HIV RISK REDUCTION INTERVENTIONS IN POPULATIONS WITH SERIOUS
MENTAL ILLNESS: A CRITICAL REVIEW OF THE “SECOND GENERATION”
by
Annie Mae Marie Watson
BS in Biochemistry, Allegheny College, 2006
Submitted to the Graduate Faculty of
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2013
:de
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEATLH
This essay is submitted
by
Annie Watson
on
2013
and approved by
Essay Advisor:
Beth A.D. Nolan, PhD
_______________________________________
Assistant Professor
Department of Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Jeremy Martinson, DPhil
_______________________________________
Assistant Professor
Department of Infectious Diseases and Microbiology
and Human Genetics
Associate Director, Bioscience of Infectious Diseases
Graduate School of Public Health
University of Pittsburgh
ii
Copyright © by Annie Watson
2013
iii
Beth A. D. Nolan, PhD
HIV RISK REDUCTION INTERVENTIONS IN POPULATIONS WITH SERIOUS
MENTAL ILLNESS: A CRITICAL REVIEW OF THE “SECOND GENERATION”
Annie Watson, M.P.H.
University of Pittsburgh, 2013
ABSTRACT
There is a disparity between the HIV prevalence in the seriously mentally ill (SMI) population
(8%) as compared to the general population (0.6%) in the United States. In order to identify
interventions for HIV prevention for people with SMI, a literature search was conducted in
PubMed and PsychInfo. For PubMed, the following Medical Subject Headings (MeSH) terms
were used: HIV Infections, Prevention and control, and Mental Disorders. For PsychInfo the
following terms were used in the search: Mental Disorders and HIV. Sixteen independent studies
were found after being subjected to inclusion and exclusion criteria. The most notable finding of
this study was that effective gender-specific interventions have been designed and implemented
in SMI populations. Also HIV prevention interventions have demonstrated changes in attitudes
and HIV related risk behaviors in this population. However analysis by some of the studies
revealed that the intervention outcomes can be impacted by individual differences (i.e. race,
psychiatric diagnosis, and reported substance use). The issue of exploring subpopulations among
people with SMI is the next suggested step in combatting this issue. This essay is of public health
significance because it explores the issue of reducing HIV related risk behaviors in people with
mental illness in order to reduce their chance of contracting this deadly virus.
iv
TABLE OF CONTENTS
1.0
INTRODUCTION ........................................................................................................ 1
1.1
HIV AND PUBLIC HEALTH THEORIES ...................................................... 2
1.1.1
HIV Overview .................................................................................................. 2
1.1.2
Public Health Theories of Behavioral Change .............................................. 2
1.2
HIV AND SMI...................................................................................................... 3
1.2.1
SMI .................................................................................................................... 3
1.2.2
HIV Risk Factors ............................................................................................. 5
1.2.3
HIV Prevalence ................................................................................................ 7
1.3
INTERVENTIONS (1988 - 1996) ....................................................................... 7
1.3.1
1.4
METHODS ......................................................................................................... 10
1.4.1
2.0
Review Procedure .......................................................................................... 10
RESULTS .................................................................................................................... 12
2.1.1
3.0
Intervention study Review .............................................................................. 7
Overview ......................................................................................................... 12
2.2
MALES AND FEMALES ................................................................................. 14
2.3
MALES ............................................................................................................... 21
2.4
FEMALES .......................................................................................................... 24
DISSCUSSION ........................................................................................................... 27
v
3.1.1
Differences in the Intervention by Gender .................................................. 27
3.1.2
Race & Ethnicity ............................................................................................ 29
3.1.3
Psychiatric Diagnosis ..................................................................................... 30
3.1.4
Dosage of Intervention .................................................................................. 30
3.1.5
Theory ............................................................................................................. 31
3.1.6
Limitations ..................................................................................................... 32
3.1.6.1 Limitations to the literature search ................................................... 33
3.1.6.2 Limitations to the research studies .................................................... 33
3.1.7
Future Directions ........................................................................................... 34
3.1.7.1 Literature Search ................................................................................ 35
3.1.7.2 HIV Prevention Studies ...................................................................... 35
3.1.8
Conclusions..................................................................................................... 38
APPENDIX...................................................................................................................................41
BIBLIOGRAPHY ....................................................................................................................... 43
vi
LIST OF TABLES
Table 1. HIV Intervention Studies ......................................................................................... 40
vii
PREFACE
Acknowledgements: My Family for all their love and support (Joan Watson, Joanie ‘Vina’
Watson; Roman Watson-Bush, Dr. Richard Watson, Jennie Watson, Benji Watson, and Teddy
Watson); My essay advisor Dr. Beth Nolan; My mentor Dr. Vishwajit Nimgaonkar; Dr. Martha
Terry; My Inspiration Dr. DeGenna Natacha; David Roofeh; Dr. Mikhil Bamne; Dr. Hader
Mansour; Dr. Jeremy Martinson; NAMI Southwestern Pennsylvania and Mim Schwartz.
viii
1.0
INTRODUCTION
There is a disparity between the prevalence of human immunodeficiency virus (HIV) in the
population of those with serious mental illness (SMI): 8% (Meade & Sikkema, 2005) as
compared to the general population 0.7% (The World Bank, 2011) in the United States (US).
Due to this disproportion disease burden the National Institute of Mental Health (NIMH)
consider those with SMI to be part of an HIV vulnerable population (1993). The purpose of this
essay is to critically review studies that have conducted HIV prevention interventions in those
with SMI. The essay will first give brief information about HIV, then frame HIV as a public
health issue in this population and discuss a previous review of HIV interventions that have been
conducted in those with SMI. The methodology used in this literature review and then an
extensive review of all of the identified intervention studies will be presented. Finally, themes in
the literature will be identified, limitations to the field and this literature review will be
discussed, future directions will be suggested and finally conclusions about the field will be
made.
1
1.1
HIV AND PUBLIC HEALTH THEORIES
1.1.1 HIV Overview
Awareness of HIV that can develop into acquired immune deficiency syndrome (AIDS) first
occurred in the US in 1981, but the identification of the virus and knowledge about transmission
were not determined until later (AVERT, 2013). HIV is primarily spread through unprotected
sex with an infected partner, sharing needles and other intravenous (IV) drug equipment with an
infected individual and vertical transmission from an infected mother to a child. Despite major
advances in the diagnosis and treatment of HIV infection, there is no cure (CDC, 2012).
Therefore, evidence based effective HIV primary prevention programs continue to be important
against the HIV epidemic (The White House, 2010).
1.1.2 Public Health Theories of Behavioral Change
The use of behavioral health theory is considered to be the best practice and essential to
establishing effective evidence-based HIV prevention programs by the U.S. government
organizations such as the Center for Disease Control (CDC) (Jacobs, Jones, Gabella, Spring, &
Brownson, 2012) and NIMH (2012). HIV prevention programs target behavioral change at one
or more of these levels: individual, interpersonal, community and structural and environmental
factors. Evidence based HIV interventions have utilized behavioral change theories or models
such as Social Cognitive Theory (Bandura, 1986), Social Learning Theory (Bandura, 1977),
AIDS Risk Reduction Model (Catania, Kegeles, & Coates, 1990), Information-Motivation2
Behavioral Model (Fisher & Fisher, 1992), Health Belief Model (Rosenstock, Strecher, &
Becker, 1988), Stages of Change (Transtheoretical) Model (Prochaska, DiClemente, & Norcross,
1992), and the Theory of Gender and Power (Connell, 1987) to design and evaluate their
interventions (Holtgrave et al., 1995; Lyles et al., 2007; Traube, Holloway, & Smith, 2011;
Washington State Department of Health, n.d). Many other competing behavioral health theories
are also used and research is still being conducted to determine which of the multitude of
theories are the more effective at targeting this public health issue (Holtgrave et al., 1995; Lyles
et al., 2007; Traube et al., 2011).
1.2
HIV AND SMI
1.2.1 SMI
The most widely accepted definition of severe mental illness (SMI) was defined by NIMH in
1987 and uses three criteria: the type of mental illness, the duration of the mental illness, and the
level of functional impairment (severity) experienced by the affected individual (1987). The
mental health diagnosis must be either a type of non-organic psychosis (e.g. schizophrenia,
schizoaffective disorder) or personality disorder (e.g. borderline personality disorder). Therefore
the onset of symptoms cannot be preceded by organic causes like brain trauma or drug induced
psychosis. The individual must have a prolonged duration of the illness; operationally defined as
the presence of symptoms for two of more years and can be established through previous
hospitalization or outpatient treatment history. The functional impairment is defined by
dangerous or disturbing social behavior, moderate impairment in work and occupational
3
activities and mild impairment in basic needs (National Institute of Mental Health, 1987;
Parabiaghi, Bonetto, Ruggeri, Lasalvia, & Leese, 2006; Ruggeri, Leese, Thornicroft, Bisoffi, &
Tansella, 2000). Frequently a measure of dysfunction known as the Global Assessment of
Functioning (GAF) scale (American Psychiatric Association, 1987) is used to establish severity
of the functional impairment (Ruggeri et al., 2000).
However, this definition of SMI continues to be evaluated. The most debated part of the
NIMH definition is the required mental health diagnostic criteria of non-organic psychosis and
personality disorder. Alternative definitions include only the severity and duration criteria, in
recognition of the fact that other mental health disorders (e.g. major depression, panic disorder,
and obsessive compulsive disorder) can cause impairment and long term mental health services
utilization (Parabiaghi et al., 2006; Ruggeri et al., 2000). For the purpose of this literature review
the definition of SMI will be liberal, where at least one of the three NIMH criteria should be
mentioned as inclusion criteria for study participants.
The symptoms of schizophrenia, schizoaffective disorder, bipolar disorder, and major
depressive disorder commonly can lead to severe life impairment that lasts longer than six
months. It is estimated that 2.6% of US adults meet criteria for SMI (Kessler, 1996). On average
29% of this population has a co-occurring substance abuse issue, but the percentage in the subpopulations grouped by mental health diagnosis varies (Regier et al., 1990). Many individuals
with SMI face social economic issues such as homelessness (approximately 30%) (SAMHSA,
2011).
Contrary to stigma-biased beliefs, this population is sexually active, with 60.07%
reporting sexual activity in the last twelve months, and 45.91% reporting sexual activity in the
past three months (Meade & Sikkema, 2005). The type and methodological measurement of the
4
sexual activity varied across the reviewed studies (Meade & Sikkema, 2005). While the
epidemiological factors that puts those with SMI at greater risk of sexually transmitted diseases
such as HIV are complex, the types of sexual interactions and substance abuse are contributing
factors (Meade & Sikkema, 2005).
1.2.2 HIV Risk Factors
Meade and Sikkema (2005) conducted a systematic review of the sexual risk factors in this
population, then weighed data from the studies, and reported mean HIV risk prevalence. The
authors found that the primary risk factors included: unprotected intercourse, multiple sexual
partners, high-risk partners (e.g. IV drug users), anonymous sexual partners, and use of drugs
and/or alcohol before sex. Forty three percent of the SMI population self-reported that they had
two or more partners within the past year before the original study data was collected. Forty six
percent of the SMI population surveyed had never used a condom within this same time period
(41.76% in the past three months before the original study data was collected). Twenty two
percent of the SMI population in the reviewed studies admitted to having a lifetime history of sex
trade (Meade & Sikkema, 2005).
An increase in HIV risk was associated with indirect evidence of unhealthy substance use
(e.g. alcohol use, illicit drug use, substance use disorder) (Carey, Carey, Maisto, Gordon, &
Vanable, 2001; Kalichman, Kelly, Johnson, & Bulto, 1994; Rosenberg et al., 2001).
Living in an urban area increases the HIV risk (Brunette et al., 1999), while homelessness might
be a modifying or confounding risk factor (Meade & Sikkema, 2005).
