Withholding HIV Care and Discrimination Against Mental Illness

Persons with mental illness or HIV are highly stigmatized. Though empirical research is limited, it would hardly be surprising if stigma were not compounded for individuals with MI-HIV comorbidity. As expressed in Mental Health Care for People Living with or Affected by HIV/AIDS: A Practical Guide, “The HIV-infected client [of mental health services] often finds himself/herself stigmatized in many ways—for having a fatal, transmittable disease; for being ‘crazy’; for being gay; for being sexual; for being a substance user; for being African-American; for being poor; for being Hispanic; for being an illegal immigrant; for being unemployed; for being homeless; or for being an ex-offender. HIV-related stigmatization constitutes an epidemic in itself—an epidemic of fear, prejudice, and discrimination” (Acuff et al., 1999).

A major concern is that identification of mental illness in HIV-infected individuals will lead to a particular form of medical discrimination: physicians’ withholding HIV therapy in order to prevent possible transmission of multi-drug resistant HIV. A 1998 survey of 995 infectious disease physicians, responding to hypothetical scenarios, found that 57 percent of them were either “very much against” or “somewhat against” prescribing ARV for someone with prior psychiatric hospitalization (Bogart et al., 2000). A related survey found widespread use of nonmedical factors determining physician likelihood of starting someone on ARV, although questions did not specifically assess psychiatric history or current MI (Bogart et al., 2001). These studies underscore the problem that physicians may discriminate against patients on the basis of medical history or demographic group membership, rather than on the basis of their individual level of adherence. Patients’ initial level of adherence is the strongest predictor of adherence (Sherbourne et al., 1992). Research reveals that physicians, typically using other factors, are unable to predict which of their patients will adhere to therapy (Sollitto et al., 2001).

Concerned about bias in treatment recommendations, a NIH panel alerted physicians in 1998: “No individual patients should automatically be excluded from consideration for antiretroviral therapy simply because he or she exhibits behavior or other characteristics judged by some to lend itself to noncompliance” (NIH, 1998). This precise wording was later adopted verbatim in the 2002 HIV treatment guidelines. With regard to initiating therapy, those guidelines explicitly rely on CD4 levels and viral load, as well as taking into account “the likelihood, after counseling and education, of adherence to the prescribed treatment regimen” (DHHS, 2004). An editorial review echoed the theme of unwarranted discrimination and urged physicians to work with potentially nonadherent patients until they achieve sufficient understanding and social support to maximize successful antiretroviral treatment (Sollitto et al., 2001).

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