Treating people with serious mental illnesses and HIV/AIDS is one of the more challenging tasks in modern medicine. While we have well-studied, effective treatments for serious mental illnesses like schizophrenia, bipolar disorder, and major depressive disorder, using those treatments in someone with HIV/AIDS is complicated by issues of adherence, drug interactions, and the social and environmental barriers that go along with having a serious mental illness. On the other hand, advances in managing HIV have turned a once devastating terminal diagnosis into a manageable chronic illness in just a few decades. However, successfully managing an individual with a new diagnosis of HIV who needs to commit to life-long antiretroviral therapy is greatly complicated when that person has a substance use disorder as well as another psychiatric disorder, a serious mental illness (the so-called triply diagnosed). In this chapter we discuss basic principles involved in caring for someone with HIV/AIDs and a serious mental illness.
Epidemiology and Treatment Overview
Infection with HIV is now best understood as a chronic illness. According to the Centers for Disease Control and Prevention (CDC), in the United States, at least 1.2 million people are living with this infection, of which a significant minority (12%) are not aware that they are infected (CDC, 2016). Using only statistics from the United States runs the risk of understating the global HIV/AIDS problem. Persons with HIV infection in the United States account for less than 5% of the total number of people in the world dealing with this infection (about 37 million). In fact, the number of people living with HIV in the United States is equal to the number of people each year who die worldwide from this disease (Kaiser Family Foundation, 2015). In the United States, the epidemic is not generalized, but concentrated in subpopulations with higher risk. In people described as having serious mental illness (SMI), rates of infection and transmission have been estimated as more than 70 times that of the general population (Andriote and Cournos, 2012). There is also substantial research demonstrating that persons with HIV/AIDS have high risk and prevalence of SMI and other medical problems. This two-way (or often three- or four-way) street of illness has been described as a syndemic (Blank and Eisenberg, 2013a), and the triply diagnosed individual (HIV, SMI, and substance abuse) is one of the most vulnerable in the world.
Given the increased rates of HIV among people with mental illness, we might claim that HIV/AIDS has reached an epidemic proportion in this population. Persons with mental illness and HIV/AIDS are at high risk to have poor outcomes because of lack of access to healthcare, poor social and financial support, cognitive limitations, difficult environmental factors, and a propensity toward high-risk behaviors. Compared with HIV-positive individuals without mental illness, people with mental illness receive their HIV diagnoses later, are less likely to receive treatment, and are more likely to experience morbidity and earlier mortality (Blank et al., 2013).
Regarding serious mental illness, approximately 2.6% of persons in the United States meet the criteria (based on duration, disability, and diagnosis) for SMI in a given year (Kessler et al., 1996). Most individuals with SMI have schizophrenia, bipolar disorder, and major depressive disorder, requiring extended or frequent hospitalizations (Regier et al., 1990). Schizophrenia and bipolar disorder can impair a person’s ability to perceive HIV risk, modify behavior, and participate in treatment. Adequate consideration and treatment of the specific symptoms in individual patients will maximize their adherence to a comprehensive treatment plan.
Medical comorbidities, including HIV/AIDS, are common among people with mental illness (Green et al., 2003; Jones et al., 2004; McKinnon et al., 2002). The treatment of people with mental illness and HIV infection requires greater attention, more resources, and a multidisciplinary setting (Horberg et al., 2011). People with mental illness and HIV/AIDS often frustrate their HIV clinicians, who may not have adequate training to treat the comorbid psychiatric disorders.
The National HIV/AIDS Strategy’s treatment cascade (The White House, 2015) highlights that over 50% of people diagnosed with HIV are not in medical care (Mugavero et al., 2013). Delays in HIV treatment for people with HIV and mental illness may be due to concerns about inadequate adherence and emergence of viral resistance, a sense of futility about outcomes, and patients’ lack of cooperation and adherence to treatment recommendations. Nearly half of newly diagnosed patients with HIV enter into medical care within 3 months, and 30% enter into medical care within 4–12 months. However, 22% do not initiate medical care in the first 12 months of diagnosis (Tripathi et al., 2011). Although people with HIV and chronic mental illness are less likely to be treated with antiretroviral therapy (ART) (Fairfield et al., 1999), they may be the patients most immediately in need of treatment. Invariably, substance abuse, which is present in at least half of most samples with severe mental illness, is seen as complicating and worsening treatment outcomes and disease progression.
