- Email: [email protected]
Predictors of HIV and Hepatitis Testing and Related Service Utilization Among Individuals With Serious Mental Illness
Predictors of HIV and Hepatitis Testing and Related Service Utilization Among Individuals With Serious Mental Illness RICHARD W. GOLDBERG, PH.D., SETH HIMELHOCH, M.D., M.P.H. JULIE KREYENBUHL, PHARM.D., PH.D., FAITH B. DICKERSON, PH.D., M.P.H. ANN HACKMAN, M.D., LI JUAN FANG, M.S. CLAYTON H. BROWN, PH.D., KAREN A. WOHLHEITER, M.S. LISA B. DIXON, M.D., M.P.H.
Two hundred mentally ill adults receiving community-based outpatient psychiatric services were surveyed. Although 59% received an HIV test, only 41% received a hepatitis test. Clinic location and reports of unprotected sex were associated with receipt of an HIV test. Although no behavioral risk factors were associated with hepatitis testing, those with a comorbid medical condition were more likely to be tested. Only 15% of the sample was immunized against hepatitis B. Medical hospitalization was the only factor related to immunization. These results indicate an urgent need to improve access to HIV and hepatitis testing and related treatment. (Psychosomatics 2005; 46:573–577)
I
ndividuals with serious mental illness are at increased risk for infection with HIV, hepatitis B, and hepatitis C, with rates 8 times the estimated U.S. population rate for HIV, and 5 and 11 times the estimated population rates for hepatitis B and hepatitis C, respectively.1 Although both the U.S. Centers for Disease Control and Prevention2,3 and the National Institutes of Health4 specify best practices for screening high-risk populations for these blood-borne infections, little is known about the proportion of adults with serious mental illness receiving such services in either mental health or medical settings. In a previous study of adult outpatients with serious mental illness, many of whom were at high risk for infection, we found that only 19% and 12%, respectively, received a hepatitis B or hepatitis C test.5 The rate of hepatitis B immunization, another recommended service for those either at high risk for or infected with hepatitis C,2 was also low among this study cohort. Other related medical and psychiatric service correlates were, unfortunately, not documented for this cohort. Psychosomatics 46:6, November-December 2005
This low rate of evidence-based service receipt, in combination with high rates of infection in people with serious mental illness, could have devastating public health implications and present great challenges for both medical and mental health service systems. In this current study, we report rates of HIV and hepatitis screening and hepatitis B vaccination in a new sample of outpatients with serious mental illness and move beyond our previous findings to identify participant- and systems-level factors associated with receipt of HIV and hepatitis testing and hepatitis B immunization in this population. Received Sept. 14, 2004; revision received Jan. 24, 2005; accepted March 7, 2005. From the University of Maryland-Baltimore School of Medicine; the VA Capitol Health Care Network Mental Illness Research, Education and Clinical Center, Baltimore; and Sheppard Pratt Health System, Baltimore. Address correspondence and reprint requests to Dr. Goldberg, University of Maryland-Baltimore School of Medicine, Division of Services Research, 737 W. Lombard St., Room 500, Baltimore, MD 21201; [email protected] (e-mail). Copyright 䉷 2005 The Academy of Psychosomatic Medicine.
