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.

For example, in one study 42% were unaware they could be infected by injection drug use (Katz et al. 1994), and in another, 48% believed that careful cleansing after sex would provide protection from the virus (Otto-Salaj et al. 1998). Comparable studies about HCV knowledge among patients have not been completed. Although knowledge is necessary, it is not sufficient to reduce unsafe behaviors.

Preliminary findings from qualitative interviews with medical and mental health care providers show widespread consensus that HCV is a major public healthcare issue (P. Mendel and G. Ryan, unpublished data, February 2002). Interviews with providers at 32 agencies in New York City and Los Angeles showed adequate knowledge about how to identify HCV-antibody-positive clients, at least among agencies with established medical services. In general, testing for HCV is less burdensome because it does not involve the counseling, confidentiality, or stigma issues usually associated with HIV testing; yet there is great variation among providers on how to proceed once HCV-positive patients are identified.

Uncertainty about the efficacy of current treatments, exclusion/ inclusion criteria for treatment, and the division of responsibility among medical specialties for managing treatment are paramount concerns.

Mendel and Ryan’s qualitative data suggest that, in practice, many mental health care providers are unsure of how many of their clients have HCV, except for a general sense that the numbers are increasing. Staff in mental health agencies were more concerned with diabetes and tuberculosis (because of the difficulty in daily self-management and the risk of contagion, respectively) than with either HCV or HIV. In addition, these qualitative data show that mental health and substance abuse treatment providers were generally unaware of the depressive side effects of interferon therapy, with only two agencies in New York City recounting specific in-service trainings that covered HCV along with other diseases.

We believe that improved HCV screening followed by referral for evaluation of every HCV-positive patient, including those with schizophrenia, whose psychiatric condition is stable is now warranted.

Milton L. Wainberg, M.D.
Francine Cournos, M.D.
Karen McKinnon, M.A.
Alan Berkman, M.D.