There are many compelling reasons to make a concerted effort to provide adequate and comprehensive treatment for persons with HIV/AIDS and mental illness. Patients in successful mental health treatment have better quality of life and better care for themselves, and they participate in family and community life. As such, the goals for HIV/AIDS clinics and clinicians should be to improve quality of life by providing support, changing damaging beliefs, and reducing harmful behavior. Furthermore, improved mental health enables patients to engage, participate in, tolerate, and adhere to medical care and treatment for HIV, and it decreases the risk of transmission of HIV to others, through behavior modification and decreasing viral suppression.
Serious Mental Illness, HIV Risk, and HIV Prevention
People with chronic mental illness have an increased risk of acquiring and transmitting HIV compared to the general population (Andriote and Cournos, 2012; Hobkirk et al., 2015). In the past, it was often assumed that just having an SMI such as schizophrenia or bipolar disorder was itself a risk factor for becoming infected with HIV (Gottesman and Groom, 1997). But the reality is that factors driving risk for HIV transmission in persons with SMI is more complicated than just having a symptomatic mental illness—it is all of the social and environmental factors (homelessness, threat of violence, high-risk sexual and drug use behavior) that are often present in persons with SMI that bring about the increased risk (Hobkirk et al., 2015).
Surprisingly, some studies have found that mentally ill individuals who practice risky behaviors had greater knowledge of HIV risks than individuals who did not (Chuang and Atkinson, 1996, McKinnon et al., 1996). However, more knowledge may not translate into less risky behaviors, and subsequent studies found reduced knowledge of HIV risks in persons with schizophrenia (DeHert et al., 2011). High-risk behaviors more common among psychiatric patients include multiple partners; partners with known HIV-positive status; substance use during sex; trading sex for money, drugs, or housing; and lack of condom use (Treisman and Angelino, 2004). Interestingly, compared to individuals with substance abuse alone, persons with SMI and substance abuse have similar numbers of sexual partners and rates of unprotected oral, anal, and vaginal sex; but persons with SMI have significantly increased rates of very high–risk behaviors: trading sex for money or gifts, being forced to have sex, having sex with intravenous drug users and persons with known HIV-positive status, and sharing needles (Dausey and Desai, 2003). Coercive sexual behavior and physical violence in particular have been shown to be frequent among chronically mentally ill patients (Carey et al., 1997). Many individuals with mental illness have unstable housing and finances, making access to condoms and clean injection tools more difficult (Drake and Wallach, 1989; McKinnon et al., 2002).
Many clinicians use counseling about risky behavior as the primary means of HIV prevention. Data on people with SMI indicate that, at baseline, people with mental illness have more difficulty with behavior self-modification, limiting the degree to which better knowledge of HIV prevention actually translates into behavior change (Carey et al., 1997). Thus, the HIV clinician and clinic staff need to both educate and actively intervene to facilitate behavior change. Interventions focused on persons with SMI can be effective especially if it includes education about specific topics with regular content repetition. Such topics include training on how to combat the problem of poor medical appointment attendance, enhancing assertiveness and negotiation, and how to get away from high-risk situations (Hobkirk et al., 2015). In addition, it is important to address beliefs related to HIV risk, means of improving sexual or drug paraphernalia hygiene, negotiation of condom use, recognition of vulnerable emotional states, ways of avoiding risky behaviors, and sexual empowerment. A thorough evaluation is required in order to identify individual risk factors for acquiring HIV and develop interventions to reduce this risk. Patients with mental illness consistently underestimate the risk of their own behaviors (Carey et al., 1997). Helping patients to find other financial support or substance abuse treatment is critical toward reducing the exchange of sex for money or drugs. Screening and treatment for victims of sexual abuse and assault should be addressed, since in one group of psychiatric outpatients, 13% reported being pressured for sex, and 14% reported being coerced or forced into sex in the past year (Carey et al., 1997). In all settings, same-sex partnerships should be discussed, since there is a high prevalence of same-sex activity, particularly in men who have serious mental illness (McKinnon et al., 2002).
