Patients with Severe Mental Illnesses Slip Between Cracks in HIV Testing

Gap Represents ‘Missed Opportunity’ to Treat Virus Early, Says UCSF Researcher

People with bipolar disorder, schizophrenia and major depression with psychosis may be up to 15 more likely than the general population to be HIV positive, but are only marginally more likely to be tested for the virus, according to a study headed by UC San Francisco.

Christina Mangurian
Christina Mangurian, MD, MAS

“People with severe mental illness have higher rates of unsafe behaviors that put them at risk for HIV infection,” said first author Christina Mangurian, MD, MAS, of the UCSF Department of Psychiatry. “This includes engaging in unprotected sex with HIV positive partners and partners of unknown HIV status, injecting drugs, using substances in the context of sexual activity and episodes of sexual violence.”

The researchers reviewed the medical records of 56,895 California residents who were on one or more anti-psychotic medications for their illnesses, and found that over a one-year period 6.7 percent underwent HIV testing. This compares with the 5.2 percent self-reported HIV-testing rate among California’s general population in 2011.

The participants were aged 18 to 67, with 42 percent over the age of 48, and all were enrolled in Medicaid for the period from Oct. 1, 2010 to Sept. 30, 2011. The study was published in the journal Psychiatric Services on Jan. 17, 2017.

Early Deaths a Reality for Seriously Mentally Ill

“Previous studies have found that people with severe mental illness die up to 25 years earlier than the general population,” said Mangurian, associate professor of clinical psychiatry at the UCSF School of Medicine. “Although this is mostly due to cardiovascular disease – related to anti-psychotic medications that increase risk for obesity, diabetes and high blood pressure – HIV and other infectious diseases also contribute to this premature mortality.”

Two recent analyses have quantified HIV prevalence among people with severe mental illness as ranging from 1.8 to 6 percent. This is several times higher than the general population in which 1.2 million or approximately 0.4 percent of Americans are HIV positive, according to the Centers for Disease Control and Prevention.

James Dilley
James Dilley, MD

The researchers found disparities in the number of patients undergoing HIV testing, according to age, gender and ethnicity. Some 7.7 percent of women were tested in the one-year duration, versus 5.5 percent of men. Among black participants, 10.8 percent were tested, compared with 6 percent and 2.7 percent of whites and Asian/Pacific Islanders respectively. While 7.9 percent of patients under age 27 were tested, 5.1 percent in the 48-to-67 age bracket were tested.

The researchers also noted that those participants who had received non-psychiatric medical care were twice as likely to undergo testing as those that did not. “This finding supports national efforts to integrate behavioral health and primary care,” said senior author James Dilley, MD, from the UCSF Department of Psychiatry and the UCSF Alliance Health Project.

“People with severe mental illness often have low rates of primary care use, but do seek care at community mental health care clinics. As such, we believe this is an excellent opportunity for community psychiatrists to help promote their patients’ health by making HIV testing a part of their care,” he said.

Treatment Compliance Not an Issue

“This is a missed prevention opportunity to detect HIV early in the course of illness,” said Mangurian. “Effective treatments are widely available and people with severe mental illness appear to comply with antiretroviral therapies at rates similar to other groups. We believe that annual HIV testing should be strongly considered by public mental health administrators.”

The U.S. Preventive Services Task Force, a volunteer panel of national medical experts, recommends annual HIV testing for men who have sex with men and people who are active injection drug users. It recommends testing every three-to-five years for those having unprotected sex and sex with HIV-positive partners, and for sex workers and injection drug users.

The study was supported by funding from the National Institutes of Health, and the Health Resources and Services Administration.

Co-authors are Francine Cournos, MD, of Columbia University, New York; Penelope Knapp, MD, of UC Davis, Calif.; and Dean Schillinger, MD; Eric Vittinghoff, PhD; Jennifer Creasman; Bernard Lee and Elena Fuentes-Afflick, MD, all of UCSF.

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.