http://psy.psychiatryonline.org
573
Case Reports
METHOD
Data were drawn from a larger study of somatic comorbidity and related service utilization that used a cross-sectional design to survey a random stratified sample of 200 adults diagnosed with serious mental illness who were receiving community-based outpatient psychiatric services.6 The study survey, which has been previously described,6 included interview items drawn from the National Health Interview Survey (NHIS),7 the National Health and Nutrition Examination Survey III (NHANES III),8 and the Medical Expenditure Panel Survey. The interview also included questions about lifetime receipt of HIV and hepatitis screening tests and a question regarding receipt of the hepatitis B immunization series. These latter items were used to derive the main outcome variables for this investigation. Interviews were conducted between March and December 2000. The study was approved by the institutional review boards of the University of Maryland School of Medicine and the Sheppard Pratt Health System. Subjects were a mean of 44 years of age (SD⳱8.9). Baseline participant characteristics and summaries of service utilization, which served as the set of patient and systems factors used in our analyses, are presented in Table 1. Statistical Analysis Univariate logistic regression analyses were performed to identify individual variables significantly associated with each of the three main outcomes: receipt of an HIV test, receipt of a hepatitis screening test, and receipt of the hepatitis B vaccination series. Variables achieving statistical significance at an alpha level of 0.05 were included in adjusted logistic regression models along with age, race, gender, educational status, psychiatric diagnosis, and recruitment site. These models were used to estimate relative odds ratios and 95% confidence intervals to adjust for differences in outcome predictors. All regression models were sequentially built using the variable selection method described by Hosmer and Lemeshow.10
RESULTS
HIV testing was reported in 59.5% (N⳱119) of the sample. As seen in Table 2, those reporting unprotected sex 574
http://psy.psychiatryonline.org
were about three times as likely to receive an HIV test. Respondents from the urban site were more than three times as likely to have been tested than those from the suburban site. Hepatitis testing was reported by 41.0% (N⳱82) of respondents. Of those, 50% were unable to report what type of screening they received (e.g., hepatitis B, hepatitis C, or both). Medical comorbidity was the only independent predictor associated with receipt of a hepatitis test; those with a comorbid condition were more than two times as likely to be tested (Table 2). Receipt of the hepatitis B vaccination series was reported in only 15% of the sample. Those who had been hospitalized had more than four times the odds of being immunized than were those who were not hospitalized.
DISCUSSION
While nearly 60% of the sample reported receipt of an HIV test, less than half (41%) were tested for hepatitis. Further, half of those screened for hepatitis were uncertain as to which hepatitis virus tests they received, indicating poor knowledge about hepatitis and hepatitis screening. These results replicate earlier findings4 and provide additional support for increased efforts to educate mental health consumers about hepatitis. Given that outpatient psychiatric clinics are frequently a regular source of contact for people at risk for contracting hepatitis and HIV/AIDS, efforts to improve screening and immunization programs for such settings are recommended.11 The fact that 89% of the sample reported having a regular source of medical care (with 85% reporting having seen a medical provider in the past year) suggests that despite access to somatic providers, adults with serious mental illness are not being adequately screened for HIV and hepatitis in medical settings either. A comparison of predictor variables for the three outcomes also warrants discussion. None of the three behavioral risk factors (unprotected sex, drug use, or alcohol use) were related to receipt of a hepatitis screening test. Although engagement in unprotected sex was related to HIV screening, neither alcohol nor drug use were. Given the high rates of co-occurring substance abuse diagnoses among those with serious mental illness12,13 and the fact that substance abuse is associated with increased risk of contracting HIV, hepatitis B, and hepatitis C in general and especially among those with serious mental illness,1,14 these results suggest that mental health and medical proPsychosomatics 46:6, November-December 2005
Case Reports viders may not be adequately screening those with serious mental illness and using such assessments to inform decisions about who to test for HIV and hepatitis and who to refer for vaccination against hepatitis B. Those with a comorbid medical condition were over two times more likely to have been screened for hepatitis than were those without a medical condition. This finding, in combination with the aforementioned risk behavior data, suggests that although hepatitis is screened for in the context of medical illness follow-up, it is not being viewed as a primary condition linked to high-risk behavior. As such, it is important to ensure that interventions and prevention materials targeting high-risk behaviors include specific information on hepatitis and its relationship to high-risk behavior. Further, given the emerging problem of HIV/hep-
TABLE 1.
