1. Persons with Serious Mental Illness Michael B. Blank, PhD Center for Mental Health Policy and Services Research University of Pennsylvania HIV Screening and Access to Care Institute of Medicine of the National Academies April 15 th 2010

2. External Support R01 NR088514-01 (PI - Blank)NINR Nursing Intervention for HIV Regimen Adherence among SMI R01 DA015627-01A1 (PI - Blank) NIDA HIV Prevention Program among Substance Abusing SMI P30-AI45008 (PI – Hoxie) NIAID Center for AIDS Research (CFAR) U18PS000704 (PI - Blank) CDC Multi-Site Rapid HIV Testing in Urban Community Mental Health Settings

3. Today’s Talk   Present epidemiology of HIV and SMI in Philadelphia   Describe findings from discarded blood and estimate rates of undetected illness at HUP   Present differential outcomes of HIV infections from Medicaid Claims   Describe differential costs of treatment for comorbid persons from Medicaid Claims

4. Cross of 1994-6 Medicaid Claims & PDPH AIDS Surveillance Registry

5. DependentCovariatesP <Exp(B) HIV Positive Sex (Male).0004.27 Age (18 yrs.).000.98 Black.0001.67 Hispanic.0001.53 Asian.000.06 Time on Welfare.0001.25 Schizophrenia.0002.13 Affective Disorder.0004.68 Constant.000.00 Claims combined with AIDS Registry Logistic Regression of Positive HIV/AIDS Diagnosis (N=391,454)

6. DependentCovariatesP <Exp(B) HIV Positive Sex (Male).0004.27 Age (18 yrs.).000.98 Black.0001.67 Hispanic.0001.53 Asian.000.06 Time on Welfare.0001.25 Schizophrenia.0002.13 Affective Disorder.0004.68 Constant.000.00 Claims combined with AIDS Registry Logistic Regression of Positive HIV/AIDS Diagnosis (N=391,454)

7. DependentCovariatesP <Exp(B) Sex w/ MSM Sex (Male)*.00057.58 Age (18 yrs.)*.000.95 Black*.001.72 Hispanic*.000.24 Schizophrenia.889 1.03 Affective Disorder.310.86 Both Disorders.753.89 Constant*.000.08 Logistic Regression – Modes of Transmission (N=4,092)

8. DependentCovariatesP <Exp(B) IDU Sex (Male).101.89 Age (18 yrs.)*.003 1.01 Black.565 1.05 Hispanic*.012 1.32 Schizophrenia.449 1.13 Affective Disorder*.033 1.27 Both Disorders.953 1.02 Constant.106.78 Logistic Regression – Modes of Transmission (N=4,092)

9. DependentCovariatesP <Exp(B) Sex w/ MSM& IDU Sex (Male)*.00016.50 Age (18 yrs.)*.001.97 Black.168.79 Hispanic*.035.59 Schizophrenia*.023 1.97 Affective Disorder.256 1.30 Both Disorders.303.54 Constant*.000.02 Logistic Regression – Modes of Transmission (N=4,092)

10. DependentCovariatesP <Exp(B) Heterosexual Males Age (18 yrs.)*.0031.03 Black*.0052.15 Hispanic*.0142.20 Schizophrenia.1451.69 Affective Disorder.1681.44 Both Disorders.7161.24 Constant*.000.01 Logistic Regression – Modes of Transmission (N=4,092)

11. DependentCovariatesP <Exp(B) Heterosexual FemalesAge (18 yrs.)*.005.98 Black*.0002.97 Hispanic*.0004.65 Schizophrenia.1401.57 Affective Disorder.778.94 Both Disorders.119.38 Constant*.000.29 Logistic Regression – Modes of Transmission (N=4,092)

12. Costs to Medicaid in 2003

13. Opportunistic Infection Rates  Examine adverse events for 405,969 persons with co-occurring HIV, mental illness and controls  Calculate rates of opportunistic infections over an 11 year period  Identify types of opportunistic infections that differentially affect HIV+ persons with mental illness

17. Conclusions  Persons with co-morbid HIV and SMI have much higher rates of OI than any other group  Three clusters of OIs are identifiable and have different patterns for HIV/SMI  AIDS-defining OIs are lower for HIV/SMI, perhaps reflecting greater mortality before reaching very low levels of immune functioning

18. Discarded Blood Study  This study identified previously undetected infectious disease among persons with serious mental illness.  Observational-naturalistic methods were used to simulate universal screening among 588 adult psychiatric patients  Laboratory results showed that 10% of patients had HIV, 32% had Hepatitis B

19. Table 1 Rates of metabolic and infectious diseases among 588 adults with serious mental illness admitted to psychiatric inpatient units Method of detection a Abstracted Clinical data Laboratory test data Variable a Total N N%N% Hepatitis B Hepatitis C High glucose levels b 461 546 588 7 59 81 2 11 14 146 117 40 32 21 7 High total cholesterol levels High triglyceride levels HIV 568 572 388 14 3 31 218218 124 103 39 22 18 10 a Abstracted clinical data was gathered from a review of admission history, physical examinations, physician-ordered laboratory results, standardized nursing assessment forms and discharge summaries, and electronic records of all inpatient and outpatient services rendered in the year before admission. Laboratory testing involved physician-ordered laboratory blood tests and laboratory blood tests conducted for the purposes of this study (simulated universal screening). b The number of positive laboratory test results for diabetes is less than the number based on history, which suggests that metabolic conditions were well controlled at the time of admission or that patients may have given a false positive history. Rothbard, et al. Previously Undetected Metabolic Syndromes and Infectious Diseases Among Psychiatric Inpatients. Psychiatric Services, April 2009 Vol. 60 Mo4 p536

20. Recommendations   Make rapid HIV testing routinely available in Community Mental Health Settings   Screen for Blood-borne Infections routinely in inpatient settings   Integrate teaching condom skills, HIV risk reduction, and positive sexuality curricula into ongoing treatment   Consider the use of Peer Specialists to deliver HIV prevention messages   Integrate medication adherence interventions into ongoing care for HIV+ persons with mental illness

21. Acknowledgments  Linda Aiken  Tiffany Brown  James Coyne  Martin Fishbein  Robert Gross  Trevor Hadley  Nancy Hanrahan  Janet Hines  Ann Kutney Lee  David Metzger  Aileen Rothbard  Phyllis Solomon  Julie Tennille  Tom Ten Have  Evan Wu  City of Philadelphia Department of Public Health  City of Philadelphia Community Behavioral Health