Correlates of HIV antiretroviral adherence in persons with serious mental illness

Although several studies have examined the relationship between symptoms of depression or psychological distress and medication adherence, this is the first published study of HIV antiretroviral adherence and its correlates among persons diagnosed with serious mental illness. Forty-five of 47 (96%) participants completed a two-week study in which their adherence to antiretroviral medication was measured using electronic monitoring caps. Mean adherence (proportion of prescribed doses taken) was 66% (SD=34). There were several correlates (p<0.05) of adherence among background and medical characteristics, physical symptoms and side effects, cognitive and psychosocial functioning, and treatment-related attitudes and beliefs. However, in a forward stepwise regression, attendance at recent clinical appointments was the sole predictor that entered the model--accounting for 49% of the variance in adherence. Using attendance at recent clinic appointments as the criterion, adherence readiness (90+% adherence to antiretrovirals) was correctly determined for 72% of the sample. Although not sufficient to serve as the basis for treatment decision making, review of appointment-keeping records may provide clinicians with a simple, cost-effective method for predicting adherence to ongoing treatment, as well as for evaluating adherence readiness to inform the decision of whether to prescribe or defer treatment.     

Patterns of HIV care for patients with serious mental illness

Individuals with serious mental illness are at higher risk for HIV than are members of the general population. Although studies have shown that individuals with serious mental illness experience less adequate care and worse physical health outcomes than comparable patients without serious mental illness, little is known about HIV care among individuals with serious mental illness who become infected with HIV. In the present study, we describe patterns of highly active antiretroviral treatment (HAART) use and physician monitoring received by 154 patients with serious mental illness infected with HIV. Participants were recruited from mental health agencies in Los Angeles, California. Data from 762 HIV-only patients from a separate Western U.S. probability sample were used for comparison. High proportions of serious mental illness patients with HIV in our sample appeared to be receiving adequate HIV care. Fifty-one percent of all serious mental illness patients with serious mental illness with HIV were taking HAART, and the majority received close monitoring of their CD4 counts (84%) and viral loads (82%) throughout a 1-year period. HAART use and patterns of CD4 count and viral load monitoring did not differ significantly between patients with both serious mental illness and HIV, and patients with HIV only (all p > 0.05). Specialized programs providing assistance to serious mental illness populations with HIV may be helping to narrow health care disparities as a result of having serious mental illness.     

Specifying cigarette smoking and quitting among people with serious mental illness

People with serious mental illnesses (SMI) have a high prevalence of cigarette smoking. Details of their smoking and quitting behaviors are needed to create effective interventions. This study aims to describe the smoking and quitting histories, current behaviors, and motivations of an outpatient sample of smokers with SMI. A structured interview and Breathalyzer assessment were administered to 120 smokers from four diverse mental health settings. Participants' smoking and quitting self-report data are presented in combination with demographic and clinical variables; the results provide implications for smoking cessation, amelioration, and prevention interventions and for future research.     

Correlates of severity of smoking among persons with severe mental illness

Individuals with schizophrenia and severe mental illness smoke cigarettes at rates that well exceed the general population. Little is known about the correlates and sequelae of increased smoking severity on persons with severe mental illness. A total of 304 smokers from six community mental health centers were assessed for smoking history, psychiatric symptoms, co-occurring disorders, subjective quality of life, and expired carbon monoxide (CO). Statistical analyses identified correlates of smoking severity, as assessed by number of cigarettes smoked per week. The average number of cigarettes smoked per week was 136+/-83. Increased smoking was associated with higher levels of expired CO and being Caucasian, and with a greater likelihood of a current diagnosis of hypertension and oral/gum disease. Greater smoking severity was also associated with greater perceived stress, poorer overall subjective quality of life, and lower satisfaction with finances, health, leisure activities, and social relationships. This study confirms high rates of heavy smoking among persons with severe mental illness. The association of increased quantity of cigarettes smoked with being Caucasian is consistent with previous reports in mentally ill and non-mentally ill populations. The linkage of heavy smoking with poorer quality of life and co-occurring medical disorders suggests the importance of smoking reduction and cessation strategies to reduce smoking and decrease patients' total pack years of smoking.     

