What Can Be Done to Reach People With Comorbid HIV, Severe Mental Illness?

Individuals with severe mental illness (SMI) have a 10-fold greater likelihood of HIV infection, and they are notoriously difficult to engage and retain in HIV care due to fragmented health care policies and systems that perpetuate stigma. Solutions to remedy this were presented in the electronic poster “Designing Health Care Policy and Care Systems to Reach and Retain Those With Severe Mental Illness in HIV Prevention and Care Efforts: Insights From Five US States,” at AIDS 2020, this year’s virtual rendering of the International AIDS Conference.

“We sought to identify solutions at the health care delivery system level, as well as policies at the state and local level, that might affect HIV-related health outcomes for this key population and inform 'Ending the HIV Epidemic's efforts,” the authors stated.

The team comprised investigators from the University of California, San Francisco; the Kaiser Family Foundation; Rutgers University; and Columbia University, whose case-study design involved 27 semi-structured interviews of key stakeholders (eg, academics, state and county-level public administrators in HIV and/or behavioral health, service providers at no-profit agencies) from 5 states between September 2018 and December 2019:

• California
• Illinois
• Louisiana
• New York
• Texas

Among the many interview topics addressed, and discussed, were HIV testing and treatment policies, the organization of SMI and HIV health care systems, care integration efforts, and electronic data sharing.

The authors found several main obstacles to increasing care among individuals with SMI:

1. It is difficult to integrate such different specialties as mental health care and HIV. “I don’t know that there is a single policy fix,” an interviewee stated.
2. Current policies limit how much data can be shared, as well as care coordination. “We’re working hard trying not to violate federal law,” another interviewee noted
3. Stigma limits service delivery and uptake for people with SMI. “Each level of stigma interferes with the service access and utilization, even amongst professionals,” said a third interviewee.
4. Poor working relationships between behavioral health and infectious disease leaders. “These are two very, very different specialties,” the authors wrote.

“Case studies in five high HIV prevalence states yield important insights into health care delivery systems and policies that improve HIV-related health outcomes for those with SMI,” they concluded.

So what can be done to prevent those with SMI and HIV from falling through the care gap? Key ideas include the following:

• Integrating mental and physical health services at state and local levels through charismatic leaders
• Striking down licensing restrictions
• Instituting value-based reimbursement programs
• Transitioning behavioral health facilities to Federally Qualified Health Centers

More money also is needed, and the authors suggested that in order to incentivize engaging people with SMI in HIV care, making funding through state block grants dependent on offering HIV testing, especially if a behavioral health community clinic, could be a solution. The authors also believe in making HIV screening a routine part of care at emergency departments and drug treatment facilities, providing assistance to those getting out of jail or prison by linking them to care programs as they reenter civilian life, and sharing electronic health records.