Integrated Care Needed for Patients With HIV, Drug Abuse, and Mental Illness

Abstract

PATIENTS WHO ARE INFECTED WITH HIV and who also have simultaneous substance abuse problems and mental illness have complex medical and psychosocial needs that challenge traditional care models. But a growing body of research suggests that integrated care models may improve the quality of life for these patients and reduce further spread of the infection. As many as half of individuals with substance abuse problems are estimated to have comorbid mental illness, and these dual-diagnosis patients have a relatively high risk of becoming infected with HIV. Studies have found that between 10% and 40% of patients at HIV clinics have a “triple diagnosis” of HIV, substance abuse disorder, and psychiatric illness, said Antoine Douaihy, MD, an associate professor of psychiatry at the University of Pittsburgh School of Medicine. The interrelationship between the 3 conditions is complex. Individuals experiencing psychiatric symptoms may be more likely to engage in behaviors that put them at risk of HIV infection, and HIV infection can also contribute to poor mental health (Parry CD et al. Curr Opin Psychiatry. 2007;20[3]:235241). Patients with psychiatric disorders often develop substance abuse disorders, but substance abuse also may contribute to the emergence of mental illness. Persons with substance abuse disorders are also more likely to engage in behaviors such as sharing drug injection equipment or trading sex for drugs or money that may put them at risk of infection with HIV. All 3 of these conditions may impair judgment or cognition, which may increase risk taking, making it more difficult for them to adhere to medication regimens and contributing to psychosocial problems, said Douaihy. PREVENTION Preventing the spread of HIV, especially in particularly vulnerable populations such as individuals who inject opiates, is an important way to reduce the burden of triple diagnosis. Testing for HIV is one important component of prevention, according to Lisa R.Metsch,PhD,associateprofessor in the Department of Epidemiology and Public Health at the University of Miami Miller School of Public Health. In 2006, the US Centers for Disease Control and Prevention published a revised guideline for HIV testing (http://www.cdc.gov /mmwr/preview/mmwrhtml/rr5514a1 .htm) intended to expand identification of individuals with HIV infection, including patients in substance abuse treatment settings. About 25% of the more than 1 million individuals in the United States who are infected with HIV are unaware of their status, and the majority of new infections stem from such individuals (Marks. AIDS. 2006;20[10]:14471450), said Metsch in a presentation at the National Institute on Drug Abuse’s (NIDA’s)BlendingAddictionScienceand Treatment conference in June. “The literature shows very clearly that if someone learns their HIV-positive status, they are more likely to reduce their risk behaviors,” Metsch said in a subsequent interview. Additionally, routine testing provides an opportunity to diagnose HIV infection and link infected individuals with treatment earlier in the course of their illness, which may prolong their lives, she said. Substance abuse treatment programs are particularly well positioned to help identify patients with HIV infection, Metsch said in her presentation, because patients enrolled in these programs have a higher risk of infection. The programs also often have networks in place to refer patients for HIV care. However, less than half of such programs offer HIV testing. In some cases, the programs may not have the money orresources tooffer testing, saidMetsch, ortheymayfeeltestingconflictswiththeir philosophy. Inexpensive rapidHIVtests mayhelpremovethishurdle.Metschand colleagues are launching a clinical trial to assess the effects of rapid HIV testing, with and without counseling, in a substance abuse treatment setting.