Psychiatric Treatment in Persons with SMI and HIV/AIDS
Psychiatric treatment is especially important for individuals with psychosis, as there may be a correlation between active psychiatric symptoms and high-risk behaviors (Hobkirk et al., 2015). Successful reduction of positive symptoms of schizophrenia or manic symptoms in someone with bipolar disorder may lead to a reduction in risky behaviors and improved overall treatment adherence and outcomes. Antidepressant therapy can be helpful for patients with depression, as individuals with depression may also engage in risky behavior because of a sense of hopelessness.
It is critical that patients set goals toward healthy partnerships and discuss what a healthy relationship entails, as many patients may never have experienced a stable romantic relationship. Having positive goals toward developing loving relationships also helps patients maintain a positive focus and appeals to reward-seeking extroverts; HIV risk counseling often focuses solely on risks and thus appeals less to extroverts who are less risk avoidant. Although HIV risk counseling in patients with SMI can produce significant reductions in risk behavior after fewer than 10 treatment sessions (McKinnon et al., 2002), the practice of risk reduction fades over time, thus sessions that help maintain risk reduction may help to sustain subsequent benefits.
The prototypical psychotic disorder, schizophrenia, is at its core a neurocognitive disorder with executive dysfunction. Viewed in this light, patients can be expected to have difficulties planning and carrying out complex tasks, particularly when an adaptive and flexible response to environmental and interpersonal situations is needed. Executive dysfunction in the context of HIV interferes with optimal HIV treatment and with the ability to manage risks and modify behaviors to reduce the chances of acquiring HIV in the first place.
In addition to the cognitive deficits, schizophrenia is characterized by both positive and negative features. The more chronic and disabling negative features are often the least well understood by medical practitioners and yet may profoundly influence the relationship with the clinician. The “positive” features include episodes of psychosis in which individuals develop hallucinations (usually auditory), delusions (often paranoid and bizarre), and disordered thinking. These intrusive experiences are often disturbing and can lead to unpredictable and bizarre behavior that alienates them from others and may be dangerous to the self or others.
In general, there is no difference between the pharmacological treatment of schizophrenia in an HIV-infected individual and the treatment of an uninfected person, but some specific considerations should be kept in mind. It is important to take into consideration interactions between ART medications and antipsychotics; psychiatrists and HIV practitioners must work together closely during initiation of or changes in antiretroviral or antipsychotic treatment, as concomitant alterations in dosing may be needed (Treisman and Angelino, 2004). Antipsychotics are associated with potentially severe side effects, such as tardive dyskinesia and parkinsonian syndromes, known as extrapyramidal symptoms (EPS). Patients with HIV are more sensitive to the extrapyramidal side effects of antipsychotics than patients who are HIV negative, particularly during advanced disease stages. In addition, antipsychotics have effects on metabolism, including weight gain, increased insulin resistance, and increased lipids, that may aggravate similar effects produced by antiviral medications (Ferrera et al., 2014)
Treatment principles for persons with schizophrenia apply universally. They include medications for the control of hallucinations, delusions, thought disorders, and negative symptoms, as well as psychosocial rehabilitation for reintegration into the community. Studies have shown that adequate treatment of positive symptoms leads to significant reductions in HIV risk behaviors (McKinnon et al., 1996). The treatment of negative symptoms may help to motivate and engage the patient in treatment. Reality testing should be supported at all times, and the confrontation of delusional thoughts should be gentle and appropriately timed.