Other factors that increase the susceptibility of this population to HIV are the severity and
symptomology of psychopathology. Studies examining the association between symptoms
5
(psychopathology, cognitive, excitement, positive and negative symptoms) have found that
current symptoms are associated with sexual risk factors, though specific results varied across
studies (Cournos et al., 1994; Horwath, Cournos, McKinnon, Guido, & Herman, 1996;
McKinnon, Cournos, Sugden, Guido, & Herman, 1996; Rosenberg et al., 2001).
Although most studies also found no association between the primary Axis I psychiatric
diagnosis (e.g. schizophrenia, bipolar disorder, major depressive disorder; (American Psychiatric
Association, 2000) and HIV risk (e.g. Brunette et al., 1999; Carey et al., 1999; Carey et al.,
2001), there are differences in HIV risk factors by psychiatric diagnosis. Most studies find that
people with schizophrenia spectrum disorders were significantly less likely to be sexually active
as compared to those with other major psychiatric disorders (e.g. Carey et al., 1999; Carey et al.,
2001). A diagnosis of unipolar depression was associated with injection drug use (McDermott,
Sautter, Winstead, & Quirk, 1994). There is an association between having both a primary
psychiatric diagnosis and a personality disorder with greater HIV risk (Sacks, Perry, Graver,
Shindledecker, & Hall, 1990).
Other factors that increased HIV risk directly or an HIV risk factor are trauma exposure
(Rosenberg et al., 2001), social relationship status (i.e. single or in a relationship) (Grassi,
Pavanati, Cardelli, Ferri, & Peron, 1999; Kalichman et al., 1994; Kelly et al., 1992) and
cognitive–behavioral factors (e.g. self-efficacy and lower motivation for condom use; e.g. Carey,
Carey, Weinhardt, & Gordon, 1997; Kelly et al., 1995; McDermott et al., 1994; Meade &
Sikkema, 2005). Given the unique and complex HIV risk factors, it is not surprising that HIV
seroprevalence of adults with SMI in the US is higher than the rest of the general US population
(Cournos & McKinnon, 1997).
6
1.2.3 HIV Prevalence
The studies conducted to date have estimated the seroprevalence of adults with SMI range from
4% to 23% of the US population with SMI (Cournos & McKinnon, 1997). The lowest rate of
HIV infection (4%) was found among patients on a long-term stay acute psychiatric unit (Meyer
et al., 1993). The highest rate of HIV infection (22.9%) was found in a unit treating patients with
a dual-diagnosis of severe mental illness and substance use disorder (Silberstein et al., 1994).
The second highest HIV seroprevalence (19.4%) population was among homeless,
nonhospitalized males receiving community psychiatric treatment (Susser, Valencia, & Conover,
1993). Cournos and McKinnon (1997), estimated the aggregated seroprevalence of HIV in SMI
populations from several studies to be 8.1% for males and 6.4% for females, which is higher than
the CDC’s (2011) estimated prevalence of the general US population of 0.52% for males and
0.16% for females. Based on this difference in HIV prevalence, the NIMH identified the SMI
population as one of the AIDS groups of concern (1993).
1.3
INTERVENTIONS (1988 - 1996)
1.3.1 Intervention study Review
This is not the first literature review of intervention studies targeting SMI individuals to reduce
their HIV related risk behaviors (e.g. unprotected sexual intercourse and multiple sexual
partners); a systematic review identified studies published between 1988 and 1996 (Kelly, 1997).
All of the studies used public health theories [e.g. the Social Learning Theory (Bandura, 1977) or
7
Cognitive Behavioral Theory (Bandura, 1986), the Theory of Reasoned Action (Fishbein &
Ajzen, 1975) to develop and evaluate the HIV risk reduction interventions (Kelly, 1997). These
studies were conducted primarily on mixed gender participants, while only one was conducted
on HIV negative adults (Susser et al., 1996). None of the studies were conducted on female only
populations (Kelly, 1997). Of the reviewed studies (Kelly, 1997), three were randomized control
trials (RCT) of the adult SMI participants (Kalichman, Sikkema, Kelly, & Bulto, 1995; Kelly et
al., 1996; Susser et al., 1996).
Kelly (1997) concluded that:
“relatively intensive, theoretically-based, and culturally-tailored behavior change
programs can impact so as to reduce sexual risk practices even among persons with long
histories of mental illness and other coexisting problems” (p. 306-307).
Effective interventions were intensive (6 to 15 hours long; Kalichman et al., 1995; Susser
et al., 1996). They had multiple theoretical construct outcomes (e.g. attitudes towards HIV
prevention related behaviors, behavioral intention, and self-efficacy; Kalichman et al., 1995;
Kelly et al., 1996; Susser et al., 1996). Many studies tailored their intervention to SMI
participants by using small group formats and cognitive and behavioral skills building to
improve and encourage use of HIV preventative skills in real world situations, as this has been
found to be effective format in other psychosocial rehabilitation programs (Wallace, Liberman,
MacKain, Blackwell, & Eckman, 1992)
Kelly (1997) suggested that HIV prevention programs would benefit from more RCT
design (previously the studies were mostly anecdotal reports or uncontrolled pre-post evaluation
8
design), use of realistic risk situations, instead of “generic” ones, more external validation
measures, increased use of behavioral change endpoints and larger samples. Other suggestions
included targeting more interventions levels (individual and community), having longer followup periods and having gender specific interventions (Kelly, 1997). Kelly speculated that people
with SMI would probably benefit the most from and HIV program if their other basic and
psychiatric needs were met though community resources. Community or system level
interventions have been found to be effective for other AIDS-vulnerable populations (Danya
International, 2012; Kelly, 1997). Longer follow-up periods are necessary to establish
maintenance of behavior change, which is important if people with SMI are continuously as risk
for contraction of HIV infection. As females with SMI have different HIV risk profile than males
with SMI (e.g. economic dependence on the male partner, relationship power imbalance, and
whom partner resistance to condom use; e.g. Amaro, 1995; Ickovics & Rodin, 1992; Nyamathi,
Bennett, Leake, Lewis, & Flaskerud, 1993) separate interventions designed specifically for males
or females could target these unique HIV risk factors.
Kelly advocated for using the individual format, so that HIV infection in SMI individuals
could be offered screening as part of routine admission to psychiatric facilities, as high rates of
undetected HIV infection have been found in those receiving inpatient services (Sacks, Dermatis,
Looser-Ott, Burton, & Perry, 1992). Also, HIV testing and counseling is usually preformed on a
one-on-one basis (Kelly, 1997). Kelly’s (1997) review of the HIV interventions conducted with
SMI participants found that HIV risk behavior could be reduced in this population, but there
were several aspects in the scientific design and implementation that could be improved.
Individuals with SMI have a higher prevalence of HIV than the general population (Meade &
Sikkema, 2005), as such they are considered to be an HIV vulnerable population by the NIMH
9
(National Institute of Mental Health, 1993). Previous research in this area found that HIV
interventions were an effective way to reduce HIV risk behaviors in this population, but the field
would benefit from more well-designed studies (Kelly, 1997). A recent study found that an HIV
intervention conducted in an SMI population was cost effective when considering the long-term
cost of treatment of HIV in these individuals (Pinkerton, Johnson-Masotti, Otto-Salaj, Stevenson,
& Hoffmann, 2001). A critical review of the outcomes, study design, and the participants’
characteristics will further the objectives of the NIMH and systematically explore this important
public health issue facing this marginalized population.
1.4
METHODS
1.4.1 Review Procedure
A systematic review of the published literature was performed to identify empirical studies on
HIV prevention interventions among adults with SMI in the United States and internationally.
PsychInfo and PubMed, two online databases in the social and health sciences, were searched for
English publications. For PubMed, the following Medical Subject Headings (MeSH) terms were
used: HIV Infections, Prevention and control, and Mental Disorders. For PsychInfo the following
terms were used in the search: Mental Disorders and HIV. Additionally, studies were obtained
through bibliographic review of acquired publications.
The inclusion criteria were: (1) sample of adults with SMI, (2) the population studied had
a primary psychiatric diagnosis that is not alcohol or substance abuse, (3) presentation of
10
quantitative data, (4) assessment of at least one knowledge acquisition or behavioral outcome
(e.g., an increase in HIV risk knowledge, decrease in sexual activity, decrease number of
partners, and increase in condom use for males or females), (5) studies appeared in a peer
reviewed journal, and (6) those studies not published in a previous comprehensive review. The
exclusion criteria were: (1) studies that reported aggregate results of populations with a SMI and
without (for example many studies conducted in correctional facilities), (2) studies with
anecdotal or qualitative data collected in a non-systematic way, and (3) publications reviewed by
J. A. Kelly in 1997 were excluded because critical analysis and commentary has already been
concluded (Kelly, 1997); with the exception of a study by Susser and colleagues (Susser et al.,
1998) of which some of the unpublished results (Susser et al., 1996) were reviewed by Kelly
(1997).
The first round exclusion of search results was based on the title, second round exclusion
was based on the abstract, and then finally the exclusion criteria were applied to the entire paper.
Multiple publication using the same data were counted as one study. Findings on the outcomes of
the HIV intervention in SMI populations were compiled.
11
2.0
RESULTS
An overview of the HIV intervention studies conducted on SMI populations that were found as
part of this critical literature review will be presented, then the studies will be presented based on
the gender of the participants (Males and Females, Males, and Females) with a brief summary of
the main findings given.
2.1.1 Overview
A PubMed database search using “HIV Infections AND prevention and control AND Mental
Disorders NOT Needle NOT opioid” yielded 4,145 results on January 25, 2012. A PsychInfo
database search using “Mental Disorders AND HIV” yielded 6,719 results on February 1, 2012.
After applying exclusion and inclusion criteria, only 16 independent studies were found (Table
1). Two studies yielded two publications from the same data or a subset thereof (Otto-Salaj,
Kelly, Stevenson, Hoffmann, & Kalichman, 2001; Pinkerton et al., 2001). Sample sizes ranged
from seven (Jordan & Selwyn, 2008) to 408 participants (Carey et al., 2004). Ten of the studies
were RCTs (Berkman, Cerwonka, Sohler, & Susser, 2006; Berkman et al., 2007; Carey et al.,
2004; Collins, Geller, Miller, Toro, & Susser, 2001; Collins et al., 2011; The National Institute
Of Mental Health Multisite HIV Prevention Trial Group, 2006; Hajagos, Geiser, Parker, &
Tesfa, 1998; Otto-Salaj et al., 2001; Susser et al., 1998; Weinhardt, Carey, Carey, & Verdecias,
12
1998). Studies recruited participants from outpatient clinics (50%) (Collins et al., 2011;
Weinhardt et al., 1998; Berkman et al., 2007; Carey et al., 2004; The National Institute Of
Mental Health Multisite HIV Prevention Trial Group, 2006; Kalichman, Malow, Devieux, Stein,
& Piedman, 2005; Otto-Salaj et al., 2001; Rosenberg et al., 2004), inpatient units (19%) (Collins
et al., 2001; Williams, Donnelly, & Proesher, 2001; Meyer, Cournos, Empfield, Agosin, &
Floyd, 1992) and other community programs (31%) (Berkman et al., 2006; Collins et al., 2011;
Jordan & Selwyn, 2008; Sikkema et al., 2007; Susser et al., 1998); 37.5% of studies were
implemented at multiple sites (Carey et al., 2004; Collins et al., 2011; The National Institute Of
Mental Health Multisite HIV Prevention Trial Group, 2006; Otto-Salaj et al., 2001; Rosenberg et
al., 2004; Sikkema et al., 2007). Although the geographic location was not an exclusion criteria,
all of the 16 studies were conducted in the United States, primarily in New York (11 studies)
(Collins et al., 2001; The National Institute Of Mental Health Multisite HIV Prevention Trial
Group, 2006; Weinhardt et al., 1998; Berkman et al., 2006; Berkman et al., 2007; Carey et al.,
2004; Collins et al., 2011; Hajagos et al., 1998; Jordan & Selwyn, 2008; Meyer et al., 1992;
Susser et al., 1998), other urban areas (five studies) (The National Institute Of Mental Health
Multisite HIV Prevention Trial Group, 2006; Kalichman et al., 2005; Otto-Salaj et al., 2001;
Sikkema et al., 2007; Williams et al., 2001), one in a rural area (Rosenberg et al., 2004). The
majority of the participants had a diagnosis of SMI for all studies except one of the studies that
discussed SMI criteria without collecting a formal psychiatric diagnosis The National Institute
of Mental Health Multisite HIV Prevention Trial Group, 2006). Thirty one percent collected
psychiatric diagnosis data through a diagnostic interview (e.g., The Structured Clinical Interview
for DSM-IV; Berkman et al., 2006; Berkman et al., 2007; Carey et al., 2004; Collins et al., 2011;
First, Gibbon, Spitzer, Williams & Benjamin, 1997; Susser et al., 1998) and 56% relied on
13
medical charts, clinician report, or clinical referrals (Collins et al., 2001; The National Institute
Of Mental Health Multisite HIV Prevention Trial Group, 2006; Hajagos et al., 1998; Jordan &
Selwyn, 2008; Kalichman et al., 2005; Meyer et al., 1992; Otto-Salaj et al., 2001; Rosenberg et
al., 2004; Sikkema et al., 2007; Weinhardt et al., 1998; Williams et al., 2001), a diagnosis was
not collected for one of the studies (The National Institute Of Mental Health Multisite HIV
Prevention Trial Group, 2006), and one study did not provide enough details (Jordan & Selwyn,
2008); 13% included some measure of functional impairment in their criteria (Carey et al., 2004;
The National Institute Of Mental Health Multisite HIV Prevention Trial Group, 2006). Table 1
reports the study details and eligibility criteria beyond a diagnosis of SMI, except specific high
risk HIV risk criteria that varied across studies (e.g., homelessness, substance dependence, HIV
negative) and participant characteristics by study.
