Risk Reduction Interventions and Strategies for HIV/HCV
HIV prevention programs that primarily dispense AIDS information have not been shown to influence risk behavior levels because, as evidence from studies demonstrates, knowledge by itself is necessary but not sufficient to produce behavioral changes. Intensive, small-group programs that simultaneously target knowledge, attitudes, motivations, and cognitive and behavioral skills have been tried and found to produce reductions in high-risk sexual behaviors, including some that are substance related, among people with serious mental illness.

Effective elements from randomized outcome trials of these HIV risk-reduction interventions (Kelly 1997; Otto-Salaj et al. 2001) include

1) information and skills training in sexual assertiveness, negotiation, problem solving, use of condoms, and risk self-management;
2) intensive sessions (6­15 hours to achieve reductions in high-risk behaviors);

3) training participants to become AIDS educators or advocates;
4) booster or maintenance sessions, which appear to be necessary to sustain safer behaviors;
5) gender sensitivity training employing single-gender groups for dealing with same-sex partner issues or for decreasing patients’ anxiety about discussing sexual issues with the opposite sex, or mixed-gender groups for increasing generalization from group exercises to real-life situations for heterosexual patients;
6) inclusion of sexually abstinent patients to train those who may not remain abstinent or who may validate for other patients the legitimate choice of an abstinent lifestyle; and
7) harm reduction as the ultimate goal for both sexual and drug-related risk behaviors. Patients can benefit from participating in mixed­HIV serostatus prevention groups; no one need reveal their HIV status unless they wish to do so.

Whatever the group’s composition, group leaders should leave time at the end of each session to discuss patients’ personal issues privately and to address their needs by making appropriate referrals, including ones to HIV test sites.

Because HCV shares modes of transmission with HIV, groups focused on HIV risk reduction may also wish to impart information about HCV and the possibility of acquiring HCV infection through high-risk behaviors. Prevention efforts aimed at HCV are essential for patients who are currently (or at risk for) injecting drugs, because injection drug use is the risk factor responsible for the majority of HCV cases. Once staff have received training to perform prevention interventions, they typically become motivated to start intervention groups for patients.

Keeping groups going can be difficult in programs that have little patient turnover; groups work best in day programs and outpatient programs. In inpatient units, short lengths of stay may limit the number of sessions patients can attend, but that should not discourage staff from setting up such programs. In the case of HIV-positive patients, individual counseling can reinforce patients’ motivations to protect themselves and others. Clinicians can encourage disclosure to sex partners and use of condoms. Fully informed decisions about risk and protection of others are the goals.

Support groups also are effective at reducing the isolation many patients experience after receiving an HIV diagnosis.

Milton L. Wainberg, M.D.
Francine Cournos, M.D.
Karen McKinnon, M.A.
Alan Berkman, M.D.