Patients might need additional support (e.g., a visiting nurse) or assisted treatment (e.g., court-ordered treatment where available) to achieve sufficient medication compliance. Long-acting injectable antipsychotics (LAIs) may be helpful for patients unable to adhere to oral regimens (Peng et al., 2011). However, LAIs are no panacea, as the patient still needs to accept the injection. The incorporation of friends and family into the treatment plan can improve adherence to treatment and reinforce consistency of the treatment message and provide support to these caregivers. Occasionally, issues arise because of delusions the schizophrenic person has concerning the HIV infection itself. The most common of these is the belief that the person does not have an HIV infection and that the situation is a hoax, created to monitor the person’s activity or somehow control the person (Treisman and Angelino, 2004). Adequate antipsychotic treatment combined with a consistent but supportive message from the family, psychiatric team, and HIV team can address delusions and hallucinations that interfere with HIV treatment. Given its pernicious effect on adherence in particular, substance abuse needs to be addressed in all patients with schizophrenia (Drake and Wallach, 1989).
Bipolar disorder is an illness that impacts the affective domain of one’s mental health and accounts for many patients with severe mental illness. This condition may be misdiagnosed as schizophrenia when psychosis is prominent, overshadowing the mood disturbance. In the classic descriptions of bipolar disorder, patients spend extended periods of time depressed, usually weeks to months at a time, followed by shorter periods when they are in an elevated, euphoric, and energized state, referred to as mania. Most often, patients cycle from one type of mood to the other, these cycles often interspersed with periods of normal moods but occasionally with intermediate mixed states that have features of both depressive and elevated mood states simultaneously or in rapid succession. The emotions and emotional changes in persons with bipolar disorder run their lives and can have a strong effect on their attitude toward treatment from minute to minute (Treisman and Angelino, 2004). Bipolar disorder is covered in more detail in Chapter 15 of this book.
In contrast to the bipolar disorder found in the general population, another type of mania appears to be specifically associated with late-stage HIV infection (CD4 count <200 per mm3), and it occurs in cognitive impairment or dementia (Kiburtz et al., 1991). This syndrome has been called “AIDS mania” and probably represents a related but different condition, as the patients show a lack of previous episodes or family history (Lyketsos et al., 1997). Clinically, patients with AIDS mania may be difficult to distinguish from patients with delirium, because the sleep–wake cycle is often disturbed and individuals show a good deal of confusion and cognitive impairment. For this reason, the workup begins with a careful evaluation of the causes of delirium. Persons with AIDS mania may differ clinically from persons with familial bipolar disorder, as the predominant mood tends to be irritability rather than elation or euphoria. A review at a hospital AIDS clinic in the United States found that 8% of patients with AIDS experienced a manic syndrome at some point during the course of the illness (Lyketsos et al., 1993). Of these patients experiencing manic syndromes, half had no personal or family history of bipolar disorder and were more likely to have later-stage AIDS. Another study in Uganda found that, compared to persons with primary bipolar disorder, persons with AIDS mania were more often female, older, less educated, and more cognitively impaired (Nakimuli-Mpunga et al., 2006). They also had more manic symptoms, including more irritability, more aggression, and more auditory hallucinations. Personal or family history, imaging findings, and other clinical indicators may help to distinguish between AIDS mania and bipolar mania associated with AIDS (Lyketsos et al., 1993).
Major Depressive Disorder
Depression is the most common psychiatric disorder and is common among individuals with HIV/AIDS. A meta-analysis of studies reported active depression in 9.4% of individuals with HIV/AIDS compared with 5.2% in HIV-negative individuals (Ciesla and Roberts, 2001). Individuals with depression are predisposed to greater HIV/AIDS risk for several reasons. Higher HIV risk may result from a sense of hopelessness about the future. Additionally, persons with depression may seek to alleviate their symptoms with alcohol and other drugs. Alcohol abuse and dependence are prevalent among persons with depression. For persons with depression, alcohol use is a major source of HIV risk; under the influence of alcohol depressed persons are more likely to engage in risky sexual behaviors and intravenous drug use (IDU) because of decreased inhibition (McKinnon et al., 2002). Impairments of memory and attention may distract depressed individuals from self-care and risk reduction behaviors and can decrease the likelihood of being diagnosed or entering treatment. Depressive disorder with psychotic features magnifies suffering that is further intensified when it is self-medicated with chronic alcohol or stimulant misuse. This complex multimorbid combination of psychosis, depression, and substance misuse results in difficult-to-understand symptoms at presentation.