2.2
MALES AND FEMALES
There were eight studies that included both males and females as participants. Of these, only one
of the interventions included medical services including testing and counseling for the results of
an HIV blood test as part of their methodology (Rosenberg et al., 2004). The rest used solely
knowledge and skills based approaches to HIV prevention behavior.
The smallest study was completed in a community psychiatric facility, referred to as a
Clubhouse. The initial ten session behavioral skill and decision making centered intervention
was shortened to six sessions to increase study retention. Although the total enrollment of three
iterations of the intervention was 47 SMI individuals, only seven of these completed pre- and
14
post- intervention surveys. Due to the small number of completed surveys, a formal statistical
analysis could not be completed, however HIV knowledge and self-efficacy (a person’s belief in
their own ability to perform the HIV prevention behavior; (Glanz, 2008) scores increased from
pre- to post- intervention testing (Jordan & Selwyn, 2008).
In another small study, 12 patients recruited from an inpatient psychiatric unit located in
New York participated in a program that consisted of 75 minute sessions held once a week, for
seven weeks (Meyer et al., 1992). The program used the Health Belief Model (Rosenstock et al.,
1988) to modify the participants’ perceived susceptibility/risk of getting HIV, perceived severity
of HIV, perceived barriers to reducing HIV risk behaviors, the perceived benefits of reducing
HIV risk behaviors, and self-efficacy. The study used informational materials, educational
videotapes, discussions, role play and other educational games. Some of the titles of the topics
included AIDs Knowledge, Heterosexual/Homosexual Transmission and IV Drug Use. Increasing
the participants’ sense of self-efficacy of procuring and using condoms was part of the program.
Due to the small sample size Meyer and colleagues (1992) were unable to access their pilot study
for statistical significance, so efficacy could not be established. However, the mean scores on the
AIDs Knowledge Questionnaire did improve; the questionnaire was developed by the Meyer and
colleagues (1992).
The health belief model was not the only public heath theory used in HV interventions
with SMI populations. Another intervention used both the social learning theory (Bandura, 1977)
and the Transtheoretical model of behavior change (Prochaska et al., 1992) to promote readiness
to change HIV prevention behavior among a sample of psychiatric patients recruited from an
inpatient unit (Williams et al., 2001). There were 50 participants who completed the four, 30
minute long intervention sessions titled Facts for Life. Facts for Life consisted of repetitive
15
iterations of material, role-playing, simple assignments, and skills training. The Rhode Island
Change Assessment (McConnaughy, DiClemente, Prochaska, & Velicer, 1989) was
administered pre- and post-intervention and differences in scores were evaluated using two-tailed
t-tests. Differences of readiness for change were noted between male and female participants.
Females had a significant change in the domain of pre-contemplation, while males had
significant change in the domain of action. The type of SMI diagnosis was associated with
different intervention outcomes, significant changes in the domain of contemplation was found
for patients diagnosed with a psychotic disorder and in the domain of action for those with a
mood disorder (Williams et al., 2001).
Instead of recruiting participants from inpatient psychiatric units, a study by Otto-Salaj
and colleagues (2001) recruited 189 males and females from five community outpatient
programs in Milwaukee, WI. All participants had at least one of five study specific HIV high risk
criteria and were randomly assigned to attend either a seven-session, small-group, cognitivebehavioral, HIV risk reduction intervention derived from social cognitive theory (Bandura, 1986)
or a time-matched, comparison intervention. The intervention was held biweekly and a “booster”
session was held at month-one and month-three. Self-reported measures for HIV risk behavior,
knowledge, high-risk sexual behavior, risk reduction behavioral intentions and condom attitudes
were assessed at baseline, immediately post-intervention, and then every three months postintervention for one year. Changes in high-risk sexual behavior were measured by frequency of
protect and unprotected sexual intercourse and the number of sexual partners. Gender was an
important demographic variable that impacted the intervention outcomes. When compared to
male controls, the males in the intervention group had a significant change in HIV risk
knowledge scores between baseline and the three, six, and nine-month follow-up. When
16
compared to the female controls, the females in the intervention group had significant changes in
attitudes toward condom use, risk reduction behavioral intentions, and sexual behavior between
baseline and the three, six and nine-month follow-up The most notable sexual behavior change
was the percentage of condom protected vaginal intercourse occasions in the female intervention
group increased significantly, compared to the controls. The attitude and behavioral changes
associated with the intervention were not maintained to the 12-month follow-up (Otto-Salaj et
al., 2001). Although cost is an important factor in program planning, this was the only study to
publish a formal cost-effectiveness analysis of the HIV prevention intervention on the SMI
participants. Data was analyzed using the entire participant group and due to the above noted
differences in gender, only the females were used for this analysis. Two analyses were conducted
one with all the females and another with only a subset that self-reported being sexually active in
the three months prior to the intervention. The authors modeled the costs of HIV related medical
costs that could be saved given the intervention’s small effect on reducing HIV risk to calculate
the cost per quality-adjusted life year saved (QALYS). The QALYS was $136,295 for all the
females in the intervention and $71,367 per QALYS for the sexually active females. The
QALYS for the intervention was between the $60,000 to $180,000, which is the range that is
generally considered to be cost-effective and fundable by society (Tengs et al., 1995). Due to the
difference in the QALYS, the authors suggested screening for recent sexual activity to increase
the cost-effectiveness, but also acknowledge that this type of screening could potentially lead to
exclusion of some high risk individuals (Pinkerton et al., 2001).
In another randomized control trial (RCT), outpatients with SMI participated in a 10session HIV-risk-reduction intervention (HIV-R) and a substance use reduction intervention
(SUR). The 221 female and 187 male participants were assigned to the HIV-R, SUR or the
17
treatment as usual group. The HIV-R was designed using the information-motivation-behavioral
skills theory (IMB; Fisher & Fisher, 1992). The participants self-reported historical occasions of
unprotected vaginal sex, number of sexual partners, and communication skills regarding safer
sex at pre-, post-intervention and 3 and 6-month follow-ups. The history of a sexually
transmitted infection (STI) was also collected at baseline and 6-month follow-up. All the
constructs of the IMB (Fisher & Fisher, 1992) were assessed. Compared to the control group, the
HIV-R group significantly decreased the occasions of unprotected vaginal sex and number of
sexual partners, and increased the communication skills regarding safer sex with a partner. The
SUR group improved in all but the later variable. The HIV-R group significantly improved HIV
knowledge, increased positive condom attitudes, had stronger condom use intentions and
improved behavioral skills relative to patients in the SUR and control conditions. The HIV-R
group reported fewer new STIs than the control group. Gender difference in HIV-R outcomes
were noted, with females benefiting the most. The type of SMI diagnosis also impacted the HIVR outcomes, with individuals with Major Depressive Disorder benefiting the most (Carey et al.,
2004).
A one-hour medical model of HIV prevention known by the action verbs: screen, test,
immunize, reduce risk, and refer (STIRR), was evaluated at two community mental health
centers. The intervention consists of HIV risk screening, testing for HIV and hepatitis,
immunization for hepatitis A and B, risk-reduction counseling and treatment referral for bloodborne infections. Changes in AIDS risk was only assessed at one of the sites, where 50
participants completed the AIDS Risk Inventory (measures self-reported HIV knowledge,
motivation, and risk behaviors) (Chawarski, Pakes, & Schottenfeld, 1998). Results were
analyzed with paired t-test and the intervention was associated with significant increased HIV
18
knowledge and motivation to reduce risk in the participants. Although a formal cost-utility
analysis was not performed for this intervention, the direct cost for the intervention were about
$220 plus the cost of the Hepatitis A and hepatitis B vaccine per individual (Rosenberg et al.,
2004).
A study using the IMB model (Fisher & Fisher, 1992) recruited only participants (N =
320; 150 females and 170 males) who were considered to have a SMI and unhealthy alcohol or
drug use who were attending a community based treatment abuse programs located in MiamiDade Florida. Assessments for all the IMB (Fisher & Fisher, 1992) constructs were used with the
primary outcomes focused on condom use during vaginal intercourse. Direct observations of
participants’ condom skills were assessed. A measure of sexual risk behavior was also included.
The results of the intervention differed by gender. Males showed only significant changes in HIV
knowledge scores in response to the intervention between baseline and 6-month follow-up.
Females showed significant changes in condom attitudes, risk reduction behavioral intentions,
and reported reductions in sexual risk behaviors between baseline and 6-month follow-up. The
study developed a theoretical model of HIV prevention in SMI based on the data collected.
Briefly, a positive personal attitude about condoms, perceived pro-condom norms, and increasing
condom self-efficacy is associated with increased condom use in SMI population, especially in
females (Kalichman et al., 2005).
A study using the social cognitive theory (Bandura, 1986) was conducted at two
community supportive housing programs (SHP) for people with SMI. The intervention consisted
of an initial six-sessions (nine hours total) of HIV prevention skills group training and then a four
month intervention targeted at changing social norms surrounding HIV prevention. Peer leaders
from the residents of the SHPs and the staff of the SHPs were trained to implement the social
19
norms intervention. A total of 28 residents (17 males and 11 females) answered questions about
sexual behavior, substance abuse, HIV knowledge, condom self-efficacy, sexual communication
self-efficacy, condom attitudes, safer sex norms and risk reduction behavioral intentions at
baseline, after skills training, and after the social norms intervention. There were significant
differences between the baseline and the post assessment (after the skills training intervention)
and the baseline and the follow-up (after the skills training and social norms intervention) in the
areas of condom use, sexual communication, condom attitudes, and behavioral intentions. After
both the skills training and social norms intervention the participants reported significant changes
in HIV knowledge. Self-reported sexual activity was low in the population, so behavioral
analysis was not feasible (Sikkema et al., 2007).
All eight studies that included both males and females as participants were successful in
demonstrating a changes in HIV risk knowledge (Kalichman et al., 2005; Sikkema et al., 2007;
Carey et al., 2004; Williams et al., 2001; Otto-Salaj et al., 2001; Pinkerton et al., 2001; Jordan &
Selwyn, 2008; Meyer et al., 1992), but due to a small sample size two studies were unable to
demonstrate statistical efficacy (Jordan & Selwyn, 2008; Meyer et al., 1992). Only four
(Williams et al., 2001; Otto-Salaj et al., 2001; Carey et al., 2004; Kalichman et al., 2005) of the
eight studies were able to demonstrate differences in HIV risk behavior in a subset of their
subjects (i.e. male or female). In these four studies, a difference was noted between males and
females in study outcomes, with females generally benefiting more from the interventions
(Williams et al., 2001; Otto-Salaj et al., 2001; Carey et al., 2004; Kalichman et al., 2005). As
such, the following sections provide information of interventions by gender.