Demographic and Clinical Characteristics of 200 Adults With Serious Mental Illness Surveyed to Assess Receipt of HIV and Hepatitis Prevention Services
Characteristic Gender Male Female Race Caucasian African American Other Education Less than high school High school graduate Diagnosis Schizophrenia spectrum disorder Major mood disorder Recruitment site Urban outpatient clinic Suburban outpatient clinic At least one comorbid medical condition Health risk behaviors Alcohol use (past month) Drug use (past month)a Unprotected sex (past 6 months) Medical health services Usual source of care Seen practitioner (past year) Medical hospitalization (past year) Mental health services (past year) Case management Psychiatric day program Psychiatric hospitalization
N
%
95 105
47.5 52.5
112 72 16
56.0 36.0 8.0
55 145
27.5 72.5
100 100
50.0 50.0
100 100 126
50.0 50.0 63.0
49 21 43
24.5 10.5 21.5
178 169 26
89.0 84.5 13.0
116 76 31
58.0 38.0 15.5
a
Although lifetime rates of illicit drug and alcohol use were not documented in this study, previous work with similar cohorts drawn from the same service systems indicate lifetime substance abuse rates of approximately 75%.9
Psychosomatics 46:6, November-December 2005
atitis C coinfection1 (with coinfection affecting up to one-third of all HIV-infected persons15), and the fact that such coinfection is associated with a more rapid progression of hepatitis C-related liver disease and increased risk of drug-induced hepatotoxicity among those receiving antiretroviral therapy for HIV,16,17 it is essential that all those engaged in high-risk drug and sexual behaviors be tested for both HIV and hepatitis. Further, given that coinfection with hepatitis B has been shown to increase the progression and severity of liver disease among those infected with other viral pathogens,18 efforts to immunize those living with or at risk for HIV and hepatitis C should be emphasized and supported. Immunization against hepatitis A, which can cause fulminant hepatitis in those infected with hepatitis B or hepatitis C,19 is also recommended for anyone who engages in unsafe sex or risky drug use.2 Although none of the variables measuring the utilization of mental health or outpatient medical services were related to receipt of an HIV or hepatitis test, participants with a recent history of medical hospitalization were more likely to have been vaccinated against hepatitis B. This finding suggests that hospitalization may provide an opportunity for vaccination. In addition to recent efforts to extend vaccination services to other settings, including clinics for the treatment of sexually transmitted disease and substance abuse,20–22 mental health and primary care service systems may also want to adapt cost-effective screening and immunization programming to meet the specific needs of consumers with serious mental illness.11 Urban site was associated with receipt of an HIV test but not for hepatitis screening or hepatitis B vaccination. This finding suggests a need for further clinician education that includes training providers in nonurban settings regarding best practices and treatment guidelines for HIV and educating providers in all settings about hepatitis prevention and treatment. Our study does have limitations. First, the study population was taken from Baltimore and may not generalize to the U.S. population as a whole. Our sample also included those actively engaged in mental health services and as such may not be representative of the many consumers with serious mental illness who are not in treatment. Second, the study was cross-sectional, and as such we are only able to identify associations and not causation. Third, we do not have information about where screening tests were performed (e.g., in mental health or medical settings) or under what conditions tests were conducted. Fourth, the validity of self-report vaccination and testing data cannot http://psy.psychiatryonline.org
575
Case Reports be determined. On the basis of our previous work,23 however, adults with serious mental illness are able to reliably report receipt of medical services. In conclusion, our findings point to the need for increased efforts to educate mental health consumers and providers (both medical and psychiatric) about hepatitis testing and related prevention services, including counseling and hepatitis B vaccination. More targeted efforts to TABLE 2.
link hepatitis infection to high-risk behavior and to emphasize this point in both screening and prevention/counseling are also indicated. It is also important to ensure that patients engaging in high-risk behaviors be screened for both HIV and hepatitis. Finally, mental health and medical service systems need to work together to coordinate care and improve access to hepatitis and HIV screening and related treatment.