Persons with major depressive disorders can be strongly resistant to HIV therapy; they may have difficulty engaging in treatment and maintaining treatment adherence. Because depressed persons feel hopeless, they are less likely to seek care or testing and counseling. It is difficult to engage depressed patients in treatment because they are preoccupied with negative ideas and low mood. Once involved in treatment, one must make an extra effort to maintain their engagement because depression leads to low motivation and energy. This obstacle can be partially overcome through the use of incremental goals and rewards (Treisman and Angelino, 2004). Because depression causes decreased memory and concentration, patients have a more difficult time with medication adherence. Visual cues and memory aids may help improve adherence, and social support can improve morale and adherence. It is therefore necessary to treat depression concomitantly with HIV/AIDS if clinicians wish to succeed in viral suppression.
Major depressive disorder is covered in further detail in Chapter 15 of this book.
Substance Use Disorders
The importance of substance abuse treatment in the care of mentally ill patients with HIV/AIDS cannot be overemphasized. To maximize risk reduction, substance abuse should be addressed in all settings, including behavioral interventions, support for maintaining risk reduction, and medical and psychiatric appointments with healthcare professionals. Numerous studies have shown that persons with schizophrenia and other chronic mental illnesses have high rates of substance abuse, generally ranging from 40% to 75% depending on the substances considered and method of ascertainment (Caton et al., 1989; Horwath et al., 1996; Miller and Tannenbaum, 1989; Regier et al., 1990; Test et al., 1989; Toner et al., 1992).
Various explanations have been given for the use of substances by psychiatric patients, one being that mentally ill persons self-medicate with substances in an attempt to alleviate symptoms or ameliorate side effects of medicines (Dixon et al., 1991; Drake et al., 1989; Khantzian, 1985; Lamb, 1982; Mueser et al., 1990; Test et al., 1989). Another theory is that chronically ill persons have disruptions of social functioning and use substances as a means of connecting with others (Alterman et al., 1982). Although these explanations help clinicians treat dually diagnosed patients, the epidemiological fact remains that persons with severe mental illnesses use substances frequently and should be considered at greater risk for HIV, regardless of the etiological underpinnings of this association.
Substance abuse affects many aspects of HIV/AIDS treatment. It worsens prognosis and compliance, interferes with the creation and maintenance of healthy social relationships, increases risk behaviors, and decreases judgment and insight (Drake and Wallach, 1989; Drake et al., 1996; McKinnon et al., 2002; Mueser et al., 1992). Studies have shown that substance abuse or dependence concurrent with HIV/AIDS is associated with a more severe course of illness and poor medication compliance (RachBeisel et al., 1999). Substance abuse, by worsening psychiatric disorders, may cause more symptoms or worsen one’s coping ability and lead to increased high-risk behavior. IDU must be specifically recognized and addressed, as any lifetime IDU increases the risk of HIV infection from 2- to 10-fold (Horwath et al., 1996). Five to 26% of psychiatric patients report prior injection and 1–8% report IDU in the past 3–12 months (Carey et al., 1997; Rosenberg et al., 2001; Susser et al., 1996). It is thus critical to inquire about IDU at all visits, as IDU among people with severe mental illness is often intermittent (Horwath et al., 1996; McKinnon et al., 2002). People with mental illness are more likely to be part of social networks that include intravenous drug users, increasing the risk of sexual transmission as well as IDU-related infection.
Agonist-based therapies may provide a particularly effective form of treatment for opiate users. Methadone maintenance therapy is highly effective in the management of opiate addiction among persosn who are chronically mentally ill. Adherence to a methadone program has been shown to decrease HIV risk behavior (Wong et al., 2003); it removes individuals from high-risk behaviors and environments while reducing motivation to seek IDU in the community. Moreover, individuals on methadone maintenance therapy demonstrate better adherence to ART, which decreases the overall cost of health care (Sambamoorthi et al., 2000). Methadone can be used by clinicians to give positive reinforcement for desired behaviors, such as rewarding a patient with take-home methadone after several months of negative toxicology screens. Methadone maintenance decreases drug-related morbidity and mortality and crime and improves patient function, leading to improved ability to participate in care.