  1. Acuda SW, Sebit MB: Serostatus surveillance testing of HIV-I infection among Zimbabwean psychiatric inpatients in Zimbabwe. Cent Afr J Med 42:254-257, 1996
  2. American Psychiatric Association: Practice Guideline for the Treatment of Patients with HIV/AIDS. Am J Psychiatry 157 (suppl):1-62, 2000
  3. Ayuso-Mateos JL, Montanes F, Lastra I, et al: HIV infection in psychiatric patients: an unlinked anonymous study. Br J Psychiatry 170:181-185, 1997
  4. Barnes R, Felker B, Sloan K, et al: Safety of valproic acid treatment in patients with hepatitis C. Poster presented at the 40th annual meeting of the American College of Neuropsychopharmacology, Waikoloa, HI, December 9, 2001
  5. Barre-Sinoussi F, Chermann JC, Rey F, et al: Isolation of a T-lymphotropic retrovirus from a patient at risk for acquired immunodeficiency syndrome. Science 220:868-871, 1983
  6. Broder S, Merigan TC, Bolognesi D (eds): Textbook of AIDS Medicine. Baltimore, MD, Williams & Wilkins, 1994
  7. Brunette MF, Mercer CC, Carlson CL, et al: HIV-related services for persons with severe mental illness: policy and practice in New Hampshire community mental health. J Behav Health Serv Res 27:347-353, 2000
  8. Carey MP, Carey KB, Kalichman SC: Risk for human immunodeficiency virus (HIV) infection among persons with severe mental illnesses. Clin Psychol Rev 17:271-291, 1997
  9. Carmen E, Brady SM: AIDS risk and prevention for the chronic mentally ill. Hosp Community Psychiatry 41:652-657, 1990
  10. Chuang HT, Atkinson M: AIDS knowledge and high-risk behaviour in the chronic mentally ill. Can J Psychiatry 41:269-272, 1996
  11. Cividini A, Pistorio A, Regazzetti A, et al: Hepatitis C virus infection among institutionalized psychiatric patients: a regression analysis of indicators of risk. J Hepatol 27:455-463, 1997
  12. Community Research Initiative on AIDS: HIV/hepatitis C co-infection: confronting twin epidemics., accessed January 2000
  13. Corbitt G, Crosdale E, Bailey A: Protracted sero-conversion in haemophiliacs in whom infection is confirmed by p24 antigen detection and/or positive HIV PCR, in Abstracts, 7th International Conference on AIDS, Florence, Italy, 1991, p 387
  14. Cournos F, McKinnon K: HIV seroprevalence among people with severe mental illness in the United States: a critical review. Clin Psychol Rev 17:259-269, 1997
  15. Cournos F, Guido JR, Coomaraswamy S, et al: Sexual activity and risk of HIV infection among patients with schizophrenia. Am J Psychiatry 151:228-232, 1993
  16. Fernandez F, Levy JK: The use of molindone in the treatment of psychotic and delirious patients infected with the human immunodeficiency virus: case reports. Gen Hosp Psychiatry 15:31-35, 1993
  17. Gallo RC, Salahuddin SZ, Popovic M, et al: Frequent detection and isolation of cytopathic retroviruses (HTLV-III) from patients with AIDS and at risk for AIDS. Science 224:500-503, 1984
  18. Goodman LA, Fallot RD: HIV risk-behavior in poor urban women with serious mental disorders: association with childhood physical and sexual abuse. Am J Orthopsychiatry 68:73-83, 1998
  19. Hanson M, Kramer TH, Gross W, et al: AIDS awareness and risk behaviors among dually disordered adults. AIDS Educ Prev 4:41-51, 1992
  20. Hardy AM: National health interview survey data on adult knowledge about AIDS in the United States. Public Health Rep 105:629-634, 1990
  21. Herbert B: Woman battering and HIV infection, in Abstracts (TP500), HIV Infection in Women: Setting a New Agenda. Washington, DC, Philadelphia Sciences Group, 1995
  22. Horwath E: Psychiatric and neuropsychiatric manifestations, in AIDS and People With Severe Mental Illness: A Handbook for Mental Health Professionals. Edited by Cournos F, Bakalar N. New Haven, CT, Yale University Press, 1996, pp 57-73
  23. Horwath E, Cournos F, McKinnon K, et al: Illicit-drug injection among psychiatric patients without a primary substance use disorder. Psychiatr Serv 47:181-185, 1996
  24. Kalichman SC, Kelly JA, Johnson JR, et al: Factors associated with risk for HIV infection among chronic mentally ill adults. Am J Psychiatry 151:221-227, 1994
  25. Katz RC, Watts C, Santman J: AIDS knowledge and high risk behaviors in the chronic mentally ill. Community Ment Health J 30:395-402, 1994
  26. Keet IP, Krol A, Koot M, et al: Predictors of rapid progression to AIDS in HIV-1 seroconverters. AIDS 7:51-57, 1993
  27. Kelly JA: HIV risk reduction interventions for persons with severe mental illness. Clin Psychol Rev 17:293-309, 1997
  28. Kelly JA, Murphy DA, Bahr GR, et al: AIDS/HIV risk behavior among the chronic mentally ill. Am J Psychiatry 149:886-889, 1992
  29. Levy J: Pathogenesis of human immunodeficiency virus infection. Microbiol Rev 57:183-189, 1993
  30. Liberman RP, Mueser KT, Wallace CJ, et al: Training skills in the psychiatrically disabled: learning coping and competence. Schizophr Bull 12:631-647, 1986