Effect of Demographic and Clinical Characteristics on Likelihood of Individuals With Serious Mental Illness (Nⴔ200) Receiving HIV and Hepatitis Screening Tests and Hepatitis B Immunization HIV Screen
Survey Item/Variable Site (urban site) Health risk behaviors (unprotected sex past 6 months) Medical comorbidity (yes) Medical health services (medical hospitalization past year)
Hepatitis Screen
Adjusted Odds Ratioa
95% CI
3.26**
1.54–6.91
2.93*
1.18–7.29
Adjusted Odds Ratiob
95% CI
2.44*
1.23–4.86
Hepatitis B Immunization Adjusted Odds Ratioc
95% CI
4.44**
1.66–11.88
a
Full model included age, race, gender, educational status, psychiatric diagnosis, recruitment site, past month drug use, and recent unprotected sex Full model included age, race, gender, educational status, psychiatric diagnosis, recruitment site, recent unprotected sex, and presence of a comorbid medical condition. c Full model included age, race, gender, educational status, psychiatric diagnosis, recruitment site, and medical hospitalization in past year. *p⬍0.05. **p⬍0.01. b
References
1. Rosenberg SD, Goodman LA, Osher FC, Swartz MS, Essock SM, Butterfield MI, Constantine NT, Wolford GL, Salyers MP: Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 2001; 91:31–37 2. CDC: Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998; 47(RR-19):1–33 3. CDC: Revised guidelines for HIV counseling, testing, and referral. MMWR 2001; 50(RR-19):1–53 4. National Institutes of Health: National Institutes of Health Consensus Development Conference Statement: Management of Hepatitis C. Hepatology 2002; 36:S3–S20 5. Goldberg RW: Hepatitis and HIV screening, education, and treatment for adults with serious mental illness. General Hosp Psychiatry 2004; 26:167–168 6. Dickerson FB, McNary SW, Brown CH, Kreyenbuhl J, Goldberg RW, Dixon LB: Somatic healthcare utilization among adults with serious mental illness receiving community psychiatric services. Med Care 2003; 41:560–570 7. US Department of Health and Human Services, National Center for Health Statistics: National Health Interview Survey (NHIS). Hyattsville, Md, NCHS, 1998 8. US Department of Health and Human Services, National Center for Health Statistics: Third US National Health and Nutrition Examination Survey (NHANES III), 1988–1994. Hyattsville, Md, NCHS, 1995 9. Lehman AF, Goldberg R, Dixon LB, McNary S, Postrado L, Hackman A, McDonnell K: Improving employment outcomes for per-
576
http://psy.psychiatryonline.org
sons with severe mental illness. Arch Gen Psychiatry 2002; 59:165–172 10. Hosmer DW, Lemeshow S: Applied Logistic Regression, 2nd ed. New York, John Wiley & Sons, 2000 11. Rosenberg S, Brunette M, Oxman T, Marsh B, Dietrich A, Mueser K, Drake R, Torrey W, Vidaver R: The STIRR model of best practices for blood-borne diseases among clients with serious mental illness. Psychiatr Serv 2004; 55:660–664 12. Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank RG, Leaf PJ: The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. Am J Orthopsychiatry 1996; 66:17–31 13. Reiger D, Farmer M, Rae D, Locke BZ, Keith SJ, Judd LL, Goodwin FK: Cormorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990; 264:2511–2518 14. Osher FC, Goldberg RW, McNary SW, Swartz MS, Essock SM, Butterfield MI, Rosenberg SD: Blood-borne infections and persons with severe mental illness: substance abuse and the transmission of hepatitis C among persons with severe mental illness. Psychiatr Serv 2003; 54:842–847 15. Sterling RK, Sulkowski MS: Hepatitis C in the setting of HIV or hepatitis B virus coinfection. Semin Liver Dis 2004; 24(suppl 2): 61–68 16. Sulkowski MS: Hepatitis C virus infection in HIV-infected patients. Curr Infect Dis Rep 2001; 3:469–476 17. Sulkowski MS, Thomas DL: Hepatitis C in the HIV-infected person. Ann Intern Med 2003; 138:197–207 18. Shukla NB, Poles MA: Hepatitis B virus infection: co-infection
Psychosomatics 46:6, November-December 2005
