HIV and Schizophrenia: Partners in Disparities

Dr Christina Mangurian

"People don't think about schizophrenia when they think about HIV," Christina Mangurian, MD, professor of clinical psychiatry and vice chair for diversity and health equity at the University of California-San Francisco (UCSF), told Medscape Medical News.

The problem is complicated. According to the Centers for Disease Control and Prevention and National Institutes of Health, roughly 6% of people with serious mental illness are living with HIV, a rate that is about 10 times higher than the general US population (0.4%). However, findings from a study by Mangurian and her team, published online in the journal AIDS, demonstrated that half of Medicaid patients with schizophrenia and HIV admitted to inpatient units in New York State were not coded as such upon discharge.

These data raise the question: How many people living with comorbid HIV and serious mental illness are diagnosed, virally suppressed, and/or lost to treatment as a result of the stigma associated with both conditions, lack of social support, and under-recognition by practitioners that a problem even exists?

Lost in the Care Continuum

Mangurian and her research team examined documentation of preexisting HIV/AIDS diagnoses and absence of ICD-9-CM HIV/AIDS coding at psychiatric discharge among 14,602 adults (aged 18-64 years) admitted to hospital inpatient units in New York State between January 1, 2012, and December 31, 2013. HIV diagnoses were defined as recent (within 30 days of admission) or distant (within 30-366 days of admission), and first admission was used as the index in people with multiple hospitalizations.

People living with HIV comprised 5.1% (741) of the overall dataset; 34% were diagnosed with schizophrenia and 27.9% with bipolar disorders. Overall, 54.5% were male and 50.7% were non-Hispanic Black. And 58.3% were discharged without HIV/AIDS ICD-9 coding, reinforcing the likelihood that they were lost in the care continuum.

Mangurian explained that this break in the chain of care upon discharge can have an important impact on efforts to break the cycle of HIV transmission.

"There's data that people with serious mental illnesses like schizophrenia are less likely to have sex, but when they do they're more likely to engage in risky sexual behaviors, including sex for money, unprotected sex with partners who use injection drugs or who have HIV," she said.

Although the majority of patients — both with and without prior HIV diagnoses — were older, adjusted models demonstrated that people aged 18-24 years had more than twice the odds of having their HIV/AIDS undocumented at discharge (compared with older adults aged 55-64 years, adjusted odds ratio [aOR] 2.37; P = .038), as were those aged 25-34 years (aOR, 2.17; P = .003). Individuals with more distant HIV diagnoses had three times the odds for an undocumented HIV/AIDS discharge compared with more recent diagnoses (aOR, 3.25; P < .001).

Dr Sarah Andrews

Additional factors contributing to the lack of ICD-9 discharge coding included shorter lengths of stay (0-3 days vs 15-30 days; aOR, 0.03; P = .01) and fewer HIV claims for HIV/AIDS services before hospitalization (1-2 vs 3-9; aOR, 0.34; P < .01). Hospitals serving medium or high levels of Medicaid patients were also less likely to document HIV/AIDS before discharge (medium aOR, 1.69, P = .01; high aOR, 1.71, P = .03).

The study is not without limitations. For example, the 10-year-old dataset might not entirely reflect more recent structural or systemic changes for improving HIV detection on inpatient psychiatric units. Moreover, there was no comparator group without psychiatric inpatient admission.

Still, "[If these patients] didn't have a discharge diagnosis, then it's possible that they were not managed for their HIV or their HIV was not addressed while they were in the hospital," Sarah Andrews, MD, assistant professor of psychiatry and behavioral sciences and AIDS psychiatrist at Johns Hopkins School of Medicine, Baltimore, Maryland, explained.

Andrews, who was not involved in the study, noted that this omission is significant. "A psychiatric admission or medical admission in general is a great opportunity to further manage and treat comorbidities. When we have a patient who comes in with HIV and they haven't been on an antiviral prior to admission, we try to get infectious disease to give us recommendations of what to start, what labs to draw, to help them reestablish care," she said.

Severe Mental Health an HIV Disparity

Despite the burden of HIV among patient populations with serious mental health issues and data suggesting that these populations are over-represented among new HIV infections, the study findings point to an important missed opportunity for meeting several key outcomes on the HIV/AIDS care continuum, especially linkage to and retention in care.

The challenge is multifactorial.

In an earlier publication appearing in April 2021 in The Lancet HIV, Mangurian and colleagues explore a concept known as the "purview paradox," which refers to a practitioner's belief about who should be responsible for offering patients a particular intervention.

Structural and systemic issues also abound, as psychiatry records are often kept separate from the rest of the medical system due to insurer billing issues. "The true integration of all psychiatric and medical care has to happen to make sure that all of our patients receive the care that they deserve," explained Mangurian.

Andrews agrees. "HIV care as well as psychiatry, case management, pharmacy...putting them together really helps decrease the risk of falling through the cracks and being able to refer appropriately for mental health," she said.

Aside from changing practitioner attitudes and awareness and changing systems to include the wrap-around care model, current guidelines also need to reflect the role that patients with HIV and psychiatric comorbidities play in HIV transmission. Andrews and Mangurian agree: routine screening in psychiatric inpatient units might be a good start.

The study was independently supported. Mangurian has reported grant funding from Genentech Charitable Foundation. Andrews has reported no relevant financial relationships.

AIDS. Published online February 9, 2022. Abstract

Liz Scherer is an independent journalist specializing in infectious and emerging diseases, cannabinoid therapeutics, neurology, oncology, and women's health.
Twitter: @LizScherer.

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