HIV and Hepatitis C in Patients With Schizophrenia
Milton L. Wainberg, M.D. Francine Cournos, M.D. Karen McKinnon, M.A. Alan Berkman, M.D.
Among the chronic health conditions experienced by people with schizophrenia, infection with human immunodeficiency virus (HIV) or hepatitis C virus (HCV) occurs with notable frequency. People who contract HIV face chronic illness, the likelihood of premature death, complicated medication regimens, barriers to medical care, and the neuropsychiatric sequelae of HIV infection itself. HCV is emerging as a significant public health issue due to the persistence of viremia in over 75% of infected persons, with resultant cirrhosis in up to 20% after 10 to 30 years and, in rare cases, hepatocellular carcinoma. It is estimated that in the United States less than 30% of people with HCV know they are infected (National Institutes of Health Consensus Development Conference Panel 1997).
Published rates of HIV infection among psychiatric patients are 3.1% to 23.9%, at least eight times higher than estimates for the general population (Cournos and McKinnon 1997; Rosenberg et al. 2001). These seroprevalence studies were all conducted on the East Coast; in other parts of the United States, no published seroprevalence studies exist to shed light on whether people with severe mental illness in those localities are at increased risk of HIV infection. HIV infection rates among patients with schizophrenia rarely have been differentiated from rates among others with psychotic disorders; but when they have, no significant differences emerged, countering expectations that infection rates might be lower among those with schizophrenia than among those with other severe mental illnesses.
Rates of HCV infection among people with schizophrenia have received far less attention. A large retrospective Italian study found that 6.7% of 1,180 patients hospitalized for mental retardation, psychosis, and dementia were infected with HCV (Cividini et al. 1997). Psychosis and a history of trauma were statistically significant independent risk factors associated with HCV infection
Sexual Risk Behaviors Among People With Schizophrenia and Their Association With Psychiatric and Situational Factors
Most studies of sexual risk behavior among people with psychiatric disorders have not linked behaviors to biological outcomes, but risk for HIV transmission is potentially very high; the role of sexual transmission in HCV infection is weak and poorly understood even in the general population.
Sexual risk behaviors among people in psychiatric treatment are common, with interview studies in Brazil, Canada, Spain, and the United States revealing that a majority of patients were sexually active with a partner in the past year (Acuda and Sebit 1996; Carey et al. 1997; Chuang and Atkinson 1996; Oliveira 1997). Moreover, reports of multiple sex partners are common among sexually active psychiatric patients (Chuang and Atkinson 1996). The sexual activity of people with serious mental illness also is characterized by a lack of condom use in a majority of sexual occasions, a finding true for both men and women (Carey et al. 1997; Cournos et al. 1993; Hanson et al. 1992).
Few studies have differentiated risks by psychiatric diagnosis, so critical information is lacking about patients with schizophrenia-spectrum illnesses; however, data on diagnostic and symptom contributions to sexual risk behavior are beginning to appear.
Being sexually active has been found to be associated with a diagnosis of schizophrenia but not with bipolar disorder ....
Substance Use Risk Behaviors Among People With Schizophrenia and Their Association With Psychiatric and Situational Factors
In the United States, psychiatric patients with identified comorbid alcohol or other drug use disorders have a significantly higher rate of HIV infection than those without (McKinnon and Cournos 1998), even if they have never injected drugs. In this population, any lifetime instance of drug injection or needle sharing appears to increase the risk of being HIV infected more than sixfold (Ayuso-Mateos et al. 1997; Horwath et al. 1996; Rosenberg et al. 2001).
Similar to the case for the general population, HCV infection in psychiatric patients is most strongly associated with injection drug use, and to a lesser extent with other drug use and poverty. Of 122 patients identified with HCV in Rosenberg's study, 91 were injection drug users, 21 reported sniffing cocaine, 17 had used crack, and 24 had used both types of cocaine, with only 7 reporting no drug-related risks (Rosenberg et al. 2001).
A history of drug injection has been noted among 1% to 26% of psychiatric patients (Carey et al. 1997; Rosenberg et al. 2001; Susser et al. 1996), and 5% to 12% report having ever shared needles or other injection paraphernalia
HIV/HCV Knowledge Among People With Severe Mental Illness and Their Providers
AIDS is the ultimate result of HIV infection, and knowledge about AIDSrelated issues among United States and Canadian psychiatric patients appears to be relatively good compared with that of nonpsychiatric groups. Correct responses to AIDS knowledge questionnaires in a variety of psychiatric patient groups ranged from 63% to 80% (Chuang and Atkinson 1996; McKinnon et al. 1996; Otto-Salaj et al. 1998), a comparable accuracy rate to that found in the general United States population (Hardy 1990). Still, many psychiatric patients held critical misinterpretations.
Although HIV has been isolated from a variety of body fluids, including blood, semen, vaginal secretions, breast milk, urine, saliva, and tears, the risk of transmission is a consequence of the amount of virus present and the type of exposure to infected bodily fluids. HIV is found in such small quantities in tears, saliva, and urine that casual contact with these fluids is a theoretically possible but very unlikely mode of transmission.