20
2.3
MALES
There were five studies that included just males as participants. Of these, three used variations of
a cognitive-behavioral intervention based on social learning theory known as “Sex, Games, and
Videotapes” (SexG), while the other two used a similar multi-faceted approach to HIV
prevention behavior.
A randomized clinical trial with an 18 months follow-up assigned participants to one of
two intervention groups: a15-session, experimental group intervention known as “Sex, Games,
and Videotapes” (SexG) or to a 2-session control intervention. The participants had a SMI, and
were recruited from a psychiatric program in a homeless shelter. A total of 97 males participated,
but only a subset of 59 participants who were sexually active was used for the sexual risk
behavior outcomes. Compared to the control cohort, the intervention cohort had a three times
lower sexual risk index as measured by the Sexual Risk Behavior Assessment Schedule
(SERBAS; Meyer-Bahlburg, Ehrhardt, Exner, & Gruen, 1991) at the 6-month follow-up.
Essentially, the SERBAS measures number of protected and unprotected sexual interactions
(vaginal, anal, and oral) and sexual partners and then a sexual risk index score is derived.
Therefore a lower sexual risk index indicates less unprotected sex with casual and occasional
partners. The differences on the SERBAS between the two cohorts decreased by the 18-month
follow-up (Susser et al., 1998). The data from this study was analyzed to determine the impact of
a lifetime history of substance dependence on the efficacy of SexG intervention. When compared
to the controls, no significant reduction in HIV risk, as measured by the SERBAS, was found in
the substance (alcohol/drugs)-dependent males (Berkman et al., 2005).
To increase the feasibility of implementing the SexG intervention in the community
mental health settings, Berkman and colleagues (2006) developed a shorter version, with six21
sessions known as SexG-Brief. The results of an RCT with 92 male participants did not show
any significant differences in HIV risk behaviors, although a decreasing trend was noted (a
twofold reduction in sexual risk scores for those in the intervention group at the 6-month followup as compared to the control group). The participants were recruited from a homeless shelter
and three transitional living communities for males with SMI in New York City (Berkman et al.,
2006).
Based on the results of interventions with SexG and SexG-Brief, Berkman and colleagues
(2007), developed another version of the intervention, Enhanced SexG (E-SexG), with 10sessions, peer advocacy, and three month booster sessions (total of three). To test the efficacy of
E-SexG intervention, 149 eligible participants were recruited from eight psychiatric outpatient
clinics in the New York metropolitan area and were randomly assigned to the experimental or
control conditions. Participants completed assessments pre-intervention and post-intervention,
and every 3-months, for one year. The SERBAS-MOI (Meyer-Bahlburg et al., 1991) was used to
assess sexual risk behavior and vaginal episodes equivalent scores were analyzed as the primary
outcome. Similar to the results with the SexG-Brief intervention, there was no significant change
between the control and experimental group (Berkman et al., 2007).
The SexG intervention is not the only HIV risk reduction intervention being conducted in
an all-male SMI population, there are two other interventions. One of these is applied an
intervention known as Project LIGHT (Living in Good Health Together). This intervention
consisted of seven, 90-minute sessions about HIV knowledge, personal risk assessment, risk
reduction problem solving skills, condom use skills, assertiveness with sexual partners, strategies
for risk reduction, and relapse prevention. The efficacy of Project LIGHT was tested using a
RCT, where the control parameter was a one-session video about HIV. The participants
22
completed assessments of four sexual risk behaviors at baseline and at three-month intervals
after the intervention for one year. Ninety nine eligible participants were recruited from
outpatient mental health clinics in New York City, NY and Los Angeles, CA. Compared to the
control group, the intervention group had significantly fewer sexual risk acts at the 12-month
follow-up. The most significant benefit of the intervention was seen in the African American
participants, who had significant changes in condom use (The National Institute Of Mental
Health Multisite HIV Prevention Trial Group, 2006).
The other is a two-session intervention that provided HIV knowledge, risk assessment,
and condom application skills. In this RCT study 75 males from a psychiatric inpatient unit were
assigned to one of four groups: control-individual; control-group; intervention-individual; or
intervention-group. The participants completed the “Facts about AIDS” assessment pre-,
immediately post-intervention, and two weeks after the intervention. The greatest improvement
in HIV knowledge between baseline and posttest was found in the intervention-individual group,
where participants had one-on-one interaction with the intervention staff. The authors concluded
that the delivery of education, either individually or in a group, was important for the HIV
intervention outcomes (Hajagos et al., 1998).
Three of the five intervention studies conducted on male participants with SMI to reduce
their risk of contracting HIV used variations of SexG. Only the original 15-session SexG
intervention (Susser et al., 1998) was successful in reducing the sexual risk behavior of males
with SMI, but decreasing trends were noted in the other two studies (Berkman et al., 2006;
Berkman et al., 2007). The treatment group in the other intervention known as ProjectLight, also
had a significant decrease in the number of risky sexual acts (vaginal or anal intercourse without
a condom) as compared to the controls (The National Institute of Mental Health Multisite HIV
23
Prevention Trial Group, 2006). Hajagos and collegues, (1998) did not test reduction in sexual
risk behaviors, but individuals in the intervention one-on-one sessions showed increased HIV
knowledge in the as compared to the controls.
2.4
FEMALES
There were three studies that included just females as participants. The three studies were RCTs
using interventions designed to empower females to make safer sex choices. Of these, two used
the same intervention known as “Ourselves, Our Bodies, and Our relatives” that included
information about the female condom, while the other intervention concentrated primarily on
female assertiveness and the use of the male condom to increase HIV prevention behavior.
A RCT study designed to increase the sexual assertiveness skills of females recruited 20
female outpatients from a community psychiatric facilities in NY. The females completed ten,
75-minute sessions designed to decrease their HIV behavioral risk by using constructs derived
from IMB and social cognitive theory. Assessments were conducted at baseline, post
intervention, at a two-month follow-up, and at a four-month follow-up. The assessments
included the Sexual Assertiveness Simulation, HIV-Knowledge Questionnaire, Perceived Risk
Questionnaire, Behavioral Intentions Questionnaire, and Timeline Follow back Sexual Behavior
Interview. Compared with controls, females in the intervention group increased their sexual
assertiveness skills, HIV knowledge, and frequency of protected intercourse; the most significant
changes were seen at the two-month follow-up (Weinhardt et al., 1998).
24
A RCT design was also used to the 10-session HIV risk reduction intervention,
“Ourselves, Our Bodies, Our Realities.” The intervention is 50 minute program based on the
social cognitive theory. This study targeted empowerment of SMI females by teaching about
female-initiated HIV protection methods including the female condoms and a spermicide
(Advantage 24). The participants were 35 females recruited from inpatients from a state hospital
in NYC, NY. The control design was a two-session HIV education program. The Subjective
Norms of Women-Controlled Methods (SNOW-CM; Geller, n.d.) and the SERBAS were
conducted at baseline, post-intervention, and at a six week follow-up. Very limited sexual
behavior was reported on the SERBAS; therefore analysis of change in sexual risk behavior
could not be determined. Compared to controls, the experimental group had significant changes
in attitudes to female condom, at the six week follow-up. Trending but non-significant changes
in attitudes were noted for the male condoms (Collins et al., 2001).
Another RCT tested the efficacy of the “Ourselves, Our Bodies, and Our relatives,” on 79
females recruited from two transitional living facilities and four day treatment programs in NYC,
NY. The SERBAS for mentally ill sheltered women (SERBAS-A-MIS-F; Meyer-Bahlburg et al.,
1991) and SNOW-CM (Geller, n.d.) were assessed at baseline, post-intervention and at followup periods. The primary sexual risk behavior outcome was the vaginal episode equivalent (VEE),
the number of unprotected oral, vaginal, and anal sexual acts. To evaluate the longevity of the
benefits of the intervention, the follow-up period was extended from the six-week period used in
the pilot study to three-months and six-months. No significant changes were noted in the sexual
risk behavior, VEE scores, between the control and experimental group at pre- and postintervention. When compared with the controls, the significant changes were noted in female
25
condom knowledge, insertion, and use with a partner at 3-month follow-up. Difference in female
condom insertion between the two groups, persisted at six-months (Collins et al., 2011).
All three of the female only interventions were effect as measured by their respective
evaluated outcomes. The initial implementation of “Ourselves, Our Bodies, and Our relatives,”
resulted in an increase in positive attitudes towards the use of the female condom in the treatment
participants as compared to the controls, but change in sexual behavior could not be assessed due
to the limited amount of sexual behavior at baseline (Collins et al., 2001). In the follow-up study,
behavior and attitudes were measured (Collins et al., 2001). The treatment females were not only
significantly more knowledgeable about female condoms, but they also were more likely to have
inserted one and used it with a sexual partner at the three month follow-up. However, the number
of times the treatment group had unprotected oral, anal, and vaginal intercourse as compared to
the controls did not decrease significantly at the three month follow-up (Collins et al., 2001).
Similarly, Weinhardt and colleagues (1998), detected a trending but non-significant decrease in
the frequency of unprotected intercourse in the treatment group as compared to the controls.
However, this intervention did significantly increase sexual assertiveness, HIV- related
knowledge, and protected sex at the two month follow-up.
26
3.0
DISCUSSION
The purpose of this literature review examine HIV prevention intervention studies conducted on
SMI populations by doing a critical literature review in PubMed and PsychInfo since 1996.
Sixteen independent studies were identified; of these studies eight were conducted on mixed
gender, five on all male, and three on all female SMI participants. These participants were
recruited from different settings including mental health outpatient clinics, inpatient units and
other community programs. One major theme emerged from the study results: HIV intervention
outcomes varied based on gender. Four other interesting themes emerged: (1) results varied
based on race/ethnicity (2) psychiatric diagnosis and (3) efficacy changes based on the “dosage”
of the program, and (4) there were several different public health theories used in these studies.
Finally, limitations and future directions are discussed.
3.1.1 Differences in the Intervention by Gender
After reviewing HIV intervention studies conducted before 1996, Kelly and colleagues (1997)
recommended that future researcher studies examine study outcomes to see if there are
differences due to gender. Kelly and colleagues (1997) theorized that since females with SMI
had different HIV risk profiles than males (e.g. Amaro, 1995; Ickovics & Rodin, 1992; Nyamathi
et al., 1993), separate interventions designed specifically for each gender could target these
27
unique HIV risk factors and be more effective. Four (Carey et al., 2004; Kalichman et al., 2005;
Otto-Salaj et al., 2001; Williams et al., 2001) of the eight studies (Carey et al., 2004; Kalichman
et al., 2005; Otto-Salaj et al., 2001; Williams et al., 2001) (Jordan & Selwyn, 2008; Meyer et al.,
1992; Rosenberg et al., 2004; Sikkema et al., 2007) that conducted an intervention using a mixed
gender population noted differences in the outcome results between the two genders. In general,
when gender differences were reported in differential outcomes, females benefited more than
males from the interventions (Carey et al., 2004; Kalichman et al., 2005; Otto-Salaj et al., 2001;
Williams et al., 2001), except in one study where males made more significant changes in their
HIV prevention behavioral actions, than females (Williams et al., 2001).
Effective gender specific interventions had been designed. The original 15-session SexG
intervention (Susser et al., 1998) and ProjectLight (The National Institute Of Mental Health
Multisite HIV Prevention Trial Group, 2006) were successful in reducing the sexual risk
behavior of males with SMI. Another male intervention was successful in increasing HIVrelated knowledge in males with SMI (Hajagos et al., 1998).