Although IDU often receives more attention than other substance use in addressing HIV risk and care from clinicians, all forms of substance abuse contribute to risk and a person’s level of function. Alcohol, cocaine, and methamphetamine abuse are particularly important to address in HIV treatment, as their use is associated with high-risk sexual behaviors (McKinnon et al., 2002). Most importantly, substance abuse stands between the goals of HIV treatment and helping the patient with chronic mental illness, as it demoralizes patients; prevents them from achieving stable living situations, work, and healthy relationships; and increases the severity of underlying psychiatric illness. Without the ability to achieve consistency and stability in life, individuals have little opportunity to achieve consistent treatment adherence and improved functional outcome. Substance abuse among individuals with chronic mental illness is widespread, leads to practice of behaviors that put them at risk for HIV, is a poor prognostic factor for psychiatric and HIV treatment, and is associated with increased mortality (DeLorenze et al., 2011).
Medical Treatment of Persons with SMI and HIV/AIDS
Individuals with chronic mental illness are less likely to have access to medical care and are more likely to be without insurance, homeless, and unemployed (Folsom et al., 2005; Meade and Sikkema, 2005). Not surprisingly, HIV treatment outcomes are generally worse for individuals with SMI (Cournos et al., 2005; Goldman, 2000). In addition to societal and system factors, patient and clinician factors also contribute to less optimal outcomes. For example, psychiatric patients with SMI may have a poor appreciation of their medical conditions and may be both less aware of their physical condition and less likely to have or seek adequate medical care. The treatment of mentally ill patients is often more difficult and time consuming for clinicians than for patients without mental illness. Because they are a more difficult population to treat, clinicians are hesitant to accept them as patients, and they are at higher risk for being discharged from care. Psychiatric patients also have decreased ability to participate in their care because of cognitive and emotional limitations. They often fail to appreciate benefits of treatment snot immediately apparent and are focused concretely on the here and now.
Patients with apathy and low mood may feel that treatment is pointless or feel that they just don’t have the energy to participate. Decreased concentration, memory, and executive planning function in many conditions may cause patients to forget medications and appointments.
HIV and medical screening of psychiatric patients is inadequate in psychiatric and medical settings. Patients with severe, chronic mental illness may receive limited medical attention in general and therefore are at risk for sequelae of undiagnosed disorders, such as neurosyphilis and chronic pelvic inflammatory disease. It is also known that women with HIV/AIDS are less likely to receive prenatal care during pregnancy (Turner et al., 1996) and thus are more likely to spread infection to their offspring. It is therefore necessary to aggressively screen individuals with mental illness for HIV; substance abuse and other medical illnesses, such as diabetes, hepatitis, hypertension; and heart disease (Hobkirk et al., 2015). Screening should happen in settings where patients are actually seen, which might mean that psychiatrists need to take an active role in HIV screening. It is helpful for both patients and clinicians to centralize care as much as possible, making all clinicians aware of all medical problems as well as the current treatment plan to provide a consistent message (Treisman and Angelino, 2004). Frequent pregnancy testing and on-site prenatal care may improve outcomes for pregnant women or women of child-bearing age with HIV.
It is important to incorporate preventative medicine whenever possible, including smoking cessation, weight management, and risk reduction; this counseling has been often overlooked in patients with multiple medical problems and with HIV but is even more crucial now that HIV/AIDS has become a chronic illness. Psychiatric practitioners should be vigilant about screening for medical illnesses, even using a standard medical review questionnaire for the periodic assessment of a patient’s medical status. Patients with altered mental status in particular need special attention and careful physical examinations because they may be less likely or able to report symptoms. In addition, we urge medical practitioners in clinics to take extra care in examining individuals who are chronically mentally ill because often their illnesses, or the stigma attached to them, prevent open lines of communication.