Epidemiological studies indicate that semen, cervical and vaginal secretions, breast milk, and blood and blood products are the predominant, if not exclusive, vehicles for viral transmission (Staprans and Feinberg 1997). Although uncommon, infection is possible through the exposure of cuts in skin or mucous membranes to HIV-infected blood.
HIV is typically spread by sexual contact, exposure to infected blood (transfusions, blood products, percutaneous or intravenous injections with contaminated syringes or needles, etc.) and through perinatal transmission from mother to child (Warner 1997). Penilevaginal and penileanal intercourse are considered the highest-risk sexual behaviors, in addition to activities that cause a rupture of tissue and the presence of blood. Although the risk of infection is somewhat higher for the recipient of semen than for the insertive partner, transmission has been documented in both directions.
The most commonly used HIV test-enzyme-linked immunosorbent assay (ELISA) followed, if positive, by Western blot--detects the presence of antibodies produced by the host as an immune response to certain genetic components of the virus, but not the presence of the virus itself. Although sensitive and specific, these tests can give false negative or indeterminate results, especially early in the course of infection.
False positive results may occur as well, which is why blanket testing is problematic when carried out in a population in which the prevalence of HIV infection is very low. There is a period following initial infection and before antibody development when an individual is infectious but has negative ELISA and Western blot test results
Natural History of HIV Disease
Although most persons with schizophrenia do not have a family history of it, genetic factors have been implicated. Persons who have a first-degree relative with schizophrenia have about a 15% risk of developing the disorder, compared with a 1% risk among the general population. A monozygotic twin whose co-twin has schizophrenia has a > 50% probability of developing it. Sensitive neurologic and neuropsychiatric tests often indicate that aberrant smooth-pursuit eye tracking, impaired performance on tests of cognition and attention, and deficient sensory gating occur more commonly among patients with schizophrenia than among the general population. These psychophysiologic markers also occur among first-degree relatives of persons with schizophrenia and may indicate vulnerability before overt onset of illness.
Various environmental stressors can trigger the emergence or recurrence of symptoms in vulnerable persons. Examples are stressful life events such as ending a relationship or leaving home for the armed forces, work, or college and biologic stressors such as substance abuse. Stressful family relations can cause or result from frequent illness exacerbation. Protective factors that may mitigate the effect of stress on symptom formation or exacerbation are discussed under Treatment, below.
Clinical management is intended to decrease viral load, increase CD4 cell count, provide prophylaxis against OIs as appropriate, treat OIs when present, and decrease morbidity and mortality. New knowledge about the life cycle of HIV and the advent of different classes of antiretroviral medications have altered the state-of-the-art of treatment, which now requires combination antiretroviral therapies and the prophylaxis of OIs according to guidelines based on the prevalence of each OI at various stages of immunodeficiency. Except in cases of HIV primary infection, pregnancy in an HIV-infected woman, or symptomatic HIV disease, antiretroviral therapy in asymptomatic patients known to be HIV positive is usually initiated when the CD4 cell count is between 200 and 350.
Part of instituting antiretroviral therapy involves ensuring that patients recognize their HIV infection, have access to health care, develop ongoing provider relationships, and are motivated to adhere to complicated treatments, even during an asymptomatic phase of infection. Taking a combination of at least three antiretroviral medications is currently the best way to accomplish this objective. ....
HCV Transmission and Testing
Given preliminary estimates that one in five patients with severe mental illness is infected with HCV, a strong argument can be made that all such persons should be screened for the virus. Certainly, all patients known to be infected with HIV should be screened for anti-HCV antibodies as part of their initial evaluation, as should those with high-risk behavior. HCV is primarily spread through infected blood and is therefore a common complication of injection drug use. HCV may be spread by maternal fetal transmission and by noninjected drug use activities as well. Risk for sexual transmission is low but not absent. In a significant minority of cases the mode of transmission is unknown. Like HIV, rates of HCV in the United States are higher in African Americans and Latinos than among Caucasians.
HCV infection should be confirmed with qualitative PCR assay if the patient is at low risk and the diagnosis seems in doubt. Moreover, there is a small but measurable false negative rate for antibody testing in patients who are severely immunosuppressed.
Accessing the Range of HIV/HCV-Related Services That Psychiatric Patients Need
Mental health service settings vary in their ability to offer HIV-related interventions, and the range of services available may not yet be meeting the needs of people with severe mental illness (McKinnon et al. 1999).
With respect to HCV, Mendel and Ryan's preliminary findings suggest that patients with these psychiatric disorders often are thought "not good candidates" for HCV treatment, with several HIV clinics implementing policies excluding patients with serious psychiatric histories from HCV treatment despite the lack of evidence to support their concerns about maintaining adherence or triggering a major psychiatric event. One medical director at a clinic in a large hospital was willing to engage severely mentally ill patients in HCV treatment, but only if they were under heavily supervised mental health care. Implementing such arrangements could be helpful in initiating treatment and conducting mental health evaluations of candidates already on HCV treatment.
Milton L. Wainberg, M.D.
Francine Cournos, M.D.
Karen McKinnon, M.A.
Alan Berkman, M.D.
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