References

1. Acuda SW, Sebit MB: Serostatus surveillance testing of HIV-I infection among Zimbabwean psychiatric inpatients in Zimbabwe. Cent Afr J Med 42:254-257, 1996
2. American Psychiatric Association: Practice Guideline for the Treatment of Patients with HIV/AIDS. Am J Psychiatry 157 (suppl):1-62, 2000
3. Ayuso-Mateos JL, Montanes F, Lastra I, et al: HIV infection in psychiatric patients: an unlinked anonymous study. Br J Psychiatry 170:181-185, 1997
4. Barnes R, Felker B, Sloan K, et al: Safety of valproic acid treatment in patients with hepatitis C. Poster presented at the 40th annual meeting of the American College of Neuropsychopharmacology, Waikoloa, HI, December 9, 2001
5. Barre-Sinoussi F, Chermann JC, Rey F, et al: Isolation of a T-lymphotropic retrovirus from a patient at risk for acquired immunodeficiency syndrome. Science 220:868-871, 1983
6. Broder S, Merigan TC, Bolognesi D (eds): Textbook of AIDS Medicine. Baltimore, MD, Williams & Wilkins, 1994
7. Brunette MF, Mercer CC, Carlson CL, et al: HIV-related services for persons with severe mental illness: policy and practice in New Hampshire community mental health. J Behav Health Serv Res 27:347-353, 2000
8. Carey MP, Carey KB, Kalichman SC: Risk for human immunodeficiency virus (HIV) infection among persons with severe mental illnesses. Clin Psychol Rev 17:271-291, 1997
9. Carmen E, Brady SM: AIDS risk and prevention for the chronic mentally ill. Hosp Community Psychiatry 41:652-657, 1990
10. Chuang HT, Atkinson M: AIDS knowledge and high-risk behaviour in the chronic mentally ill. Can J Psychiatry 41:269-272, 1996
11. Cividini A, Pistorio A, Regazzetti A, et al: Hepatitis C virus infection among institutionalized psychiatric patients: a regression analysis of indicators of risk. J Hepatol 27:455-463, 1997
12. Community Research Initiative on AIDS: HIV/hepatitis C co-infection: confronting twin epidemics. http://www.CRIANY.org, accessed January 2000
13. Corbitt G, Crosdale E, Bailey A: Protracted sero-conversion in haemophiliacs in whom infection is confirmed by p24 antigen detection and/or positive HIV PCR, in Abstracts, 7th International Conference on AIDS, Florence, Italy, 1991, p 387
14. Cournos F, McKinnon K: HIV seroprevalence among people with severe mental illness in the United States: a critical review. Clin Psychol Rev 17:259-269, 1997
15. Cournos F, Guido JR, Coomaraswamy S, et al: Sexual activity and risk of HIV infection among patients with schizophrenia. Am J Psychiatry 151:228-232, 1993
16. Fernandez F, Levy JK: The use of molindone in the treatment of psychotic and delirious patients infected with the human immunodeficiency virus: case reports. Gen Hosp Psychiatry 15:31-35, 1993
17. Gallo RC, Salahuddin SZ, Popovic M, et al: Frequent detection and isolation of cytopathic retroviruses (HTLV-III) from patients with AIDS and at risk for AIDS. Science 224:500-503, 1984
18. Goodman LA, Fallot RD: HIV risk-behavior in poor urban women with serious mental disorders: association with childhood physical and sexual abuse. Am J Orthopsychiatry 68:73-83, 1998
19. Hanson M, Kramer TH, Gross W, et al: AIDS awareness and risk behaviors among dually disordered adults. AIDS Educ Prev 4:41-51, 1992
20. Hardy AM: National health interview survey data on adult knowledge about AIDS in the United States. Public Health Rep 105:629-634, 1990
21. Herbert B: Woman battering and HIV infection, in Abstracts (TP500), HIV Infection in Women: Setting a New Agenda. Washington, DC, Philadelphia Sciences Group, 1995
22. Horwath E: Psychiatric and neuropsychiatric manifestations, in AIDS and People With Severe Mental Illness: A Handbook for Mental Health Professionals. Edited by Cournos F, Bakalar N. New Haven, CT, Yale University Press, 1996, pp 57-73
23. Horwath E, Cournos F, McKinnon K, et al: Illicit-drug injection among psychiatric patients without a primary substance use disorder. Psychiatr Serv 47:181-185, 1996
24. Kalichman SC, Kelly JA, Johnson JR, et al: Factors associated with risk for HIV infection among chronic mentally ill adults. Am J Psychiatry 151:221-227, 1994
25. Katz RC, Watts C, Santman J: AIDS knowledge and high risk behaviors in the chronic mentally ill. Community Ment Health J 30:395-402, 1994
26. Keet IP, Krol A, Koot M, et al: Predictors of rapid progression to AIDS in HIV-1 seroconverters. AIDS 7:51-57, 1993
27. Kelly JA: HIV risk reduction interventions for persons with severe mental illness. Clin Psychol Rev 17:293-309, 1997
28. Kelly JA, Murphy DA, Bahr GR, et al: AIDS/HIV risk behavior among the chronic mentally ill. Am J Psychiatry 149:886-889, 1992
29. Levy J: Pathogenesis of human immunodeficiency virus infection. Microbiol Rev 57:183-189, 1993
30. Liberman RP, Mueser KT, Wallace CJ, et al: Training skills in the psychiatrically disabled: learning coping and competence. Schizophr Bull 12:631-647, 1986