Correlates of HIV infection among patients with mental illness in Brazil

People living with mental illness are at increased risk for HIV. There are scarce data on correlates and prevalence of HIV infection, and none with a nationally representative sample. We report on correlates of HIV infection from a cross-sectional national sample of adults receiving care in 26 publicly funded mental health treatment settings throughout Brazil. Weighted prevalence rate ratios were obtained using multiple log-binomial regression modeling. History of homelessness, ever having an STD, early age of first sexual intercourse before 18 years old, having suffered sexual violence, previous HIV testing, self-perception of high risk of HIV infection and not knowing one's risk were statistically associated with HIV infection. Our study found an elevated HIV seroprevalence and correlates of infection were not found to include psychiatric diagnoses or hospitalizations but instead reflected marginalized living circumstances and HIV testing history. These adverse life circumstances (history of homelessness, having suffered sexual violence, reporting a sexually transmitted disease, and early sexual debut) may not be unique to people living with mental illness but nonetheless the mental health care system can serve as an important point of entry for HIV prevention in this population.     

The Evolution of HIV illness representation among marginally housed persons

Many HIV-infected marginally housed individuals have difficulty engaging in health care. To investigate HIV health-related behaviour, 14 in-depth interviews with marginally housed HIV-infected individuals were conducted and analysed utilizing standard qualitative methodologies. The analysis was based on the Illness Representation Model, which describes five conceptual dimensions of illness: identification; cause; timeline; management; and consequences. A theoretical model of illness representation at two distinct time points emerged and included the two categories: 'didn't suspect and didn't believe it' and 'knew but needed proof'. In this study illness representation categories were found to evolve and change over time, and were associated with engagement in HIV care. This study may help guide programmes that focus on enhancing health-promoting behaviour and improving engagement in health care among marginally housed individuals.     

The HIV epidemic among individuals with mental illness in the United States

People with depression and other mental illness comprise a growing proportion of individuals living with HIV in the United States; at the same time, the prevalence of HIV among mentally ill individuals is at least seven times higher than in the general population. Individuals with mental illness are particularly vulnerable to infection with HIV because of several factors, including the higher prevalence of poverty, homelessness, high-risk sexual activities, drug abuse, sexual abuse, and social marginalization found in this population. Nevertheless, mentally ill individuals are often not screened for HIV and may not be appropriately targeted in current HIV prevention efforts. Moreover, despite widespread access to antiretroviral treatment in the United States, HIV outcomes among mentally ill individuals continue to be poor. This disparity can be explained by several interrelated factors, including lower rates of highly active antiretroviral therapy (HAART) utilization, lower rates of adherence to HAART, and immunologic changes associated with mental illness itself. We need to improve our design of prevention, screening, and treatment programs to better reach individuals with comorbid HIV and mental illness.     

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.     

Adherence practices among people living with HIV

This paper offers a critique of patient-deficit models of adherence by examining the articulation of dosing schedules and food prohibitions with the structure of everyday lives. Interviews with 31 men and 4 women taking HAART show that doses associated with regular daily life events are most consistently taken, but many individuals rework official dosing guidelines around timing and food consumption. Barriers to adherence often arise from conflicting demands imposed by work schedules, different medications, food prohibitions, and even outright discrimination as in the case of US immigration policy. Adherence may be the outcome of compromises made in an effort to solve contradictory demands, and may be situational and related to the qualities of particular drugs, as much as to personality traits. Autobiographical narratives that give order to one's sense of self provide foundations upon which adherence decision making occurs. Finally, perceptions of drug effectiveness may lead to self-reinforcing adherence practices.     

Supported medical care: a multi-faceted approach to helping HIV/hepatitis C virus co-infected adults with serious mental illness

This paper presents a multi-faceted supported rehabilitation and health management model to inform the development of interventions for mentally ill adults who are HIV/hepatitis C virus co-infected. The model, referred to as 'supported medical care' (SMC), calls for the combination of chronic illness self-management skills training and enhanced case management. Illustrative examples of each SMC intervention component are provided. Integrated delivery of these intervention components shows promise for improving the coordination of psychiatric and medical care. Research and related policy challenges regarding ongoing quality improvement efforts are also discussed.     

