Ending HIV, hepatitis B, and hepatitis C: what about people with severe mental illness?
Authors: Milton Wainberg, Lisa Dixon
Journal: The Lancet Psychiatry (2017)

HIV, hepatitis B (HBV), and hepatitis C (HCV) are preventable serious blood-borne infections. Early detection and accessible and user-friendly treatments improve prognosis, cure (for HCV), and prevent further transmission. 30 years of previous studies in a range of population samples have suggested that severe mental illness is a risk factor for contracting blood-borne viruses (BBVs).1Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2016; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (132) Google Scholar In The Lancet Psychiatry, Clarissa Bauer-Staeb and colleagues2Bauer-Staeb C Jörgensen L Lewis G Dalman C Osborn DPJ Hayes JF Prevalence and risk factors for HIV, hepatitis B, and hepatitis C in people with severe mental illness: a total population study of Sweden.Lancet Psychiatry. 2017; (published online July 4.)http://dx.doi.org/10.1016/S2215-0366(17)30253-5Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar confirm the elevated risk for BBVs experienced by individuals with severe mental illness in a total population study of Sweden, finding that the odds of HIV were 2·57 (95% CI 2·25–2·94, p<0·0001) times higher in people with severe mental illness than in the general population, whereas the odds of HBV were 2·29 (2·09–2·51, p<0·0001) times higher and the odds of HCV were 6·18 (5·98–6·39, p<0·0001) times higher. This result increases confidence in the validity of previous studies with more narrowly selected samples. After the first case of HIV infection among people with severe mental illness was identified in 1983,3Cournos F Empfield M Horwath E et al.HIV seroprevalence among patients admitted to two psychiatric hospitals.Am J Psychiatry. 1991; 148: 1225-1230Crossref PubMed Google Scholar multiple studies worldwide have reported high prevalence of HIV infection among people with severe mental illness.1Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2016; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (132) Google Scholar Since then, pioneering research in the USA with people with severe mental illness has shown positive effects on a range of outcomes including measures of condom use, HIV knowledge, and sexual behaviours4Pandor A Kaltenthaler E Higgins A et al.Sexual health risk reduction interventions for people with severe mental illness: a systematic review.BMC Public Health. 2015; 15: 138Crossref PubMed Scopus (23) Google Scholar—yet the epidemic among people with severe mental illness continues to be inadequately addressed. High prevalence of HBV and HCV are also well known and are similarly unaddressed.1Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2016; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (132) Google Scholar Over the past 5 years, the increasingly well established disparities in the physical health of people with severe mental illness have become health policy priorities; however, these policies do not target sexual health and risk factors facilitating transmission of BBVs.1Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2016; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (132) Google Scholar Transmission of BBVs occur through unprotected anal, vaginal, or oral sex; through mother to child vertical transmission; by sharing drug-injecting paraphernalia; and parenterally with contaminated blood and blood products or contaminated instruments and needles. In some circumstances, people with severe mental illness might be more vulnerable to engaging in behaviours that increase their risk of infection with BBVs, including unprotected sex, sex in exchange for a commodity (eg, money, shelter, food), and sharing equipment for intravenous drug use. Ending the HIV epidemic requires routine testing for HIV infection; prevention of infection among HIV-negative individuals with effective risk-reduction interventions and prescriptions of pre-exposure prophylaxis; and antiretroviral treatment for individuals who are HIV-positive until viral suppression is accomplished (treatment as prevention) to decrease forward transmission.5Piot P Karim SSA Hecht R et al.Defeating AIDS—advancing global health.Lancet. 2015; 386: 171-218Summary Full Text Full Text PDF PubMed Scopus (198) Google Scholar A vaccine against HBV confers greater than 95% immunity in three doses.6WHOHepatitis B. Fact sheet.http://www.who.int/mediacentre/factsheets/fs204/en/Google Scholar Screening for HCV followed by treatment can cure infection in more than 95% of patients.7WHOHepatitis C. Fact sheet.http://www.who.int/mediacentre/factsheets/fs164/en/Google Scholar One question raised by Bauer-Staeb and colleagues' Article2Bauer-Staeb C Jörgensen L Lewis G Dalman C Osborn DPJ Hayes JF Prevalence and risk factors for HIV, hepatitis B, and hepatitis C in people with severe mental illness: a total population study of Sweden.Lancet Psychiatry. 