  31. Lifson AR, Buchbinder SP, Sheppard HW, et al: Long-term human immunodeficiency virus infection in asymptomatic homosexual and bisexual men with normal CD4+ lymphocyte counts: immunologic and virologic characteristics. J Infect Dis 163:959-965, 1991
  32. Masliah G, Achim CL, DeTeresa R, et al: The patterns of neurodegeneration in HIV encephalitis. Journal of NeuroAIDS 1:161-173, 1996
  33. McDaniel JS, Purcell DW, Farber EW: Severe mental illness and HIV-related medical and neuropsychiatric sequelae. Clin Psychol Rev 17:311-325, 1997
  34. McDermott BE, Sautter FJ, Winstead DK, et al: Diagnosis, health beliefs, and risk of HIV infection in psychiatric patients. Hosp Community Psychiatry 45:580-585, 1994
  35. McKinnon K, Cournos F: HIV infection linked to substance use among hospitalized patients with severe mental illness. Psychiatr Serv 49:1269, 1998
  36. McKinnon K, Cournos F, Sugden R, et al: The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness. J Clin Psychiatry 57:506-513, 1996
  37. McKinnon K, Cournos F, Herman R, et al: AIDS-related services and training in outpatient mental health care agencies in New York. Psychiatr Serv 50:1225-1228, 1999
  38. McKinnon K, Wainberg ML, Cournos F: HIV/AIDS preparedness in mental health care agencies with high and low substance use disorder caseloads. J Subst Abuse 13:127-135, 2001
  39. Mellors JW, Rinaldo CR Jr, Gupta P, et al: Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science 272:1167-1170, 1996
  40. Menon AS, Pomerantz S: Substance use during sex and unsafe sexual behaviors among acute psychiatric inpatients. Psychiatr Serv 48:1070-1072, 1997
  41. Meyer JM: Prevalence of hepatitis A, hepatitis B and HIV among hepatitis C seropositive state hospital patients: results from Oregon State Hospital. J Clin Psychiatry (in press)
  42. Mulder RT, Ang M, Chapman B, et al: Interferon treatment is not associated with a worsening of psychiatric symptoms in patients with hepatitis C. J Gastroenterol Hepatol 15: 300-303, 2000
  43. National Digestive Diseases Information Clearinghouse: Chronic hepatitis C: current disease management. Available at: Accessed February 17, 2003
  44. National Institutes of Health Consensus Development Conference Panel: Management of hepatitis C. Hepatology 26:2S-10S, 1997
  45. O'Brien WA: Genetic and biologic basis of HIV-1 neurotropism, in HIV, AIDS and the Brain. Edited by Price RW, Perry SW. New York, Raven, 1994, pp 47-70
  46. O'Brien WA, Hartigan PM, Martin D, et al: Changes in plasma HIV-1 RNA and CD4 + lymphocyte counts and the risk of progression to AIDS. N Engl J Med 334:426-431, 1996
  47. Oliveira SB: Avalia'o do comportamento sexual, conhecimentos e atitudes sobre AIDS, dos pacientes internados no instituto de psiquiatria da UFRJ, in O Campo da Aten'o Psicossocial. Edited by Venncio AT, Leal EM, Delgado PG. Rio de Janeiro, Te Cor, 1997, pp 343-351
  48. Oquendo M, Tricarico P: Pre- and post-HIV test counseling, in AIDS and People With Severe Mental Illness: A Handbook for Mental Health Professionals. Edited by Cournos F, Bakalar N. New Haven, CT, Yale University Press, 1996, pp 97-112
  49. Otto-Salaj LL, Heckman TG, Stevenson LY, et al: Patterns, predictors and gender differences in HIV risk among severely mentally ill men and women. Community Ment Health J 34:175-190, 1998
  50. Otto-Salaj LL, Kelly JA, Stevenson LY, et al: Outcomes of a randomized smallgroup HIV prevention intervention trial for people with serious mental illness. Community Ment Health J 37:123-144, 2001
  51. Resnick L, Berger JR, Shapshak P, et al: Early penetration of the blood brain barrier by HTLV-III/LAV. Neurology 38:9-15, 1988
  52. Rosenberg SD, Goodman LA, Osher FC, et al: Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 91:31-37, 2001
  53. Sewell DD, Jeste DV, McAdams LA, et al: Neuroleptic treatment of HIV-associated psychosis. Neuropsychopharmacology 10:223-229, 1994
  54. Staprans SI, Feinberg MB: Natural history and immunopathogenesis of HIV-1 disease, in The Medical Management of AIDS, 5th Edition. Edited by Sande MA, Volberding PA. Philadelphia, PA, WB Saunders, 1997, pp 29-56
  55. Susser E, Miller M, Valencia E, et al: Injection drug use and risk of HIV transmission among homeless men with mental illness. Am J Psychiatry 153:794-798, 1996
  56. Varmus H: Retroviruses. Science 240:1427-1435, 1988
  57. Vento S, Garofano T, Renzini C, et al: Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 338:286-290, 1998
  58. Wainberg ML, Forstein M, Berkman A, et al: Essential medical facts for mental health practitioners, in What Mental Health Practitioners Need to Know about HIV and AIDS. Edited by Cournos F, Forstein M. San Francisco, CA, Jossey-Bass, 2000, pp 3-15
  59. Warner GC: Molecular insights into HIV-1 infection, in The Medical Management of AIDS, 5th Edition. Edited by Sande MA, Volberding PA. Philadelphia, PA, WB Saunders, 1997, pp 17-28

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