In medicine, physicians often seek to educate patients about risks to their health and benefits of treatment and health maintenance in an effort to influence patients’ behavior toward compliance and improved quality of life. Clinicians treating people with chronic mental illness, however, have to take a modified approach to therapy, as many patients will need sustained support over time and tailored toward impairments characteristic for patients with SMI (e.g., executive dysfunction). As discussed earlier, chronically mentally ill individuals with HIV who engage in risky behaviors are often better educated about risks than their HIV-positive counterparts who are not mentally ill (Chuang and Atkinson, 1996, McKinnon et al., 1996), perhaps because of their clinicians’ efforts to motivate them to change through increased education about HIV risk. This suggests that education alone may be successful in increasing knowledge in this population, but not in changing behavior. Cognitive-behavioral therapy can be useful in this regard; identifying harmful attitudes, ideas, and behaviors and creating a framework of new, healthy attitudes and behaviors is helpful for patients who struggle to modify their behavior. Interventions in which patients actively practice health hygiene, behavior modification, safer-sex negotiation, and positive interactions with others help patients to realize their own ability to retrain patterns of harmful behaviors.
Although education is essential, and negative outcomes must be discussed with patients, an optimistic, behavior-focused plan for patients is often more helpful than general discussion of health risks. We encourage clinicians to take small steps in behavior modification, setting one or two concrete goals at each visit and following their progress, praising success, and exploring the cause of failures. These steps also help patients to build rapport with clinicians and build confidence in patients as well as clinicians, who tend to get discouraged with negative outcomes of mentally ill patients.
Nonadherence to medical treatment is one of the major problems in treating individuals with HIV/AIDS. It has been demonstrated that greater than 90% adherence to an ART regimen is needed in order to achieve effective suppression in most patients, at least for regimens that used to be standard just a few years ago (Moreno et al., 2000; Paterson et al., 2000). One study that examined individuals with directly observed therapy (DOT) found that 93% adherence led to 85% of patients achieving an undetectable viral load (Kirkland et al., 2002). Good adherence to ART is related to improved HIV-related mortality, morbidity, and reduced hospitalization (Press et al., 2002).
Difficulty with adherence is compounded among patients with chronic mental illness because they have characteristics predisposing them to poor adherence, including disease-specific problems (e.g., trouble with memory and concentration and the aforementioned executive dysfunction) but also environmental difficulties (e.g., less funds available for medications, lack of transportation, lack of stable housing, homelessness, unemployment, and lack of social support; Chander et al., 2006). A recent study demonstrated that, in patients with bipolar disorder and HIV, greater depressive symptoms and more negative opinions about medication worsened adherence (Casaletto et al., 2016). Factors adversely affecting adherence the most for HIV-positive individuals with severe mental illness are problems with planning, lack of interaction with others, failure to use cues, and HIV/AIDS treatment issues related to lack of motivation, side effects, and hopelessness (Kemppainen et al., 2004). Thus, each patient with HIV/AIDS should be given a thorough assessment for access to medications, transportation, housing, social support, work and ability to work, finances, including ability to afford necessities, and cognitive abilities. A strong patient–clinician relationship not only improves adherence but also enables the physician to anticipate barriers to adherence and intervene early. Patients frequently focus on immediate side effects without appreciating the benefits of treatment. It is important to treat side effects and symptoms whenever possible in order to improve patients’ ability to realize the benefits of treatment.
The patient’s belief system about treatment and their diagnoses can strongly affect their willingness to take any medications. The belief that treatment will be successful improves adherence to proposed medications. The burden of regular appointments and daily medication is greater on this population, and demoralized patients may easily give up on treatment, sometimes citing futility of treatment due to lack of a cure for HIV. Persons experiencing depression have less ability to perform self-care and subjectively experience more pain than when they are well; treating pain adequately may improve adherence. Persons with decreased memory, concentration, or other cognitive limitations should have reminders or alarms placed in their home and, ideally, a friend or family member to help remind them or even observe the person taking medications and provide encouragement of treatment. Psychiatric consults and referrals can also help address these issues, as remission of illness maximizes the ability to tolerate medical therapy.