2017; (published online July 4.)http://dx.doi.org/10.1016/S2215-0366(17)30253-5Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar is whether individuals with a diagnosis of severe mental illness have as much access to these interventions as do people without severe mental illness. Education alone does not confer prevention. Routine HIV, HBV, or HCV testing has not been implemented in most mental health settings. Efficacious HIV and HCV risk-reduction interventions are available; however, they are either not offered in psychiatric settings or, when they are, they are offered only to those known to be HIV-infected or who self-disclose risky sexual behaviour. People whose risks are not so obvious are easily overlooked. Similarly, HBV vaccination and HCV treatment are seldom available in mental health-care settings. The inaccurate assumption made by some mental health providers that people with severe mental illness do not engage in intravenous drug use or unprotected sex can result in patients not receiving proper care.1Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2016; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 8Yehia BR Cui W Thompson WW et al.HIV testing among adults with mental illness in the United States.AIDS Patient Care STDS. 2014; 28: 628-634Crossref PubMed Scopus (26) Google Scholar Psychiatric facilities are perfect settings for implementation of testing, prevention, and treatment of BBVs tailored to individuals with severe mental illness.9Wainberg ML González MA McKinnon K et al.Targeted ethnography as a critical step to inform cultural adaptations of HIV prevention interventions for adults with severe mental illness.Soc Sci Med. 2007; 65: 296-308Crossref PubMed Scopus (51) Google Scholar Caring and supportive providers already engaged in therapeutic relationships with their patients can address barriers, alleviate concerns, and facilitate comprehensive prevention and care. Barriers to provision of prevention, testing, and care to people with severe mental illness include insufficient training of mental health staff in evidence-based interventions; inadequate funds, including little money for condoms; the separation of psychiatric and medical services; and providers' failure to address patients' romantic partnerships, sexual needs, and psychotropic medication side-effects.9Wainberg ML González MA McKinnon K et al.Targeted ethnography as a critical step to inform cultural adaptations of HIV prevention interventions for adults with severe mental illness.Soc Sci Med. 2007; 65: 296-308Crossref PubMed Scopus (51) Google Scholar Global efforts to end HIV, HBV, and HCV as a public health threats are underway, but the extent to which public psychiatric care systems are participating is unknown despite evidence that individuals with severe mental illness have higher prevalence of BBVs than those in the general population. Recovery guidelines include integration of physical health and mental health care,10Patel V Araya R Chatterjee S et al.Treatment and prevention of mental disorders in low-income and middle-income countries.Lancet. 2007; 370: 991-1005Summary Full Text Full Text PDF PubMed Scopus (583) Google Scholar, 11Pincus HA Spaeth-Rublee B Sara G et al.A review of mental health recovery programs in selected industrialized countries.Int J Mental Health Syst. 2016; 10: 73Crossref PubMed Scopus (44) Google Scholar but uptake of prevention and intervention strategies for HIV, HBV, and HCV has been scarce in real-world mental health settings.12Whiteman KL Naslund JA DiNapoli EA Bruce ML Bartels SJ Systematic review of integrated general medical and psychiatric self-management interventions for adults with serious mental illness.Psychiatr Serv. 2016; 67: 1213-1225Crossref PubMed Scopus (47) Google Scholar People with severe mental illness must be specifically included in current well funded global initiatives to reduce transmission of BBVs and achieve the goal of ending the HIV, HBV, and HCV epidemics.5Piot P Karim SSA Hecht R et al.Defeating AIDS—advancing global health.Lancet. 2015; 386: 171-218Summary Full Text Full Text PDF PubMed Scopus (198) Google Scholar This goal requires a greater commitment from governments and public mental health-care systems to systematically and comprehensively reach this disproportionally affected population. We declare no competing interests. Prevalence and risk factors for HIV, hepatitis B, and hepatitis C in people with severe mental illness: a total population study of SwedenOur results highlight the need to address the issue of higher prevalence of BBVs in people with severe mental illness and identify interventions preventing infection. Targeting of comorbid substance misuse would have particular effect on reduction of BBV prevalence in this population. Full-Text PDF Open AccessSocial exclusion and human rights at the intersection of HIV and severe mental illnessIn their comprehensive Comment, Wainberg and Dixon1 described potential policy implications of the increased prevalence of HIV among people with severe mental illness. HIV and human rights frequently collide and particular caution is required when considering matters of cause and consequence in an already stigmatised and socially excluded population. Full-Text PDF Social exclusion and human rights at the intersection of HIV and severe mental illness – Author's ReplyWe agree with Nathan Hodson and Susan Bewley that the social exclusion of people with severe mental illness is associated with intimate partner and sexual violence as an important factor among others that contribute to HIV risk behaviours. Even without the presence of violence, mental illness stigma, and especially "relationship discrimination" stigma has been shown to be associated with HIV sexual risk behaviours.1,2 Full-Text PDF