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标题：A Multisite Study of the Prevalence of HIV With Rapid Testing in Mental Health Settings
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作者：Michael B. Blank ; Seth S. Himelhoch ; Alexandra B. Balaji 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2014
卷号：104
期号：12
页码：2377-2384
DOI：10.2105/AJPH.2013.301633
语种：English
出版社：American Public Health Association
摘要：Objectives. We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. Methods. We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). Results. Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. Conclusions. HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care. People with serious mental illness (SMI) are at increased risk for being infected with HIV. Risk factors associated with HIV infection among persons with SMI mirror those in the general population and include unprotected sexual activity and injection drug use (IDU). 1–5 Studies that estimated HIV prevalence from samples of patients with SMI during the 1990s and early 2000s found that HIV prevalence ranged from 1% to 23%. 6–16 The wide variation in estimates has been attributed to small sample sizes, the use of regional convenience samples, differences in sampling frames, and inadequate adjustment for confounding effects of factors associated with HIV risk. 17,18 Analysis of administrative data indicates that many HIV-infected persons who receive Medicaid also have comorbid mental illnesses. Walkup et al. found that among persons in the New Jersey HIV/AIDS registry receiving Medicaid, 5.7% had a diagnosis of schizophrenia, 19 much higher than the prevalence of schizophrenia in the general population, which is estimated to be about 1%. 20 A clear weakness of this method is that HIV diagnoses identified in administrative records may not capture all HIV diagnoses and may not be linked to confirmed HIV-positive test results. An approach to measuring rates of HIV among individuals with SMI taken by investigators in Philadelphia, Pennsylvania, was to conduct HIV testing on remnant blood specimens collected from patients on 2 inpatient psychiatric units in the city. In this study, 10.1% of patients were found to be HIV-infected. Chart reviews up to the time of testing of the remnant blood failed to find documentation of previous HIV diagnosis in the clinical record for approximately one third of these persons. However, this study used a very specific sample that does not generalize to all patients seeking mental health services. 16 As the demographics of the HIV epidemic have shifted in the past decade, the degree to which HIV prevalence among persons with SMI has changed remains unclear. Accurate estimates of HIV prevalence among these persons and more information about access to and retention in care for HIV-positive persons with SMI is needed. The approval of rapid HIV testing by the US Food and Drug Administration and widespread availability of multiple rapid testing assays provides new opportunities for HIV testing and more efficient determination of prevalence estimates in hard-to-reach populations. Rapid HIV testing results can be obtained in approximately 20 minutes, allowing delivery of immediate posttest counseling and referral and linkage to HIV care. Prevention services for persons with preliminary positive test results can also reduce risks of transmission to others. The rapid turnaround for obtaining and delivering test results increases the flexibility of service delivery and might be useful for testing those with SMI within mental health settings. This is particularly important as the mental health system has been increasingly called upon to provide basic medical and preventive health services 21–24 for those with SMI and is the most common place for where they receive care. 25 Rapid testing thus holds great promise for integrating routine HIV testing into ongoing mental health services in a variety of clinical settings. The specificity of current US Food and Drug Administration–approved rapid HIV tests is high. 26 Sensitivity for established infections is also high, but currently available rapid tests do not detect early infections that can be detected by laboratory tests. 27 Prevention services for HIV-positive patients in mental health centers have the potential to reduce risks of transmission to others. This is consistent with a positive prevention model proposed by Sikkema et al. 28 although the empirical evidence to date has been mixed, 29–31 with additional studies in progress. 32 There is also an opportunity for rapid testing to facilitate linkage to infectious disease care for these individuals. 33–36 The purpose of this study was to use rapid HIV testing to estimate HIV prevalence and examine risk factors associated with HIV infection among people receiving treatment in the mental health system. We focused on 2 large urban communities (Philadelphia, PA, and Baltimore, MD) that have a high burden of HIV infection. By drawing the study sample from inpatient psychiatric units, outpatient community mental health centers (CMHCs), and outpatient intensive case management (ICM) programs, we captured patients served by the 3 predominant modalities of mental health service delivery in the United States.