Comprehensive, Integrated HIV Services Lead to Improved Outcomes for Patients and Clinicians
There is great need to develop specialized, integrated care programs to provide excellent care for persons with HIV/AIDS and SMI (Blank et al., 2013). In few other populations of patients could meeting the so-called triple aim in healthcare be so critical. That triple aim speaks to accomplishing effective, high-quality health care that also serves the needs of populations and decreases costs (Berwick et al., 2008). One excellent example of specialized and integrated care for this population is the Preventing AIDS through Health for HIV Positive persons (PATH+) trail that was completed in Philadelphia (Blank et al., 2011). In this pilot program, an advanced practice nurse care manager provided comprehensive medical and psychiatric care for patients, and the intensity of treatment was guided by objective measures of treatment effect. In addition, this was done in consultation with physicians, pharmacists, and other critical members of the healthcare team, effectively leveraging limited resources (like infectious disease doctors and psychiatrists) to direct effective care. Over the course of the study, compared with usual care, there were significant decreases in viral load and improvements in quality of life (Blank et al., 2014). It is important to note that this approach is quite similar in overall form to the evidence-based integrated care models shown to be effective in the management of many psychiatric disorders (Archer et al., 2012).
In addition, there are collaborative clinics where persons with HIV/AIDS and SMI are cared for by co-located medical and psychiatric experts. One example of such a clinic (of which two of the authors are affiliated [GT and AA]) is the Johns Hopkins Hospital HIV clinic (The Moore Clinic). Initially, psychiatric evaluations were performed on site and patients were referred to a formal psychiatry clinic for ongoing care. During the first year of this work, 89 patients agreed to be referred for ongoing psychiatric care. Upon follow-up we learned that none of these 89 patients ever attended follow-up care (Treisman and Angelino, 2004). In response to this, the care teams decided that it would be best to co-locate psychiatric care services in the HIV clinic. This move toward a more integrated approach to care allows clinician collaboration that has the potential to improve the quality of care, with physicians educating each other in their respective specialties, prevent unnecessary care, and help physicians diagnose new problems earlier.
Patients who are able to make one visit to take care of all their needs will have greater ability to attend necessary appointments, as additional transportation and multiple appointments are avoided. On-site counseling, risk reduction, social work, and substance abuse treatment are able to be incorporated into each visit as needed. Ideally, on-site housing support could be incorporated for patients who require living assistance or are homeless. For sites that lack funding for a comprehensive treatment center, addition of psychiatric services is cost-effective, requires little equipment or facilities, and can still retain many of the benefits of collaboration between medical and psychiatric practitioners. In an ideal HIV treatment program, the treatment team would use role induction to outline the conditions of care and give the patient an opportunity to see that clinicians are working together. The program would ideally incorporate cognitive-behavioral therapy to aid with behavior modification and risk reduction, substance abuse treatment, social services, job training and assistance, and medical and psychiatric treatment (Volkow and Montaner, 2011). The program should also have an on-site pharmacy that offers adherence programs to support patients’ compliance with medications, make it easier to track medications dispensed, and increase the ability of patients with limited mobility or transportation to obtain medications. Long-acting injectable antipsychotics medications would be administered on-site for individuals needing that treatment and struggling with compliance. A program that incorporates family members or significant others can improve social support for patients and for family members as well as improve treatment adherence.
The more integrated services are, the better patients can be incorporated into a treatment regimen with a team of healthcare professionals to provide support (Mugavero et al., 2011). This includes the use of integrated electronic medical records and health surveillance data available to all clinicians (Bertolli et al., 2012; Herwehe et al., 2012). In the Johns Hopkins Hospital multidisciplinary clinic, HIV-positive patients with psychiatric disorders were more likely to receive ART and had reduced mortality compared to the general HIV-positive population and our own clinic population before the integration of services, presumably because of increased support and more advocacy by mental health professionals. We infer that these improved results in turn led to better viral suppression and reduced risk (Himelhoch et al., 2004). The Johns Hopkins experience shows that we can have success treating this population and that the appropriate management of psychiatric disorders can facilitate improved quality of life and survival in persons with HIV/AIDS.
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