There Should Be ‘No Wrong Door’ for Patients With SMI to Access HIV Care

There is a major mortality gap for people with serious mental illness (SMI), with these patients dying 15 to 20 years earlier than the general population. This gap has only widened since the 1970s, said Alison Hwong, M.D., Ph.D., psychiatry fellow at the University of California San Francisco (UCSF) Weill Institute for Neurosciences.

Hwong chaired a session on Monday that explored the intersection of SMI and HIV/AIDS. She was joined by Francine Cournos, M.D., a professor of clinical psychiatry in epidemiology at Columbia University; Alexander Bazazi, M.D., an assistant professor of psychiatry at UCSF; and Andrew Sudler, M.D., M.P.H., a PGY-2 psychiatry resident at UCSF.

Cournos described the history of the relationship between HIV and SMI. When New York City had its first case of AIDS, she was the chief medical officer for the NYC Regional Office of the New York State Office of Mental Health. “A lot of my job was to go to every state hospital after it had its first case and calm people down,” she said. There was enormous stigma around the illness when it was first discovered, she said. She described seeing an internist hug a psychiatric patient who had been diagnosed with AIDS and the tremendous effect that had on her and everybody who watched.

In many parts of the world, studies have shown that HIV infection is more common in people with SMI than in the general population, Cournos said. Bazazi pointed out that the HIV prevalence is estimated to be around 6% among people with schizophrenia or bipolar disorder, which far exceeds the prevalence in the general population.

Bazazi shared some of the findings from ongoing research that he and his colleagues are conducting at UCSF with primary investigator Christina Mangurian, M.D., M.A.S. Using Medicaid claims data, they investigated if there is a gap in retention in HIV care for people living with schizophrenia compared with people without schizophrenia. In adjusted analyses, those with schizophrenia had a 9% lower chance of being retained in HIV care annually.

Finally, Sudler presented on the prevention policies and public health reform efforts for HIV prevention, particularly for people with SMI. He pointed to local efforts aimed specifically at people with SMI to get them to start taking pre-exposure prophylaxis (PrEP), which prevents individuals from getting HIV.

PrEP is one of the most effective biomedical HIV prevention strategies available, Sudler said, yet who prescribes the medication remains a controversial topic. Very often, the focus is on prescribing within HIV specialty care or primary care settings, and mental health professionals are left out of the conversation, which is very concerning, Sudler said.

“It means that we’re missing a huge segment of the population who really may not have access to primary care or HIV specialty care, and they’re not being told that PrEP is something they could benefit from,” Sudler said.

There are numerous challenges that must be addressed to encourage more PrEP prescribing in mental health settings, such as knowledge and attitudes among professionals, the need to coordinate PrEP’s ongoing monitoring guidelines, and insurance reimbursement, Sudler said.

Yet the presenters emphasized the need to overcome these challenges and more easily connect patients with SMI to HIV care. “Until we have a more perfectly integrated system, there should be no wrong door for getting HIV care,” Bazazi said.

There has been a significant amount of research and interest in treating first-episode psychosis because it leads to better outcomes, Cournos pointed out. The same emphasis must be put on providing preventive medical care to patients as soon as they are diagnosed with an SMI. “Once we accept that the mind, brain, and body are 100% integrated—that if you’re not well in your brain then you’re not well in your body and vice versa,” we cannot ignore “the importance of beginning medical care as soon as somebody gets a severe psychiatric illness.” ■