and anxiety—are associated with risky behavior, and that youth also increases risk. A meta-analysis of 34 studies investigated the impact of depression or anxiety on high-risk sexual behaviors, defined as having multiple partners and/or unprotected sex. The samples included individuals with mental illness alone, as well as those with mental illness and HIV. The study found little evidence that depression and anxiety are associated with more risky behavior (Crepaz and Marks, 2001).

Findings suggest that serious mental illness, without co-morbid HIV, does increase the likelihood of engaging in high-risk sexual behaviors (Carey et al., 1997; Cournos and McKinnon, 1997; Sullivan et al., 1999). Two relatively small studies have addressed the question of the impact on sexual behavior of having co-morbid mental illness and HIV. These studies have found an increased likelihood of engaging in high-risk sexual behaviors for those with more psychotic symptoms, those with problem drinking, and those not receiving HIV counseling (Tucker et al., 2003). Patients with serious mental illness were also found to have high rates of risky behavior, including sex with a known injection drug user, prostitution, and male–male sexual contact (Meyer et al., 1995).

Researchers at RAND, interviewing 159 treatment providers at 72 mental health and HIV treatment programs in New York City and Los Angeles, found that screening for HIV and risk behaviors in mental health agencies occurs haphazardly, given the range of clients’ nonpsychiatric and other medical needs that compete for the attention of providers. In contrast, HIV treatment agencies tend to place high priority on screening and care for mental illness, as clinicians generally perceive the mental health of clients to be central to successful HIV treatment and adherence (Personal communication, P. Mendel, RAND Corporation, 2002). Nevertheless, because research has long established that depression is missed in 40 to 60 percent of patients in primary care (Hirschfeld et al., 1997; DHHS, 1999), it would not be surprising if depression often went undetected in HIV care. One of the few other studies of this problem found that community mental health clinicians in New Hampshire reported lack of specific knowledge about comorbid mental illness and HIV and reported interest in receiving training (Brunette et al., 2000).

Another study, which focused directly on the barriers to receiving HIV care for individuals whose co-morbid serious mental illness and HIV infection are already known, compared nearly 300 seriously mentally ill and HIV-positive patients in Los Angeles and New York City to patients from the HIV Cost and Services Utilization Study (HCSUS)6 from the same geographic region and with HIV alone. It found that people with serious


The HCSUS study is a nationally representative study of HIV-positive adults receiving care in the contiguous United States.

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