All three of the interventions designed specifically for females had significant changes in
at least one of the HIV-related prevention intervention outcomes that were tested. None of the
three interventions significantly decreased the number of unprotected sexual occasions. Two of
these interventions educated females about the female condoms; significant changes were noted
in the attitudes of the participants in the test group when compared to the controls towards this
“safe sex” method (Collins et al., 2001; Collins et al., 2011). In one of the two studies, the
participants in the test group increased their use of the female condom with a partner at the threemonth follow-up significantly as when compared to the controls (Collins et al., 2011). Similarly
in another study, a significant change in HIV risk behavior (increased frequency of protected
28
intercourse) was noted in the SMI females participants in the test group as compared to the
control group (Weinhardt et al., 1998).
3.1.2 Race & Ethnicity
The first of three minor findings that emerged was reported in one study where that the results of
the intervention varied by race and ethnicity. The study found the most significant benefit of the
intervention was seen in African American participants who had significant changes in condom
use as compared to Caucasian and Hispanic participants, and participants’ of other races. The
study was still effective in the overall group, with significant decreases in the number of
unprotected sexual risk acts reported in the participants in the test group as compared to the
control group (The National Institute Of Mental Health Multisite HIV Prevention Trial Group,
2006). The difference in condom use among African Americans versus other participants was not
observed in a previous study by this group that was conducted in a non SMI population (The
National Institute of Mental Health Multisite HIV Prevention Trial Group, 1998). However, the
HIV risk factor profile is unique for African American populations (e.g. lifetime history of
incarcerations, low social economic status and multiple partners within the same time period
(Adimora, Schoenbach, & Floris-Moore, 2009). Researchers have suggested that behavioral
interventions for African Americans to reduce sexual risk of HIV should have a culturally
relevant design and reflect the unique racial and ethnic attributes of this population (Darbes,
Crepaz, Lyles, Kennedy, & Rutherford, 2008; Johnson et al., 2009). An example of a culturally
sensitive HIV intervention is Sister to Sister, that specifically targets African American Women
(Danya International, 2012).
29
3.1.3 Psychiatric Diagnosis
The second minor theme that emerged was from three studies that reported intervention
outcomes differences by mental health diagnostic type, but the interventions were still effective
in the overall group (Hajagos et al., 1998; Williams et al., 2001; Carey et al., 2004). While the
studies varied in reported outcomes, a difference between people diagnosed with schizophrenia
and other diagnoses was noted (Hajagos et al., 1998); sometimes the same differences were
noted with other psychotic disorders (Williams et al., 2001; Carey et al., 2004).
Carey and colleagues (2004) theorized that this difference is due to greater cognitive and
social impairment among participants who had a more severe psychotic disorder and suggested
that programs be designed tailored to the needs of this subset of SMI individuals and change the
delivery format to one-on-one instead of a group format. Indeed, cognitive impairment has been
noted among people with SMI (Wykes & Dunn, 1992), especially people with Schizophrenia
(Bowie & Harvey, 2005; Elvevåg & Goldberg, 2000; Gur et al., 2007). It has been found to
predict long term rehabilitation outcomes; the people with more severe cognitive impairment
generally have worse outcomes (McGurk & Mueser, 2004; Wykes & Dunn, 1992).
3.1.4 Dosage of Intervention
The final minor theme was that three studies were conducted using the “Sex, Games, and
Videotapes” intervention on an all-male population (Berkman et al., 2006; Berkman et al., 2007;
Susser et al., 1998). The issue of the intervention’s efficacy versus feasibility of implementation
into community mental health settings was explored by this group. Only the study of participants
in the intervention with the most sessions (15) had significantly lower sexual risk index scores as
30
measured by the Sexual Risk Behavior Assessment Schedule (SERBAS; Meyer-Bahlburg et al.,
1991) than the controls (Susser et al., 1998). This importance of dosage and duration on
intervention outcomes in people with SMI has also been found in studies that promote healthy
lifestyles for weight loss, where the most effective programs reviewed lasted three months or
longer (Bartels & Desilets, 2012).
3.1.5 Theory
Primarily two different theories were cited by the authors in their efforts to design these
interventions. The Information-Motivation-Behavioral skills (IMB) model (Fisher & Fisher,
1992), was used in three of the 16 studies (Carey et al., 2004; Kalichman et al., 2005; Weinhardt
et al., 1998). Nine of the 16 studies used either the Bandura’s Social learning theory (1977) or his
later derivative the Social cognitive theory (1986) (Collins et al., 2001; Collins et al., 2011; OttoSalaj et al., 2001; Sikkema et al., 2007; Weinhardt et al., 1998; Berkman et al., 2006; Berkman et
al., 2007; Susser et al., 1998; Williams et al., 2001). Three of the studies did not mention a
specific theory that was used in their program design (Hajagos et al., 1998; Rosenberg et al.,
2004; The National Institute Of Mental Health Multisite HIV Prevention Trial Group, 2006).
Many other effective HIV behavioral intervention strategies have been listed at the CDC’s The
Diffusion of Effective Behavioral Interventions project (DEBI; Danya International, 2012).
Besides using the IMB model (Fisher & Fisher, 1992) and the social learning theory (Bandura,
1977) / social cognitive theory (Bandura, 1986), these interventions use theories like AIDS Risk
Reduction Model (Catania et al., 1990) and the Theory of Gender and Power (Connell, 1987) to
target HIV risk behavior (Danya International, 2012). Six of the 16 studies either did not test for
or did not demonstrate reductions (significant or trending) in HIV related risk behaviors (Jordan
31
& Selwyn, 2008; Meyer et al., 1992; Rosenberg et al., 2004; Berkman et al., 2007; Hajagos et al.,
1998; Collins et al., 2001). Therefore the use of more diverse theory driven strategies might be
needed to target HIV related risk behaviors in the SMI population. Also in recognition of the
heterogeneity of the people that are diagnosed with SMI, an intervention project that has been
tried on multiple types of populations (e.g. IV drug users, African Americans, Caucasians, nongay identified men who have sex with men, and female sex workers) and can encompass the
convergent and divergent HIV risk factors and behaviors among this heterogeneous population,
might be useful to try; one such CDC DEBI program is Peers Reaching Out and Modeling
Intervention Strategies. The program uses several behavior change theories to target communitylevel HIV risk behavior change through the use of peer advocates and role model stories (Danya
International, 2012). People with SMI can be trained to be peer leaders. Peer advocates were
already used in by Sikkema and colleagues (2007) in their intervention, although the efficacy of
their involvement as measured by change in peers norms from baseline to follow-up was not
established in the small study. Also community mental health peer advocates organizations have
been established in this population to combat stigma including the Peer Support and Advocacy
Network (n.d.) as well as the Peers Envisioning and Engaging in Recovery Services (PEERS;
2013).
3.1.6 Limitations
In this section the limitation of the literature review of HIV prevention interventions conducted
on SMI individuals will be presented; they include the lack of a public policy database search,
the use of only HIV instead of other sexually transmitted infections (STI) in the search terms,
32
and the types of interventions included in the review. Then the subject inclusion criteria
limitations of the research studies will be detailed.
3.1.6.1 Limitations to the literature search
The databases, PsychInfo and PubMed, used to search for the HIV intervention studies are not
public policy databases. The use of public policy databases might have provided current HIV
prevention programming policies that impact feasibility of program implementation. This
literature review focused on the prevention of HIV in SMI individuals; therefore it did not
include the early intervention studies for people who already have HIV. However, recent
attention has been given to the mental health of people with HIV and the interrelationship
between HIV and mental health might be complex, dynamic, and reciprocal (e.g. Rabkin,
McElhiney, & Ferrando, 2004; Ickovics et al., 2001; Perry, 1994). Lastly, other STIs were not
included in the search terms, but people with a history of STIs are more at high risk of HIV than
those without (Laga et al., 1993; Wasserheit, 1992).
3.1.6.2 Limitations to the research studies
There was one overarching limitation to this body of literature: the varied inclusion criteria for
participants. The inclusion criteria that are study limitations are the varied percentage of
participants with unhealthy substance use and recruitment of only psychiatric inpatients.
Different selection criteria, including unhealthy substance use, were used for the
participants in the 16 HIV intervention research studies. Three of the 16 studies included only
participants that had both a diagnosis of SMI and unhealthy substance use (Carey et al., 2004;
Kalichman et al., 2005; Rosenberg et al., 2004). One of the 16 studies examined and found
different outcomes based on the presence or absence of a lifetime history of substance
33
dependence (Berkman et al., 2005) and Carey and colleagues (2004) found that people with SMI
assigned to a substance use reduction intervention reported fewer and casual sexual partners than
the control group. Substance use, especially IV drug use, is considered to increase HIV risk in
the general population (AIDS.gov, 2011) and in the SMI population (Meade & Sikkema, 2005).
Four studies of 16 studies used participants who were on psychiatric inpatient units
(Collins et al., 2001; Hajagos et al., 1998; Meyer et al., 1992; Williams et al., 2001). Only one of
these studies assessed behavioral change by measuring change in action of HIV prevention
behaviors (Williams et al., 2001). Due to the small number of females reporting sexual activity in
one of these studies behavior change was unable to be assessed (Collins et al., 2001). This
limitation was recognized by Collins and colleagues (2001) and in a follow-up study the
recruited population was SMI people receiving outpatient services so behavioral changes could
be studied (Collins et al., 2011). HIV intervention programs conducted in this setting might need
to increase the time of their follow-up assessment, so they can assess these cohorts in outpatient
settings. Two of the studies did not evaluate behavior change as part of their objectives (Hajagos
et al., 1998; Meyer et al., 1992).
3.1.7 Future Directions
In this section future directions for the follow-up literature reviews will be presented.
They included: the use of public policy databases for literature searches, the inclusion of other
STIs in the search terms, and intervention studies of people who are HIV positive. Subsequently
future recommendations for the HIV prevention in SMI field will be presented based on the
sixteen studies detailed in this review. There are two major suggestions: (1) tailoring
interventions to SMI people with cognitive impairment and (2) designing more interventions for
34
SMI people with unhealthy substance use. Also three other possible directions that include the
use of more diverse public health theories in intervention design, testing the association between
dosage of intervention sessions and study outcomes and designing interventions that are
integrated across multiple different types of mental health facilities.
3.1.7.1 Literature Search
Future literature searches could be expanded in several ways. First, databases like Political
Science Complete could be used to examine public programing that is available or being planned
for HIV prevention in the SMI populations to examine the theoretical and scientific reasoning for
these services. Also it could be used to examine the educational programs that are available to
train providers to discuss HIV prevention skills with their patients with SMI, as this is an
important issue if the eventual goal is sustainable implementation of HIV prevention
programming at psychiatric hospitals and community mental health facilities. The relationship
between HIV and mental health could be further explored by including HIV intervention studies
that target mental health symptom management to improve quality of life for participants. Lastly,
studies of prevention of other STIs in SMI populations could be included.
3.1.7.2 HIV Prevention Studies
HIV prevention research could be improved in several ways. Since three studies reported
intervention outcomes differences by mental health diagnostic type (Hajagos et al., 1998;
Williams et al., 2001; Carey et al., 2004) and greater cognitive and social impairment among
people with a more severe psychotic disorder has been known to predict long term rehabilitation
outcomes (Wykes & Dunn, 1992), future studies could explore different ways to tailor the HIV
prevention to this subpopulation by doing formative research before implementation.
35
Collaborations between HIV prevention and cognitive remediation (i.e. through Cognitive
Enhancement Therapy; Eack, 2012) researchers working with this population could facilitate
designing more appropriate HIV intervention programing.