31. Lifson AR, Buchbinder SP, Sheppard HW, et al: Long-term human immunodeficiency virus infection in asymptomatic homosexual and bisexual men with normal CD4+ lymphocyte counts: immunologic and virologic characteristics. J Infect Dis 163:959-965, 1991
32. Masliah G, Achim CL, DeTeresa R, et al: The patterns of neurodegeneration in HIV encephalitis. Journal of NeuroAIDS 1:161-173, 1996
33. McDaniel JS, Purcell DW, Farber EW: Severe mental illness and HIV-related medical and neuropsychiatric sequelae. Clin Psychol Rev 17:311-325, 1997
34. McDermott BE, Sautter FJ, Winstead DK, et al: Diagnosis, health beliefs, and risk of HIV infection in psychiatric patients. Hosp Community Psychiatry 45:580-585, 1994
35. McKinnon K, Cournos F: HIV infection linked to substance use among hospitalized patients with severe mental illness. Psychiatr Serv 49:1269, 1998
36. McKinnon K, Cournos F, Sugden R, et al: The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness. J Clin Psychiatry 57:506-513, 1996
37. McKinnon K, Cournos F, Herman R, et al: AIDS-related services and training in outpatient mental health care agencies in New York. Psychiatr Serv 50:1225-1228, 1999
38. McKinnon K, Wainberg ML, Cournos F: HIV/AIDS preparedness in mental health care agencies with high and low substance use disorder caseloads. J Subst Abuse 13:127-135, 2001
39. Mellors JW, Rinaldo CR Jr, Gupta P, et al: Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science 272:1167-1170, 1996
40. Menon AS, Pomerantz S: Substance use during sex and unsafe sexual behaviors among acute psychiatric inpatients. Psychiatr Serv 48:1070-1072, 1997
41. Meyer JM: Prevalence of hepatitis A, hepatitis B and HIV among hepatitis C seropositive state hospital patients: results from Oregon State Hospital. J Clin Psychiatry (in press)
42. Mulder RT, Ang M, Chapman B, et al: Interferon treatment is not associated with a worsening of psychiatric symptoms in patients with hepatitis C. J Gastroenterol Hepatol 15: 300-303, 2000
43. National Digestive Diseases Information Clearinghouse: Chronic hepatitis C: current disease management. Available at: http://www.niddk.nih.gov/health/digest/pubs/chrnhepc. Accessed February 17, 2003
44. National Institutes of Health Consensus Development Conference Panel: Management of hepatitis C. Hepatology 26:2S-10S, 1997
45. O'Brien WA: Genetic and biologic basis of HIV-1 neurotropism, in HIV, AIDS and the Brain. Edited by Price RW, Perry SW. New York, Raven, 1994, pp 47-70
46. O'Brien WA, Hartigan PM, Martin D, et al: Changes in plasma HIV-1 RNA and CD4 + lymphocyte counts and the risk of progression to AIDS. N Engl J Med 334:426-431, 1996
47. Oliveira SB: Avalia'o do comportamento sexual, conhecimentos e atitudes sobre AIDS, dos pacientes internados no instituto de psiquiatria da UFRJ, in O Campo da Aten'o Psicossocial. Edited by Venncio AT, Leal EM, Delgado PG. Rio de Janeiro, Te Cor, 1997, pp 343-351
48. Oquendo M, Tricarico P: Pre- and post-HIV test counseling, in AIDS and People With Severe Mental Illness: A Handbook for Mental Health Professionals. Edited by Cournos F, Bakalar N. New Haven, CT, Yale University Press, 1996, pp 97-112
49. Otto-Salaj LL, Heckman TG, Stevenson LY, et al: Patterns, predictors and gender differences in HIV risk among severely mentally ill men and women. Community Ment Health J 34:175-190, 1998
50. Otto-Salaj LL, Kelly JA, Stevenson LY, et al: Outcomes of a randomized smallgroup HIV prevention intervention trial for people with serious mental illness. Community Ment Health J 37:123-144, 2001
51. Resnick L, Berger JR, Shapshak P, et al: Early penetration of the blood brain barrier by HTLV-III/LAV. Neurology 38:9-15, 1988
52. Rosenberg SD, Goodman LA, Osher FC, et al: Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 91:31-37, 2001
53. Sewell DD, Jeste DV, McAdams LA, et al: Neuroleptic treatment of HIV-associated psychosis. Neuropsychopharmacology 10:223-229, 1994
54. Staprans SI, Feinberg MB: Natural history and immunopathogenesis of HIV-1 disease, in The Medical Management of AIDS, 5th Edition. Edited by Sande MA, Volberding PA. Philadelphia, PA, WB Saunders, 1997, pp 29-56
55. Susser E, Miller M, Valencia E, et al: Injection drug use and risk of HIV transmission among homeless men with mental illness. Am J Psychiatry 153:794-798, 1996
56. Varmus H: Retroviruses. Science 240:1427-1435, 1988
57. Vento S, Garofano T, Renzini C, et al: Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 338:286-290, 1998
58. Wainberg ML, Forstein M, Berkman A, et al: Essential medical facts for mental health practitioners, in What Mental Health Practitioners Need to Know about HIV and AIDS. Edited by Cournos F, Forstein M. San Francisco, CA, Jossey-Bass, 2000, pp 3-15
59. Warner GC: Molecular insights into HIV-1 infection, in The Medical Management of AIDS, 5th Edition. Edited by Sande MA, Volberding PA. Philadelphia, PA, WB Saunders, 1997, pp 17-28