Positive results involving HIV prevention for the mentally ill population

Motivational interviewing is used

The HIV epidemic has disproportionately impacted people with mental illness and/or substance abuse problems, creating some inherent outreach and prevention targeting problems for providers and public health professionals.

Cookie cutter prevention interventions do not work well with this population, says Stephen Brady, PhD, director of the mental health and behavioral medicine program and associate professor of psychiatry and graduate medical sciences at Boston University School of Medicine in Boston, MA.

"The interventions need to be more individualized and delivered in routine health care settings," Brady says. "Often these days, patients aren't in groups and need to [hear] what you're giving in the context of a mental health visit or doctor visit."

Most HIV prevention messages tend to focus on educating people about HIV and the behaviors that increase the likelihood of transmission, notes Jori Berger-Greenstein, PhD, an academic-rank assistant professor in the department of psychiatry, Boston University School of Medicine.

"It's a lot of education and skills training, a generic process where everybody gets the same thing in a group format," Berger-Greenstein says.

The literature shows that these types of interventions typically succeed in the short term, but the success fades with time, she adds.

"It's like any other behavioral intervention, such as Weight Watchers, where they lose weight, time passes, and they gain the weight back," she says.

Keeping this dynamic in mind, Brady and Berger-Greenstein studied a standard prevention intervention and compared it with a behavioral intervention with the added twist of motivational interviewing techniques.

"We hope people with the augmented intervention will do better," Berger-Greenstein says.

Participants had to be at high risk for HIV within the previous three months and have a history of mental illness. They also were people who currently were engaging in high-risk behavior, Brady says.

Brady says they have enrolled more than 50 participants who have these demographics:

  • more than 70 percent are homeless;
  • 86 percent have a lifetime history of substance abuse;
  • 37 percent are African American;
  • 16 percent are Latino;
  • 19 percent are HIV positive; and
  • Nearly all have co-morbid psychiatric disorders, including 70 percent with mood disorders, 22 percent who are psychotic, 58 percent with post-traumatic stress disorder, and 68 percent with other serious anxiety disorders.

"We randomized twice the number of participants we anticipated," Brady says. "We don't have enough resources to rapidly respond to all the patient interest in this study."

The retention rate for the study is 70 percent, which is very high for this particular population, he notes.

"In a very preliminary analysis, we're not able to compare the relative effectiveness of the two interventions, but looking at them together, we have seen that people made significant improvement across almost every outcome domain we're measuring," Brady says.

Both groups have demonstrated an increased knowledge of HIV, ability to use barrier precautions, including condoms, dental dam, and clean needles, and they've shown an ability to negotiate safer sex, Brady says.

"We've evaluated pre- and post-intervention to see how well they do," Brady says. "They also report a significant reduction in the number of sexual partners and in the frequency of their use of barrier [methods] when they have sex."

The standard intervention featured education and skills training with four sessions, Berger-Greenstein says.

"The first session is about education: here's what HIV is; here's the difference between HIV and AIDS; here's what you would do if you wanted to have sex with somebody, the kind of condom you'd use, and so forth," she says.

This approach is consistent with other behavioral research where someone is educated so they'd have a knowledge base from which to determine their own risk of being infected or transmitting HIV, Brady notes.

For example, for the risk prevention strategy involving using condoms, participants are taught why it's important to use condoms during every sexual encounter, and they are shown how to put condoms on a model, Berger-Greenstein says.

Since candid talk about sex and condoms tends to make people uncomfortable, investigators have made the intervention a one-on-one session.

"People are much more likely to ask questions or be vulnerable and talk about risk in the individual sessions," Berger-Greenstein says.

"I think that's true for women because sex is so fraught with abuse and neglect," Brady notes. "But for men, the group [also may work] well."

To demonstrate how to sterilize needles before use, the intervention includes a session using medicine droppers to clean needles according to CDC guidelines, and it includes demonstrations of how to use female condoms and dental dams, Berger-Greenstein says.

"We weren't going to use female condoms, but our advisory board said that while most women don't use female condoms, the sex trade women will use them occasionally," Brady says. "And we use dental dams because although oral sex is low risk for HIV transmission, it's not as low risk in a population with gum disease and dental problems."

Given the target population of people with mental illness, investigators thought it was important to demonstrate the use of dental dams, he adds.

The intervention sessions were outlined in this way:

  • The first session and hour provided education.
  • The second session focused on sexual risk, with specific education on this topic, including demonstrations for using male and female condoms.
  • The third session focused on substance use, including information about needle cleaning and the risk of infection from dirty needles. It also covered the risk of being under the influence. "The biggest predictor of not using a condom when you have one is having had a few drinks," Brady says. "So substance use in a population that already has a mental illness has got to increase the risk."
  • The fourth session is a booster session held three months after the first session. Participants discuss whether they've encountered any high-risk situations and how they managed these.

The motivational interviewing intervention was divided the same as the standard intervention, but also included feedback about risk behaviors and questions about what the person wanted to focus on with regard to changing behaviors, Brady says.

The goal is to develop a successful intervention that fits in well with a clinical appointment schedule, Brady says.

"We're looking at how far we can cut back on the intervention and still have an effect," he says. "This is for the public health person who sees the patient every couple of months."

Researchers also are trying to create an intervention that can be translated to the community for use in non-academic, non-research settings.

"We are aware that so often people come up with interventions that cannot be translated to the real world," Brady says.

"We're aware that so often people come up with interventions that cannot be translated to the real world, in part, sometimes, because they can't be paid for," Brady says. "So we're also developing an intervention that clinicians can bill and pay for."

The motivational interviewing aspect of the study intervention involved giving participants feedback about their HIV risk, based on their behaviors, Brady says.

"You challenge them to do better, focus on talk of change, and give them a lot of feedback about their risk," he explains. "You motivate them to make and maintain change."

This type of intervention often is used with substance abusers, he adds.

"The idea is to get people to make a commitment to change," Brady says. "You're helping them to change their cognition about change, ability to change, and skill to change."

The next step is to obtain additional funding to test the intervention in a larger cohort of people with mental illness, both HIV infected and not infected, he says.

"Our offices are in the Boston Medical Center, which is close to a number of major shelters that also have the largest percentage of people with psychiatric illness and homelessness," Brady says.