Since the highest rate of HIV infection was found in a study of people with SMI and
unhealthy substance use (Silberstein et al., 1994) and substance use has been identified as a risk
factor for HIV infection in SMI people (Meade & Sikkema, 2005), this subpopulation could
benefit from more targeted HIV interventions,. Individuals with SMI who have unhealthy
substance use might require HIV intervention programs that are different than the people with
only a SMI, and possibly require an integrated programing to reduce both substance use and HIV
risk behaviors. The CDC (2002) has made the recommendation that “HIV Prevention Should be
an Integral Component of Substance Abuse Treatment” (CDC, 2002, p.1) for IV drug users in
the general public, but also recognized the challenges it presents (e.g. lack of access, shortage of
well trained staff, and continued drug use). A study by Solomon and colleagues (2007) found
that HIV case managers in a community mental health center, that services people with SMI and
unhealthy substance use and other individuals, received basic sexually transmitted disease
training, but had no formal training on teaching HIV prevention to their consumers. To help with
this issue, Solomon and colleagues are conducting an intervention where the case managers are
trained to deliver an HIV prevention intervention to people with SMI and unhealthy substance
use. At this writing, it is unknown if the results of the intervention have been published.
However, focus group data of the case managers revealed a change in their perceived attitudes’
towards the mental health consumers, most notably they recognized that their consumers were
having sex, and their own HIV prevention skills (Tennille, Solomon, & Blank, 2010). The results
of the study by Solomon and colleagues (2007) will provide more information about the
36
relationship between substance use, SMI and HIV prevention. Since almost a third of people
with SMI have a co-occurring substance abuse issue, further HIV intervention studies tailored to
this subpopulation are warranted (Regier et al., 1990).
Besides tailoring programming to subpopulations of people with SMI, there are other
areas that could be further explored in this field. More diverse public health theories could be
used to design interventions for people with SMI to target HIV risk behavior. Also the issue of
feasibility versus efficacy of a HIV intervention program could be explored by randomly
assigning participants to different number of sessions (i.e. dosage) to see the impact it has on
study outcomes. Another is changing study recruitment, such as using outpatient or community
participants, to increase the chances that the HIV intervention studies are able to demonstrate
significant HIV risk reduction behavior change. This is suggested because only one of the four
studies who recruited participants from psychiatric inpatient units was able to assess change in
HIV behavioral outcomes (Collins et al., 2001; Hajagos et al., 1998; Meyer et al., 1992;
Williams et al., 2001).
Like Kelly (1997), a more mental health system-level approach to HIV prevention for
people with SMI may be beneficial. The interventions studies in this review have conducted in
psychiatric inpatient units (Collins et al., 2001; Williams et al., 2001; Meyer et al., 1992) mental
health facilities providing outpatients services (Collins et al., 2011; Weinhardt et al., 1998;
Berkman et al., 2007; Carey et al., 2004; The National Institute Of Mental Health Multisite HIV
Prevention Trial Group, 2006; Kalichman et al., 2005; Otto-Salaj et al., 2001; Rosenberg et al.,
2004) and places within the community programs that people with SMI utilize (Berkman et al.,
2006; Collins et al., 2011; Jordan & Selwyn, 2008; Sikkema et al., 2007; Susser et al., 1998).
However, none of the studies used an integrated approach where multiple different types of
37
facilities were involved, such as an inpatient hospital and outpatient facilities. This integrated
approach to expansion of HIV interventions to multiple different types of mental health facilities
could eventually lead to a more complex, broadly encompassing social ecological perspective
approach to targeting HIV risk in the SMI population. The social ecological approach promotes
behavioral HIV change at several levels: Individual, interpersonal, community and structural and
environmental; suggested approaches to designing and implementing this type of HIV prevention
intervention exist (Latkin & Knowlton, 2005; Moore et al., 2010; Weeks et al., 2009).
3.1.8 Conclusions
Studies have found that people with SMI have a higher HIV prevalence than the general
population (Cournos & McKinnon, 1997). To learn more about the HIV prevention interventions
that are designed for this HIV high risk population, a literature search was conducted in
PsychInfo and PubMed. Sixteen intervention studies that meet inclusion and exclusion criteria
were found. A critical examination of these studies revealed that HIV prevention interventions
can change HIV related attitudes and risk behavior. The HIV prevention studies in this review
combined education and behavioral skills activities, which has been found to be an effective way
to promote behavior change in the SMI population in another health promotion subject (Bartels
& Desilets, 2012). HIV intervention prevention programs conducted with SMI individuals is a
fledgling field, but advances (e.g. more RCT designed studies, larger samples, longer follow-up
periods) have been made in the field since the Kelly (1997) critically reviewed the available
studies and made recommendations for future directions. The greatest change has occurred in the
design of gender specific interventions; previously there were no specific programs available for
females (Kelly, 1997).
38
A future area of improvement is based on changes in the study outcomes due to
psychiatric diagnosis noted in three of the studies (Hajagos et al., 1998; Williams et al., 2001;
Carey et al., 2004) and presence unhealthy substance use noted in one study (Berkman et al.,
2005) these interventions appear to still need further development in designing specific HIV
educational programing for SMI subpopulation. Further research on these subpopulations and
specifically tailored programming is recommended to decrease the HIV risk behavior in the SMI
population.
Like Kelly (1997), a more mental health system-level approach to HIV prevention for
people with SMI may be beneficial, with the eventual goal being a design and implementation of
an social ecological approach to HIV prevention (Latkin & Knowlton, 2005; Moore et al., 2010;
Weeks et al., 2009).
High risk for HIV infection is public health issue for people with SMI, while
interventions have been developed that effectively change HIV risk related behaviors in this
population, the heterogeneity of the subjects continues to impact outcomes and the HIV risk
reduction needs of this diverse individuals are still not completely met.
,
39
APPENDIX: TABLE
Table 1. Intervention Studies
Study
Name of
Intervention
(Jordan &
Selwyn, 2008)
(Meyer et al.,
1992)
(Williams et al.,
2001)
(Otto-Salaj et al.,
2001; Pinkerton
et al., 2001)
RCT
(YES/No)
Gend
er
Sample#
No
M/F
No
M/F
Criteria
(Besides SMI)
Theory
Main Findings
7
Not provided
Knowledge and self-efficacy scores increased
from pre- to post intervention (statistical
significance not established).
12
Health Belief Model
(Rosenstock et al., 1988)
The mean scores of the AIDs Knowledge
Questionnaire improved from pre- to post
intervention (Statistical Significance not
established).
Social Learning Theory
(Bandura, 1977) and
Transtheoretical Model
of Behavior Change
(Prochaska et al., 1992)
Significant changes in scores from pre- to post
intervention were found in the domain of: precontemplation for females, action for males,
contemplation for patients diagnosed with a
psychotic disorder, and action of those with a
mood disorder.
Social Cognitive Theory
(Bandura, 1986)
The intervention was associated with significant
change in HIV risk knowledge scores between
baseline and 3-,6-,and 9-month follow-up for
males and attitudes toward condom use, risk
reduction behavioral intentions, and sexual
behavior between baseline and 3-, 6-, and 9month follow-up for females.
50
Facts for Life
No
M/F
(32M, 18F )
Yes
M/F
189
(87M, 102F)
40
Table 1 Continued
(Carey et al.,
2004)
(Rosenberg et al.,
2004)
HIV-riskreduction
intervention
(HIV-R)
Yes
M/F
408
(187M, 221F)
substance use
in the past 12
months
Information-motivationbehavioral skills theory
((Fisher & Fisher, 1992).
The HIV intervention (HIV-R) was associated
with significant decreases in the occasions of
unprotected vaginal sex and the number of
sexual partners. Also, significant increases in
communication skills regarding safer sex with a
partner, HIV knowledge, positive condom
attitudes, condom use intentions, and behavioral
skills. The HIV-R group reported fewer new
STIs than the control group.
Screen, test,
immunize,
reduce risk, and
refer (STIRR)
No
M/F
50
unhealthy
substance use
diagnosis
Medical model
The intervention was associated with significant
increases in HIV knowledge and motivation to
reduce HIV risk behaviors.
320
(150M, 170F)
could not be
HIV positive;
receiving
treatment for
unhealthy
substance
abuse
Information-motivationbehavioral skills theory
(Fisher &Fisher, 1992)
The intervention was associated with significant
change in HIV knowledge scores between
baseline and the 6-month follow-up for men and
changes in condom attitudes, risk reduction
behavioral intentions, and reported reductions in
sexual risk behaviors between baseline and 6month follow-up for women.
Social Cognitive Theory
(Bandura, 1986)
Participants reported significant increases in
condom use, sexual communication, positive
attitudes towards condom use, and behavioral
intentions were observed after the skills training
intervention (with and without the social norms
part of the intervention). Participants reported
significant increases in HIV knowledge only
after both the skills training and social norms
intervention.
(Kalichman et al.,
2005)
No
(Sikkema et al.,
2007)
No
M/F
M/F
28
(17M, 11F)
(Susser et al.,
1998; Berkman et
al., 2005)
“Sex, Games,
and Videotapes”
(SexG)
Yes
M
97; 59 sexually
active
homeless
Social Learning Theory
(Bandura, 1977)
The intervention was associated with
significantly lower sexual risk index scores at
the 6-month follow-up. When compared to the
controls, no significant HIV risk reduction was
found in the substance-dependent men.
(Berkman et al.,
2006)
SexG-Brief.
Yes
M
92; 56 sexually
active
homeless
Social Learning Theory
(Bandura, 1977)
The intervention was not associated with any
significant changes in HIV risk behaviors,
although a decreasing trend was noted.
41
Table 1 Continued
(Berkman et al.,
2007)
Enhanced SexG
(E-SexG)
(The National
Institute Of
Mental Health
Multisite HIV
Prevention Trial
Group, 2006)
Project LIGHT
(Living in Good
Health
Together)
(Hajagos et al.,
1998)
(Collins et al.,
2011).
Yes
Yes
(Weinhardt et al.,
1998)
(Collins et al.,
2001)
Yes
Yes
“Ourselves, Our
Bodies, Our
Realities.”
“Ourselves, Our
Bodies, and Our
Realities.”
Yes
Yes
M
M
M
F
F
F
149
Social Learning Theory
(Bandura, 1977)
The intervention was not associated with any
significant changes in HIV risk behaviors.
99
Combined (Cognitive
behavioral theory,
theory of reasoned
action, and HIV specific
theories)
The intervention group had significantly fewer
sexual risk acts at the 12-month follow-up than
the control
75
No theory
Participants in the individually delivered
intervention group had the most significant
improvement in HIV knowledge between
baseline and posttest.
30
Information-motivationbehavioral skills theory
(Fisher &Fisher, 1992)
and Social Cognitive
Theory (Bandura, 1986)
The intervention was associated with significant
increases in sexual assertiveness skills, HIV
knowledge, and frequency of protected
intercourse; the most significant changes were
seen at the 2-month follow-up.
Social Cognitive Theory
(Bandura, 1986)
The intervention was associated with significant
increases in positive attitudes towards female
and male condoms, but not the Advantage 24,
from the baseline to 6 week follow-up.
Social Cognitive Theory
(Bandura, 1986)
The intervention was associated with significant
increases in female condom knowledge,
insertion, and use with a partner from the
baseline to 3-month follow-up. No significant
changes were noted in the sexual risk behavior
(unprotected sexual acts).
HIV negative
35
79
42
BIBLIOGRAPHY
Adimora, A. A., Schoenbach, V. J., & Floris-Moore, M. A. (2009). Ending the epidemic of
heterosexual HIV transmission among African Americans. Am J Prev Med, 37(5), 468471. doi: 10.1016/j.amepre.2009.06.020
AIDS.gov. (2011). Substance Use/Abuse. Retrieved May 10th, 2013, from http://aids.gov/hivaids-basics/prevention/reduce-your-risk/substance-abuse-use/
Amaro, H. (1995). Love, sex, and power. Considering women's realities in HIV prevention. Am
Psychol, 50(6), 437-447.
American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental
Disorders (3rd edn, revised) (DSM-III-R). Washington, DC:.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text rev.). Washington, DC: American Psychiatric Association.
AVERT. History of AIDS up to 1986. HIV and AIDS Topics. Retrieved March, 26, 2013
AVERT. (2013). History of AIDS up to 1986. HIV and AIDS Topics. Retrieved March,
26, 2013, from http://www.avert.org/aids-history-86.htm
Bandura, A. (1977). Social Learning Theory. Morristown, N.J: General Learning Press.
Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive
Theory Englewood Cliffs, N.J: Prentice-Hall.
Bartels, S., & Desilets, R. (2012). Health Promotion Programs for People with Serious Mental
Illness (Prepared by the Dartmouth Health Promotion Research Team). Washington,
D.C. :
Retrieved
from
http://www.integration.samhsa.gov/Health_Promotion_White_Paper_Bartels_Final_Doc
ument.pdf.
Berkman, A., Cerwonka, E., Sohler, N., & Susser, E. (2006). A randomized trial of a brief HIV
risk reduction intervention for men with severe mental illness. Psychiatric Services,
57(3), 407-409. doi: 10.1176/appi.ps.57.3.407
Berkman, A., Pilowsky, D. J., Zybert, P. A., Herman, D. B., Conover, S., Lemelle, S., . . . Susser,
E. (2007). HIV prevention with severely mentally ill men: A randomised controlled trial.
Aids Care-Psychological and Socio-Medical Aspects of Aids/Hiv, 19(5). doi:
10.1080/09540120701213989
Berkman, A., Pilowsky, D. J., Zybert, P. A., Leu, C. S., Sohler, N., & Susser, E. (2005). The
impact of substance dependence on HIV sexual risk-reduction among men with severe
mental illness. AIDS Care, 17(5), 635-639. doi: 10.1080/09540120412331291797
Bowie, C. R., & Harvey, P. D. (2005). Cognition in schizophrenia: impairments, determinants,
and functional importance. Psychiatr Clin North Am, 28(3), 613-633, 626. doi:
10.1016/j.psc.2005.05.004
43
Brunette, M. F., Rosenberg, S. D., Goodman, L. A., Mueser, K. T., Osher, F. C., Vidaver, R., . . .
Drake, R. E. (1999). HIV risk factors among people with severe mental illness in urban
and rural areas. Psychiatr Serv, 50(4), 556-558.
Carey, M. P., Carey, K. B., Maisto, S. A., Gleason, J. R., Gordon, C. M., & Brewer, K. K.
(1999). HIV Risk Behavior among Outpatients at a State Psychiatric Hospital: Prevalence
and Risk Modeling. Behav Ther, 30(3), 389-406. doi: 10.1016/S0005-7894(99)80017-3
Carey, M. P., Carey, K. B., Maisto, S. A., Gordon, C. M., Schroder, K. E. E., & Vanable, P. A.
(2004). Reducing HIV-risk behavior among adults receiving outpatient psychiatric
treatment: Results from a randomized controlled trial. Journal of Consulting and Clinical
Psychology, 72(2). doi: 10.1037/0022-006x.72.2.252
Carey, M. P., Carey, K. B., Maisto, S. A., Gordon, C. M., & Vanable, P. A. (2001). Prevalence
and correlates of sexual activity and HIV-related risk behavior among psychiatric
outpatients. J Consult Clin Psychol, 69(5), 846-850.
Carey, M. P., Carey, K. B., Weinhardt, L. S., & Gordon, C. M. (1997). Behavioral risk for HIV
infection among adults with a severe and persistent mental illness: patterns and
psychological antecedents. Community Ment Health J, 33(2), 133-142.
Catania, J. A., Kegeles, S. M., & Coates, T. J. (1990). Towards an understanding of risk
behavior: an AIDS risk reduction model (ARRM). Health Educ Q, 17(1), 53-72.
CDC. (2002). LINKING HIV PREVENTION SERVICES AND SUBSTANCE ABUSE
TREATMENT
PROGRAMS Retrieved
from
http://www.cdc.gov/idu/facts/HIVPrevServFin.pdf.
CDC. (2011). HIV Surveillance Report, Volume 23. Table 17 A. Retrieved June 07, 2012, from
http://www.cdc.gov/hiv/library/reports/surveillance/2011/surveillance_Report_vol_23.ht
ml
CDC. (2012). Basic Information about HIV and AIDS.
Retrieved April 12, 2012, from
http://www.cdc.gov/hiv/topics/basic/index.htm#hiv
Chawarski, M. C., Pakes, J., & Schottenfeld, R. S. (1998). Assessment of HIV risk. J Addict Dis,
17(4), 49-59. doi: 10.1300/J069v17n04_05
Collins, P. Y., Geller, P. A., Miller, S., Toro, P., & Susser, E. S. (2001). Ourselves, our bodies,
our realities: An HIV prevention intervention for women with severe mental illness.
Journal of Urban Health-Bulletin of the New York Academy of Medicine, 78(1). doi:
10.1093/jurban/78.1.162
Collins, P. Y., von Unger, H., Putnins, S., Crawford, N., Dutt, R., & Hoffer, M. (2011). Adding
the Female Condom to HIV Prevention Interventions for Women with Severe Mental
Illness: A Pilot Test. Community Mental Health Journal, 47(2), 143-155. doi:
10.1007/s10597-010-9302-8
Connell, R. W. (1987). Gender and Power. Stanford, California: Stanford University Press.
Cournos, F., Guido, J. R., Coomaraswamy, S., Meyer-Bahlburg, H., Sugden, R., & Horwath, E.
(1994). Sexual activity and risk of HIV infection among patients with schizophrenia. Am
J Psychiatry, 151(2), 228-232.
Cournos, F., & McKinnon, K. (1997). HIV seroprevalence among people with severe mental
illness in the United States: a critical review. Clin Psychol Rev, 17(3), 259-269.
Danya International, I. (2012). Effective Interventions: HIV Prevention that works. Retrieved
May
10th,
2013,
from
http://www.effectiveinterventions.org/en/HighImpactPrevention/Interventions.aspx
44
Darbes, L., Crepaz, N., Lyles, C., Kennedy, G., & Rutherford, G. (2008). The efficacy of
behavioral interventions in reducing HIV risk behaviors and incident sexually transmitted
diseases in heterosexual African Americans. AIDS, 22(10), 1177-1194. doi:
10.1097/QAD.0b013e3282ff624e
Eack, S. M. (2012). Cognitive remediation: a new generation of psychosocial interventions for
people with schizophrenia. Soc Work, 57(3), 235-246.
Elvevåg, B., & Goldberg, T. E. (2000). Cognitive impairment in schizophrenia is the core of the
disorder. Crit Rev Neurobiol, 14(1), 1-21.
First, M., M, G., RL, S., Williams, J., & LS., B. (1997). Structured Clinical Interview for DSMIV Axis II Personality Disorders, (SCID-II). Washington, D.C: American Psychiatric
Press, Inc.
Fishbein, M., & Ajzen, I. (1975). Belief, Attitude, Intention, and Behavior: An Introduction to
Theory and Research. . Reading, MA: Addison-Wesley.
Fisher, J. D., & Fisher, W. A. (1992). Changing AIDS-risk behavior. Psychol Bull, 111(3), 455474.
Geller, P. (n.d.). Use of female-controlled HIV prevention methods among women with mental
illness. Columbia University and the New York State Psychiatric Institute.
Glanz, K., Rimer, B., Viswanath, K. (2008). Health Behavior and Health Education: Theory,
Research, and Practice (4 ed.). San Francisco, CA: Jossey-Bass.
Grassi, L., Pavanati, M., Cardelli, R., Ferri, S., & Peron, L. (1999). HIV-risk behaviour and
knowledge about HIV/AIDS among patients with schizophrenia. Psychol Med, 29(1),
171-179.
Gur, R. E., Nimgaonkar, V. L., Almasy, L., Calkins, M. E., Ragland, J. D., Pogue-Geile, M. F., .
. . Gur, R. C. (2007). Neurocognitive endophenotypes in a multiplex multigenerational
family study of schizophrenia. Am J Psychiatry, 164(5), 813-819. doi:
10.1176/appi.ajp.164.5.813
Hajagos, K., Geiser, P., Parker, B., & Tesfa, A. (1998). Safer-sex education for persons with
mental illness. J Psychosoc Nurs Ment Health Serv, 36(8), 33-37.
Holtgrave, D. R., Qualls, N. L., Curran, J. W., Valdiserri, R. O., Guinan, M. E., & Parra, W. C.
(1995). An overview of the effectiveness and efficiency of HIV prevention programs.
Public Health Rep, 110(2), 134-146.
Horwath, E., Cournos, F., McKinnon, K., Guido, J. R., & Herman, R. (1996). Illicit-drug
injection among psychiatric patients without a primary substance use disorder. Psychiatr
Serv, 47(2), 181-185.
Ickovics, J. R., Hamburger, M. E., Vlahov, D., Schoenbaum, E. E., Schuman, P., Boland, R. J., .
. . Group, H. E. R. S. (2001). Mortality, CD4 cell count decline, and depressive
symptoms among HIV-seropositive women: longitudinal analysis from the HIV
Epidemiology Research Study. JAMA, 285(11), 1466-1474.
Ickovics, J. R., & Rodin, J. (1992). Women and AIDS in the United States: epidemiology,
natural history, and mediating mechanisms. Health Psychol, 11(1), 1-16.
Jacobs, J., Jones, E., Gabella, B., Spring, B., & Brownson, R. (2012). Tools for Implementing an
Evidence-Based Approach in Public Health Practice. . Preventing Chronic Disease.
Johnson, B. T., Scott-Sheldon, L. A., Smoak, N. D., Lacroix, J. M., Anderson, J. R., & Carey, M.
P. (2009). Behavioral interventions for African Americans to reduce sexual risk of HIV: a
meta-analysis of randomized controlled trials. J Acquir Immune Defic Syndr, 51(4), 492501. doi: 10.1097/QAI.0b013e3181a28121
45
Jordan, W. B., & Selwyn, P. A. (2008). HIV prevention in the clubhouse. Psychiatric Services,
59(8). doi: 10.1176/appi.ps.59.8.933
Kalichman, S., Malow, R., Devieux, J., Stein, J. A., & Piedman, F. (2005). HIV risk reduction
for substance using seriously mentally ill adults: Test of the information-motivationbehavior skills (IMB) model. Community Mental Health Journal, 41(3). doi:
10.1007/s10597-005-5002-1
Kalichman, S. C., Kelly, J. A., Johnson, J. R., & Bulto, M. (1994). Factors associated with risk
for HIV infection among chronic mentally ill adults. Am J Psychiatry, 151(2), 221-227.
Kalichman, S. C., Sikkema, K. J., Kelly, J. A., & Bulto, M. (1995). Use of a brief behavioral
skills intervention to prevent HIV infection among chronic mentally ill adults. Psychiatr
Serv, 46(3), 275-280.
Kelly, J. A. (1997). HIV risk reduction interventions for persons with severe mental illness.
Clinical Psychology Review, 17(3). doi: 10.1016/s0272-7358(97)00020-2
Kelly, J. A., McAuliffe, T. L., Sikkema, K., Murphy, D. A., Somlai, A. M., Mulry, G., . . .
Fernandez, M. (1996). “Practicing what you preach’? HIV risk reduction behavior
changes afier teachingsmerely mentally ill adults to advocate AIDS prevention to peers.
Medical College of Wisconsin. Unpublished manuscript.
Kelly, J. A., Murphy, D. A., Bahr, G. R., Brasfield, T. L., Davis, D. R., Hauth, A. C., . . . Eilers,
M. K. (1992). AIDS/HIV risk behavior among the chronic mentally ill. Am J Psychiatry,
149(7), 886-889.
Kelly, J. A., Murphy, D. A., Sikkema, K. J., Somlai, A. M., Mulry, G. W., Fernandez, M. I., . . .
Stevenson, L. Y. (1995). Predictors of high and low levels of HIV risk behavior among
adults with chronic mental illness. Psychiatr Serv, 46(8), 813-818.
Kessler, R. C., Berglund, P. A., Zhao, S., Leaf, P. J., Kouzis, A. C., Bruce, M. L., et al. (1996).
The 12-month prevalence andcorrelates of serious mental illness. . Washington, DC: US
Government Printing Office.