Adherence to HAART among HIV-infected persons in rural Louisiana

The purpose of this study was to examine factors associated with nonadherence to highly active antiretroviral therapy (HAART) in patients seen in HIV clinics throughout nonurban Louisiana. A convenience sample of 273 patients from 8 areas in nonurban Louisiana were interviewed to obtain demographic, clinical and adherence information. Associations between demographic, clinical, and behavioral factors and nonadherence were examined. Ideally, non-adherence should not exceed 5% in patients for whom HAART was prescribed. Mean age was 38.6 years (range, 19-66), 29.3% were female, 60.1% were African American, 34.4% reported nonadherence to their HAART medication (defined as the subject's self-report of missing any doses of HAART medication in the prior week). In the prior month, participants reported the following behaviors: binge drinking (12.8%), problem drinking (12.8%), and illicit drug use (16.5%). Depression was found in 49.8% of the respondents. In logistic regression analysis, problem drinking odds ratio [OR] (95% confidence interval [CI]): 3.92 (1.69,9.09) was found to be associated with nonadherence. Demographic and behavioral factors such as illicit drug use and depression were not associated with nonadherence on multivariable analysis. Problem drinking was associated with lack of adherence to HAART over the past week. Interventions to treat problem drinking are needed and may improve adherence to medication for HIV-infected persons living in rural, town, and small-city areas.     

HIV and chronic mental illness

The literature on HIV seroprevalence, risk, knowledge, and behavior is reviewed, and suggestions for treating seropositive people with chronic mental illness is outlined. In general, people with chronic mental illness have higher rates of HIV than people within the general population. Within this chronic mental illness population, seroprevalence is more prevalent among injection drug users and men who have sex with men. Homelessness is a risk factor for HIV infection and disease progression. Research indicates that mentally ill patients do not score well on assessments of their HIV-related knowledge, attitudes, and risk behavior. The provision of physical and mental health care for seropositive people with mental illness is a complex process that must take into account the full range of needs and obstacles faced by this high risk group.     

Obesity, serious mental illness and antipsychotic drugs

The prevalence of overweight and obesity is higher in people with mental illness than in the general population. Body weight is tightly regulated by a complex system involving the cortex and limbic system, the hypothalamus and the gastrointestinal tract. While there are justifiable concerns about the weight gain associated with antipsychotic medication, it is too simplistic to ascribe all obesity in people with serious mental illness (SMI) to their drug treatment. The development of obesity in SMI results from the complex interaction of the genotype and environment of the person with mental illness, the mental illness itself and antipsychotic medication. There are dysfunctional reward mechanisms in SMI that may contribute to poor food choices and overeating. While it is clear that antipsychotics have profound effects to stimulate appetite, no one receptor interaction provides an adequate explanation for this effect, and many mechanisms are likely to be involved. The complexity of the system regulating body weight allows us to start to understand why some individuals appear much more prone to weight gain and obesity than others.     

HIV infection in persons with prior mental retardation

This paper presents five case studies of persons who were mentally retarded prior to infection with human immunodeficiency virus (HIV). Particular emphasis is placed on neuropsychological functioning, and its interaction with management and treatment. The effects of HIV on neurological functioning in such persons has not been previously documented. Although it may be hypothesized that mentally retarded people are at increased risk for developing neurological complications, these preliminary data suggest this is not so and that the development of HIV-related encephalopathy is no different in the mentally retarded, manifesting in the AIDS-related complex (ARC) and AIDS stages of illness. Within the context of HIV infection, the cognitive status of the mentally retarded creates unique treatment and management difficulties, and some guidelines are presented.     

Self-reported sexual dysfunction is frequent among HIV-infected persons and is associated with suboptimal adherence to antiretrovirals

Increased occurrence of sexual dysfunction (SD) among patients treated with highly active antiretroviral therapy (HAART) has been reported. To assess prevalence of self-reported SD and to identify factors related to this alteration with special focus to its relationship with adherence behavior, we conducted an intercohort analysis among HIV-infected persons treated with HAART. In an anonymous questionnaire investigating HAART nonadherence, patients were asked to report the occurrence of dysfunction in sexual activity over the previous 4 weeks. Among 612 participants, 125 (21%) reported some degree of SD. "Moderate"/"severe" alterations were reported in 6% and were independently associated with self-reported worsening of viro-immunological parameters (OR 3.90; 95% CI 1.08-14.18), higher symptom score (OR 1.13; 95% CI 1.05-1.22), and reporting abnormal fat accumulation (OR 4.33; 95% CI 1.55-12.11). Furthermore, nonadherent persons had an increased risk of SD (OR 3.44; 95% CI 1.30-9.08). In conclusion, patients' perceived SD represents a relevant problem for HIV-infected persons treated with antiretrovirals and is strongly associated with suboptimal HAART adherence.