Case Reports with hepatitis C virus, hepatitis D virus, and human immunodeficiency virus. Clin Liver Disease 2004; 8:445–460 19. Vento S, Garofano T, Renzini C, Casali F, Ferraro T, Concia E: Enhancement of hepatitis C virus replication and liver damage in HIV-coinfected patients on antiretroviral combination therapy. AIDS 1998; 12:116–117 20. Gunn RA, Murray PJ, Ackers ML, Hardison WG, Margolis HS: Screening for chronic hepatitis B and C virus infections in an urban sexually transmitted disease clinic: rationale for integrating services. Sex Transm Dis 2001; 28:166–170
Psychosomatics 46:6, November-December 2005
21. Carter H, Robinson G, Hanlon C, Hailwood C, Massarotto A: Prevalence of hepatitis B and C infection in a methadone clinic population: implications for hepatitis B vaccination. N Z Med J 2001; 114:324–326 22. Murray P, O’Neill S: Hepatitis B immunization in an STD clinic: lessons learned in San Diego County: a practical guide (http:// www.cdc.gov/ncidod/diseases/hepatitis/spotlights/intergration.htm) 23. Goldberg RW, Seybolt D, Lehman AF: Reliable self-report of health service utilization by individuals with serious mental illness. Psychiatr Serv 2002; 53:879–881
http://psy.psychiatryonline.org
577
Two hundred mentally ill adults receiving community-based outpatient psychiatric services were surveyed. Although 59% received an HIV test, only 41% received a hepatitis test. Clinic location and reports of unprotected sex were associated with receipt of an HIV test. Although no behavioral risk factors were associated with hepatitis testing, those with a comorbid medical condition were more likely to be tested. Only 15% of the sample was immunized against hepatitis B. Medical hospitalization was the only factor related to immunization. These results indicate an urgent need to improve access to HIV and hepatitis testing and related treatment. (Psychosomatics 2005; 46:573–577)
I
ndividuals with serious mental illness are at increased risk for infection with HIV, hepatitis B, and hepatitis C, with rates 8 times the estimated U.S. population rate for HIV, and 5 and 11 times the estimated population rates for hepatitis B and hepatitis C, respectively.1 Although both the U.S. Centers for Disease Control and Prevention2,3 and the National Institutes of Health4 specify best practices for screening high-risk populations for these blood-borne infections, little is known about the proportion of adults with serious mental illness receiving such services in either mental health or medical settings. In a previous study of adult outpatients with serious mental illness, many of whom were at high risk for infection, we found that only 19% and 12%, respectively, received a hepatitis B or hepatitis C test.5 The rate of hepatitis B immunization, another recommended service for those either at high risk for or infected with hepatitis C,2 was also low among this study cohort. Other related medical and psychiatric service correlates were, unfortunately, not documented for this cohort. Psychosomatics 46:6, November-December 2005
This low rate of evidence-based service receipt, in combination with high rates of infection in people with serious mental illness, could have devastating public health implications and present great challenges for both medical and mental health service systems. In this current study, we report rates of HIV and hepatitis screening and hepatitis B vaccination in a new sample of outpatients with serious mental illness and move beyond our previous findings to identify participant- and systems-level factors associated with receipt of HIV and hepatitis testing and hepatitis B immunization in this population. Received Sept. 14, 2004; revision received Jan. 24, 2005; accepted March 7, 2005. From the University of Maryland-Baltimore School of Medicine; the VA Capitol Health Care Network Mental Illness Research, Education and Clinical Center, Baltimore; and Sheppard Pratt Health System, Baltimore. Address correspondence and reprint requests to Dr. Goldberg, University of Maryland-Baltimore School of Medicine, Division of Services Research, 737 W. Lombard St., Room 500, Baltimore, MD 21201; [email protected] (e-mail). Copyright 䉷 2005 The Academy of Psychosomatic Medicine.