Laga, M., Manoka, A., Kivuvu, M., Malele, B., Tuliza, M., Nzila, N., . . . Alary, M. (1993). Nonulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women:
results from a cohort study. AIDS, 7(1), 95-102.
Latkin, C. A., & Knowlton, A. R. (2005). Micro-social structural approaches to HIV prevention:
a social ecological perspective. AIDS Care, 17 Suppl 1, S102-113. doi:
10.1080/09540120500121185
Lyles, C. M., Kay, L. S., Crepaz, N., Herbst, J. H., Passin, W. F., Kim, A. S., . . . Team, H. A. P.
R. S. (2007). Best-evidence interventions: Findings from a systematic review of HIV
behavioral interventions for US populations at high risk, 2000-2004. American Journal of
Public Health, 97(1). doi: 10.2105/ajph.2005.076182
McConnaughy, E. A., DiClemente, C. C., Prochaska, J. O., & Velicer, W. F. (1989). Stages of
change in psychotherapy: A follow-up report. Psychtherapy, 26, 494-503.
McDermott, B. E., Sautter, F. J., Winstead, D. K., & Quirk, T. (1994). Diagnosis, health beliefs,
and risk of HIV infection in psychiatric patients. Hosp Community Psychiatry, 45(6),
580-585.
McGurk, S. R., & Mueser, K. T. (2004). Cognitive functioning, symptoms, and work in
supported employment: a review and heuristic model. Schizophr Res, 70(2-3), 147-173.
doi: 10.1016/j.schres.2004.01.009
46
McKinnon, K., Cournos, F., Sugden, R., Guido, J. R., & Herman, R. (1996). The relative
contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors
among people with severe mental illness. J Clin Psychiatry, 57(11), 506-513.
Meade, C. S., & Sikkema, K. J. (2005). HIV risk behavior among adults with severe mental
illness: A systematic review. Clinical Psychology Review, 25(4). doi:
10.1016/j.cpr.2005.02.001
Meyer, I., Cournos, F., Empfield, M., Agosin, B., & Floyd, P. (1992). HIV prevention among
psychiatric inpatients: A pilot study risk reduction study. Psychiatric Quarterly (New
York), 63(2). doi: 10.1007/bf01065989
Meyer, I., McKinnon, K., Cournos, F., Empfield, M., Bavli, S., Engel, D., & Weinstock, A.
(1993). HIV seroprevalence among long-stay patients in a state psychiatric hospital. Hosp
Community Psychiatry, 44(3), 282-284.
Meyer-Bahlburg, H., Ehrhardt, A., Exner, T., & Gruen, R. (1991). Sexual Risk Behavior
Assessment Schedule-Adult Armory Interview (SERBAS-A-ARMM-1). Programof
Developmental Psychoendocrinology. New York State Psychiatric Institute and
Department of Psychiatry, College of Physicians and Surgeons of Columbia.
New York, NY.
Meyer-Bahlburg, H., Ehrhardt, A., Exner, T. M., & Gruen, R. S. (1991). Sexual Risk Behavior
Assessment Schedule Adult Armory Interview. . New York: New York State Psychiatric
Institute and Columbia University.
Moore, D., Carr, C. A., Williams, C., Richlen, W., Huber, M., & Wagner, J. (2010). An
ecological approach to addressing HIV/AIDS in the African American community. J
Evid Based Soc Work, 7(1), 144-161. doi: 10.1080/15433710903176047
National Institute of Mental Health. (1987). Towards a Model for a Comprehensive CommunityBased Mental Health System. . Washington, DC.
National Institute of Mental Health. (1993). AIDS research: An NIMH blueprint for the second
decade. . Rockville MD: U.S. Dept. of Health and Human Services, Public Health
Service, National Institutes of Health, National Institute of Mental Health.
National Institute of Mental Health. (2012). Division of AIDS Research (DAR). Retrieved
March 26, 2013, from http://www.nimh.nih.gov/about/organization/dar/index.shtml
Nyamathi, A., Bennett, C., Leake, B., Lewis, C., & Flaskerud, J. (1993). AIDS-related
knowledge, perceptions, and behaviors among impoverished minority women. Am J
Public Health, 83(1), 65-71.
Otto-Salaj, L. L., Kelly, J. A., Stevenson, L. Y., Hoffmann, R., & Kalichman, S. C. (2001).
Outcomes of a randomized small-group HIV prevention intervention trial for people with
serious mental illness. Community Mental Health Journal, 37(2).
Parabiaghi, A., Bonetto, C., Ruggeri, M., Lasalvia, A., & Leese, M. (2006). Severe and persistent
mental illness: a useful definition for prioritizing community-based mental health service
interventions. Soc Psychiatry Psychiatr Epidemiol, 41(6), 457-463. doi: 10.1007/s00127006-0048-0
Peer Support and Advocacy Network's. (n.d.).
Retrieved May 10th, 2013, from
http://www.peer-support.org/index.html
Peers Envisioning and Engaging in Recovery Services (PEERS). (2013). Retrieved May 10th,
2013, from http://www.peersnet.org/
Perry, S. W. (1994). HIV-related depression. Res Publ Assoc Res Nerv Ment Dis, 72, 223-238.
47
Pinkerton, S. D., Johnson-Masotti, A. P., Otto-Salaj, L. L., Stevenson, L. Y., & Hoffmann, R. G.
(2001). Cost-effectiveness of an HIV prevention intervention for mentally ill adults.
Mental health services research, 3(1). doi: 10.1023/a:1010112619165
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change.
Applications to addictive behaviors. Am Psychol, 47(9), 1102-1114.
Rabkin, J. G., McElhiney, M. C., & Ferrando, S. J. (2004). Mood and substance use disorders in
older adults with HIV/AIDS: methodological issues and preliminary evidence. AIDS, 18
Suppl 1, S43-48.
Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F.
K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results
from the Epidemiologic Catchment Area (ECA) Study. JAMA, 264(19), 2511-2518.
Rosenberg, S., Brunette, M., Oxman, T., Marsh, B., Dietrich, A., Mueser, K., . . . Vidaver, R.
(2004). The STIRR model of best practices for blood-borne diseases among clients with
serious mental illness. Psychiatric Services, 55(6). doi: 10.1176/appi.ps.55.6.660
Rosenberg, S. D., Trumbetta, S. L., Mueser, K. T., Goodman, L. A., Osher, F. C., Vidaver, R.
M., & Metzger, D. S. (2001). Determinants of risk behavior for human
immunodeficiency virus/acquired immunodeficiency syndrome in people with severe
mental illness. Compr Psychiatry, 42(4), 263-271. doi: 10.1053/comp.2001.24576
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the Health
Belief Model. Health Educ Q, 15(2), 175-183.
Ruggeri, M., Leese, M., Thornicroft, G., Bisoffi, G., & Tansella, M. (2000). Definition and
prevalence of severe and persistent mental illness. Br J Psychiatry, 177, 149-155.
Sacks, M., Dermatis, H., Looser-Ott, S., Burton, W., & Perry, S. (1992). Undetected HIV
infection among acutely ill psychiatric inpatients. Am J Psychiatry, 149(4), 544-545.
Sacks, M. H., Perry, S., Graver, R., Shindledecker, R., & Hall, S. (1990). Self-reported HIVrelated risk behaviors in acute psychiatric inpatients: a pilot study. Hosp Community
Psychiatry, 41(11), 1253-1255.
SAMHSA.
(2011).
Mental
Illness
and
Homelessness.
http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf.
Sikkema, K. J., Meade, C. S., Doughty-Berry, J. D., Zimmerman, S. O., Kloos, B., & Snow, D.
L. (2007). Community-level HIV prevention for persons with severe mental illness living
in supportive housing programs: a pilot intervention study. Journal of prevention &
intervention in the community, 33(1-2). doi: 10.1300/J005v33n01_10
Silberstein, C., Galanter, M., Marmor, M., Lifshutz, H., Krasinski, K., & Franco, H. (1994).
HIV-1 among inner city dually diagnosed inpatients. Am J Drug Alcohol Abuse, 20(1),
101-113.
Solomon, P. L., Tennille, J. A., Lipsitt, D., Plumb, E., Metzger, D., & Blank, M. B. (2007).
Rapid assessment of existing HIV prevention programming in a community mental
health center. J Prev Interv Community, 33(1-2), 137-151. doi: 10.1300/J005v33n01_11
Susser, E., Valencia, E., Berkman, A., Sohler, N., Conover, S., Torres, J., . . . Miller, S. (1996).
HIV sexual risk reduction in impaired populations: A controlled trial among homeless
men. . Columbia University, New York, NY.
Susser, E., Valencia, E., Berkman, A., Sohler, N., Conover, S., Torres, J., . . . Miller, S. (1998).
Human immunodeficiency virus sexual risk reduction in homeless men with mental
illness. Archives of General Psychiatry, 55(3). doi: 10.1001/archpsyc.55.3.266
48
Susser, E., Valencia, E., & Conover, S. (1993). Prevalence of HIV infection among psychiatric
patients in a New York City men's shelter. Am J Public Health, 83(4), 568-570.
Tengs, T. O., Adams, M. E., Pliskin, J. S., Safran, D. G., Siegel, J. E., Weinstein, M. C., &
Graham, J. D. (1995). Five-hundred life-saving interventions and their cost-effectiveness.
Risk Anal, 15(3), 369-390.
Tennille, J., Solomon, P., & Blank, M. (2010). Case managers discovering what recovery means
through an HIV prevention intervention. Community Ment Health J, 46(5), 486-493. doi:
10.1007/s10597-010-9326-0
The National Institute Of Mental Health Multisite HIV Prevention Trial Group. (2006). HIV
prevention with persons with mental health problems. Psychol Health Med, 11(2), 142154. doi: K26X82157260164Q [pii] 10.1080/13548500500445094.
The NIMH Multisite HIV Prevention Trial: reducing HIV sexual risk behavior. The National
Institute of Mental Health (NIMH) Multisite HIV Prevention Trial Group. (1998).
Science, 280(5371), 1889-1894.
The White House. (2010). NATIONAL HIV/AIDS STRATEGY.
The World Bank. (2011). Prevalence of HIV, total (% of population ages 15-49).
Traube, D. E., Holloway, I. W., & Smith, L. (2011). Theory development for HIV behavioral
health: empirical validation of behavior health models specific to HIV risk. AIDS Care,
23(6), 663-670. doi: 10.1080/09540121.2010.532532
Wallace, C. J., Liberman, R. P., MacKain, S. J., Blackwell, G., & Eckman, T. A. (1992).
Effectiveness and replicability of modules for teaching social and instrumental skills to
the severely mentally ill. Am J Psychiatry, 149(5), 654-658.
Washington State Department of Health. (n.d). Theories and Models. Retrieved December, 20,
2012,
from
http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/HIVAIDS/Prevention/Int
erventions/TheoriesandModels.aspx
Wasserheit, J. N. (1992). Epidemiological synergy. Interrelationships between human
immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm
Dis, 19(2), 61-77.
Weeks, M. R., Convey, M., Dickson-Gomez, J., Li, J., Radda, K., Martinez, M., & Robles, E.
(2009). Changing drug users' risk environments: peer health advocates as multi-level
community change agents. Am J Community Psychol, 43(3-4), 330-344. doi:
10.1007/s10464-009-9234-z
Weinhardt, L. S., Carey, M. P., Carey, K. B., & Verdecias, R. N. (1998). Increasing assertiveness
skills to reduce HIV risk among women living with a severe and persistent mental illness.
Journal of Consulting and Clinical Psychology, 66(4). doi: 10.1037/0022-006x.66.4.680
Williams, E., Donnelly, J., & Proesher, E. (2001). An HIV/AIDS risk-reduction program for
mentally ill hospital patients: Assessing readiness for change. American Journal of
Orthopsychiatry, 71(3). doi: 10.1037/0002-9432.71.3.385
Wykes, T., & Dunn, G. (1992). Cognitive deficit and the prediction of rehabilitation success in a
chronic psychiatric group. Psychol Med, 22(2), 389-398.
49