The seriously mentally ill also are at risk for HIV because of their aggregate high rates of comorbidity with substance abuse. Data from the Epidemiological Catchment Area Survey sponsored by NIMH indicate that the rate of alcohol and drug abuse is 47 percent among schizophrenic patients and 61 percent among patients with bipolar disorder (Grinspoon, 1994). Moreover, substance abuse often is a cofactor in risky sexual behavior among the mentally ill (as well as other populations).
Two recent studies, in New York and Milwaukee, found that a majority of sexually active psychiatric patients used alcohol or drugs in conjunction with sex—more commonly alcohol than other substances (Cournos et al., 1994; Kalichman et al., 1994). Approximately 50 percent of these patients also exchanged sex for money, drugs, or other goods. Women were more likely to sell sex and men were more likely to buy it (Cournos et al., 1994; Kalichman et al., 1994).
While these studies provide important information about HIV risk and prevalence among the seriously mentally ill, they are limited in a number of ways. First, and most obviously, nearly all research has been conducted in one place—New York City—and may not, therefore, be generalizable. The particular demographic characteristics of that city's seriously mentally ill population—for example, the overrepresentation of racial/ethnic minorities—may not be common to the rest of America. Second, except for one study of mentally ill homeless men in a shelter (Susser, Valencia, and Conover, 1993), all research has taken place among psychiatric patients in hospitals or clinics. The population of seriously mentally ill who have not undergone treatment has not been adequately examined. Third, a number of researchers report that relating serostatus to specific risk behaviors among the mentally ill has been made difficult by the fact that hospitals and clinics often do not take sexual and drug-using histories from patients upon arrival (Cournos et al., 1991). Moreover, many inpatients are released without a record of their serostatus, suggesting a lack of testing and reporting of HIV status on their charts (Mahler et al., 1994). HIV testing and reporting among the mentally ill raise significant ethical issues, which undoubtedly contribute to this situation. (For a discussion of some of the ethical issues of testing in this population, see Satriano and Karp, 1993.)
The AIDS in Multiethnic Neighborhoods (AMEN) Study was designed to examine the possibility that similar risky sexual networks existed in an urban setting. The AMEN Study interviewed single adults residing in highrisk neighborhoods adjacent to the Castro district, the AIDS epicenter of San Francisco. Among the 1,573 heterosexually active people who did not inject drugs interviewed