http://psy.psychiatryonline.org
573
Case Reports
METHOD
Data were drawn from a larger study of somatic comorbidity and related service utilization that used a cross-sectional design to survey a random stratified sample of 200 adults diagnosed with serious mental illness who were receiving community-based outpatient psychiatric services.6 The study survey, which has been previously described,6 included interview items drawn from the National Health Interview Survey (NHIS),7 the National Health and Nutrition Examination Survey III (NHANES III),8 and the Medical Expenditure Panel Survey. The interview also included questions about lifetime receipt of HIV and hepatitis screening tests and a question regarding receipt of the hepatitis B immunization series. These latter items were used to derive the main outcome variables for this investigation. Interviews were conducted between March and December 2000. The study was approved by the institutional review boards of the University of Maryland School of Medicine and the Sheppard Pratt Health System. Subjects were a mean of 44 years of age (SD⳱8.9). Baseline participant characteristics and summaries of service utilization, which served as the set of patient and systems factors used in our analyses, are presented in Table 1. Statistical Analysis Univariate logistic regression analyses were performed to identify individual variables significantly associated with each of the three main outcomes: receipt of an HIV test, receipt of a hepatitis screening test, and receipt of the hepatitis B vaccination series. Variables achieving statistical significance at an alpha level of 0.05 were included in adjusted logistic regression models along with age, race, gender, educational status, psychiatric diagnosis, and recruitment site. These models were used to estimate relative odds ratios and 95% confidence intervals to adjust for differences in outcome predictors. All regression models were sequentially built using the variable selection method described by Hosmer and Lemeshow.10
RESULTS
HIV testing was reported in 59.5% (N⳱119) of the sample. As seen in Table 2, those reporting unprotected sex 574
http://psy.psychiatryonline.org
were about three times as likely to receive an HIV test. Respondents from the urban site were more than three times as likely to have been tested than those from the suburban site. Hepatitis testing was reported by 41.0% (N⳱82) of respondents. Of those, 50% were unable to report what type of screening they received (e.g., hepatitis B, hepatitis C, or both). Medical comorbidity was the only independent predictor associated with receipt of a hepatitis test; those with a comorbid condition were more than two times as likely to be tested (Table 2). Receipt of the hepatitis B vaccination series was reported in only 15% of the sample. Those who had been hospitalized had more than four times the odds of being immunized than were those who were not hospitalized.
DISCUSSION
While nearly 60% of the sample reported receipt of an HIV test, less than half (41%) were tested for hepatitis. Further, half of those screened for hepatitis were uncertain as to which hepatitis virus tests they received, indicating poor knowledge about hepatitis and hepatitis screening. These results replicate earlier findings4 and provide additional support for increased efforts to educate mental health consumers about hepatitis. Given that outpatient psychiatric clinics are frequently a regular source of contact for people at risk for contracting hepatitis and HIV/AIDS, efforts to improve screening and immunization programs for such settings are recommended.11 The fact that 89% of the sample reported having a regular source of medical care (with 85% reporting having seen a medical provider in the past year) suggests that despite access to somatic providers, adults with serious mental illness are not being adequately screened for HIV and hepatitis in medical settings either. A comparison of predictor variables for the three outcomes also warrants discussion. None of the three behavioral risk factors (unprotected sex, drug use, or alcohol use) were related to receipt of a hepatitis screening test. Although engagement in unprotected sex was related to HIV screening, neither alcohol nor drug use were. Given the high rates of co-occurring substance abuse diagnoses among those with serious mental illness12,13 and the fact that substance abuse is associated with increased risk of contracting HIV, hepatitis B, and hepatitis C in general and especially among those with serious mental illness,1,14 these results suggest that mental health and medical proPsychosomatics 46:6, November-December 2005
Case Reports viders may not be adequately screening those with serious mental illness and using such assessments to inform decisions about who to test for HIV and hepatitis and who to refer for vaccination against hepatitis B. Those with a comorbid medical condition were over two times more likely to have been screened for hepatitis than were those without a medical condition. This finding, in combination with the aforementioned risk behavior data, suggests that although hepatitis is screened for in the context of medical illness follow-up, it is not being viewed as a primary condition linked to high-risk behavior. As such, it is important to ensure that interventions and prevention materials targeting high-risk behaviors include specific information on hepatitis and its relationship to high-risk behavior. Further, given the emerging problem of HIV/hep-
TABLE 1.
