health services and substance abuse services did increase the likelihood of using HIV medical care, of staying in care, and of receiving more medical visits (Ashman et al., 2002). In addition, several types of tailored interventions have been studied that are designed to reduce high-risk sexual behaviors among those with MI-HIV. A 1997 review found that intensive, small-group interventions did produce short-term reductions in high-risk sexual behavior (Kelly, 1997). Subsequent studies have identified effective programs for assertiveness training for women with SMI (Weinhardt et al., 1998), cognitive–behavioral training for men and women (Otto-Salaj et al., 2001), and educational intervention for out-of-treatment cocaine users with depression and anti-social personality disorder (Compton et al., 2000). The problem is that most interventions are costly, labor-intensive, require frequent “booster” sessions, and thus not widely used (Sullivan et al., 1999). In addition, these programs were add-on services rather than attempts at integration of mental health, substance abuse, and HIV care. Integrated care has the potential to be more cost effective.

In 1998, the Substance Abuse and Mental Health Services Administration (SAMHSA), in collaboration with several other federal agencies, began a five-year demonstration program to determine the effects of integrated mental health, substance abuse, and HIV/AIDS primary care services on the three major outcomes: treatment adherence, health outcomes, and cost of treatment. Each of the eight study sites approaches integration in different ways, but most use some variation of co-location of services or intensive case management. The results have not yet been reported.

CONCLUSIONS

This appendix has described a body of literature on the impact of MI on HIV disease. Studies have found that MI increases the risk of acquiring or transmitting HIV by virtue of high-risk behavior or lower adherence to ARV. There are, however, variations in risk depending on symptoms, diagnosis, and other factors. For those with comorbid MI-HIV, studies have found wide-ranging barriers to care, including stigma, cost, inadequate detection of comorbidities, and fragmentation of services. If individuals reach care, their treatment needs are broader and more complex. Physicians may discriminate against mentally ill patients by withholding or deferring HIV therapies because of concerns about nonadherence. This form of discrimination is unwarranted because it relies on group identification, rather than on each patient’s own track record of adherence. All indications are that coordinated or integrated care—for the full range of comorbidities, including substance abuse treatment—is critical for improving adherence with HIV care, controlling the HIV epidemic, and for providing patients with the most comprehensive and effective array of health services.



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