. The need for specialized training to help community mental health professionals develop comprehensive knowledge and skills to serve this new population of clients is evident. The HIV clinical tutorial model is an innovative approach to continuing education characterized by an experiential and clinical orientation, a small participant group, and an interdisciplinary faculty. The three-day intensive workshop provides participants with experiences that can alter their perspective toward clients affected by HIV/AIDS and toward the role of the mental health system in responding to this epidemic. Similar training programs should be developed nationwide through collaboration among medical schools, teaching hospitals, public health departments and community mental health centers.