Demographic and Clinical Characteristics of 200 Adults With Serious Mental Illness Surveyed to Assess Receipt of HIV and Hepatitis Prevention Services
Characteristic Gender Male Female Race Caucasian African American Other Education Less than high school High school graduate Diagnosis Schizophrenia spectrum disorder Major mood disorder Recruitment site Urban outpatient clinic Suburban outpatient clinic At least one comorbid medical condition Health risk behaviors Alcohol use (past month) Drug use (past month)a Unprotected sex (past 6 months) Medical health services Usual source of care Seen practitioner (past year) Medical hospitalization (past year) Mental health services (past year) Case management Psychiatric day program Psychiatric hospitalization
N
%
95 105
47.5 52.5
112 72 16
56.0 36.0 8.0
55 145
27.5 72.5
100 100
50.0 50.0
100 100 126
50.0 50.0 63.0
49 21 43
24.5 10.5 21.5
178 169 26
89.0 84.5 13.0
116 76 31
58.0 38.0 15.5
a
Although lifetime rates of illicit drug and alcohol use were not documented in this study, previous work with similar cohorts drawn from the same service systems indicate lifetime substance abuse rates of approximately 75%.9
Psychosomatics 46:6, November-December 2005
atitis C coinfection1 (with coinfection affecting up to one-third of all HIV-infected persons15), and the fact that such coinfection is associated with a more rapid progression of hepatitis C-related liver disease and increased risk of drug-induced hepatotoxicity among those receiving antiretroviral therapy for HIV,16,17 it is essential that all those engaged in high-risk drug and sexual behaviors be tested for both HIV and hepatitis. Further, given that coinfection with hepatitis B has been shown to increase the progression and severity of liver disease among those infected with other viral pathogens,18 efforts to immunize those living with or at risk for HIV and hepatitis C should be emphasized and supported. Immunization against hepatitis A, which can cause fulminant hepatitis in those infected with hepatitis B or hepatitis C,19 is also recommended for anyone who engages in unsafe sex or risky drug use.2 Although none of the variables measuring the utilization of mental health or outpatient medical services were related to receipt of an HIV or hepatitis test, participants with a recent history of medical hospitalization were more likely to have been vaccinated against hepatitis B. This finding suggests that hospitalization may provide an opportunity for vaccination. In addition to recent efforts to extend vaccination services to other settings, including clinics for the treatment of sexually transmitted disease and substance abuse,20–22 mental health and primary care service systems may also want to adapt cost-effective screening and immunization programming to meet the specific needs of consumers with serious mental illness.11 Urban site was associated with receipt of an HIV test but not for hepatitis screening or hepatitis B vaccination. This finding suggests a need for further clinician education that includes training providers in nonurban settings regarding best practices and treatment guidelines for HIV and educating providers in all settings about hepatitis prevention and treatment. Our study does have limitations. First, the study population was taken from Baltimore and may not generalize to the U.S. population as a whole. Our sample also included those actively engaged in mental health services and as such may not be representative of the many consumers with serious mental illness who are not in treatment. Second, the study was cross-sectional, and as such we are only able to identify associations and not causation. Third, we do not have information about where screening tests were performed (e.g., in mental health or medical settings) or under what conditions tests were conducted. Fourth, the validity of self-report vaccination and testing data cannot http://psy.psychiatryonline.org
575
Case Reports be determined. On the basis of our previous work,23 however, adults with serious mental illness are able to reliably report receipt of medical services. In conclusion, our findings point to the need for increased efforts to educate mental health consumers and providers (both medical and psychiatric) about hepatitis testing and related prevention services, including counseling and hepatitis B vaccination. More targeted efforts to TABLE 2.
link hepatitis infection to high-risk behavior and to emphasize this point in both screening and prevention/counseling are also indicated. It is also important to ensure that patients engaging in high-risk behaviors be screened for both HIV and hepatitis. Finally, mental health and medical service systems need to work together to coordinate care and improve access to hepatitis and HIV screening and related treatment.
Effect of Demographic and Clinical Characteristics on Likelihood of Individuals With Serious Mental Illness (Nⴔ200) Receiving HIV and Hepatitis Screening Tests and Hepatitis B Immunization HIV Screen
Survey Item/Variable Site (urban site) Health risk behaviors (unprotected sex past 6 months) Medical comorbidity (yes) Medical health services (medical hospitalization past year)
Hepatitis Screen
Adjusted Odds Ratioa
95% CI
3.26**
1.54–6.91
2.93*
1.18–7.29
Adjusted Odds Ratiob
95% CI
2.44*
1.23–4.86
Hepatitis B Immunization Adjusted Odds Ratioc
95% CI
4.44**
1.66–11.88
a
Full model included age, race, gender, educational status, psychiatric diagnosis, recruitment site, past month drug use, and recent unprotected sex Full model included age, race, gender, educational status, psychiatric diagnosis, recruitment site, recent unprotected sex, and presence of a comorbid medical condition. c Full model included age, race, gender, educational status, psychiatric diagnosis, recruitment site, and medical hospitalization in past year. *p⬍0.05. **p⬍0.01. b
References
1. Rosenberg SD, Goodman LA, Osher FC, Swartz MS, Essock SM, Butterfield MI, Constantine NT, Wolford GL, Salyers MP: Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 2001; 91:31–37 2. CDC: Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998; 47(RR-19):1–33 3. CDC: Revised guidelines for HIV counseling, testing, and referral. MMWR 2001; 50(RR-19):1–53 4. National Institutes of Health: National Institutes of Health Consensus Development Conference Statement: Management of Hepatitis C. Hepatology 2002; 36:S3–S20 5. Goldberg RW: Hepatitis and HIV screening, education, and treatment for adults with serious mental illness. General Hosp Psychiatry 2004; 26:167–168 6. Dickerson FB, McNary SW, Brown CH, Kreyenbuhl J, Goldberg RW, Dixon LB: Somatic healthcare utilization among adults with serious mental illness receiving community psychiatric services. Med Care 2003; 41:560–570 7. US Department of Health and Human Services, National Center for Health Statistics: National Health Interview Survey (NHIS). Hyattsville, Md, NCHS, 1998 8. US Department of Health and Human Services, National Center for Health Statistics: Third US National Health and Nutrition Examination Survey (NHANES III), 1988–1994. Hyattsville, Md, NCHS, 1995 9. Lehman AF, Goldberg R, Dixon LB, McNary S, Postrado L, Hackman A, McDonnell K: Improving employment outcomes for per-
576
http://psy.psychiatryonline.org
sons with severe mental illness. Arch Gen Psychiatry 2002; 59:165–172 10. Hosmer DW, Lemeshow S: Applied Logistic Regression, 2nd ed. New York, John Wiley & Sons, 2000 11. Rosenberg S, Brunette M, Oxman T, Marsh B, Dietrich A, Mueser K, Drake R, Torrey W, Vidaver R: The STIRR model of best practices for blood-borne diseases among clients with serious mental illness. Psychiatr Serv 2004; 55:660–664 12. Kessler RC, Nelson CB, McGonagle KA, Edlund MJ, Frank RG, Leaf PJ: The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. Am J Orthopsychiatry 1996; 66:17–31 13. Reiger D, Farmer M, Rae D, Locke BZ, Keith SJ, Judd LL, Goodwin FK: Cormorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990; 264:2511–2518 14. Osher FC, Goldberg RW, McNary SW, Swartz MS, Essock SM, Butterfield MI, Rosenberg SD: Blood-borne infections and persons with severe mental illness: substance abuse and the transmission of hepatitis C among persons with severe mental illness. Psychiatr Serv 2003; 54:842–847 15. Sterling RK, Sulkowski MS: Hepatitis C in the setting of HIV or hepatitis B virus coinfection. Semin Liver Dis 2004; 24(suppl 2): 61–68 16. Sulkowski MS: Hepatitis C virus infection in HIV-infected patients. Curr Infect Dis Rep 2001; 3:469–476 17. Sulkowski MS, Thomas DL: Hepatitis C in the HIV-infected person. Ann Intern Med 2003; 138:197–207 18. Shukla NB, Poles MA: Hepatitis B virus infection: co-infection
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