Journal Article Annotations
2024, 1st Quarter
Annotations by John A R Grimaldi MD, Mary Ann Cohen MD, FAPM, Kelly Cozza MD, DFAPA, FACLP, Luis Pereira MD
April, 2024
Findings:
This cross-sectional study used data from the 2020-2021 National Mental Health Services Survey (NMHSS) to examine HIV and STI testing rates among US outpatient mental healthcare service providers. Secondary outcome measures included state-level HIV and STI incidence and healthcare facility characteristics: facility type, services offered, and accepted payments. HIV and STI testing were offered by 7.9% and 6.4%, respectively, of outpatient mental healthcare service providers. Certified community behavioral health clinics and multi-setting mental health facilities were more likely than other mental health outpatient settings to offer HIV and/or STI testing. Non-profit facilities, those that provided a dual-diagnosis program and those that accepted private insurance and Medicare were more likely to provide HIV and/or STI testing, when compared to for-profit facilities and those without a dual-diagnosis program and those that did not accept private insurance or Medicare, respectively. Higher state-level HIV and STI incidence were associated with a higher percentage of facilities offering HIV and STI testing, respectively.
Strengths and limitations:
The dataset utilized by this study was derived from a large, federally-sponsored, annual survey of all public and private mental health treatment facilities across 50 states. The study has several limitations including its cross-sectional design and use of self-reported data which is subject to recall bias. Additionally, independent practitioners were not surveyed and the survey did not inquire about availability of HIV prevention services, such as HIV pre-exposure prophylaxis, condom distribution and risk reduction counseling, which are important components of HIV/STI management. Lastly, the survey’s timing during the COVID-19 pandemic may have affected availability of HIV and STI testing.
Relevance:
There is growing recognition that people with major psychiatric disorders, such as schizophrenia and chronic mood disorders, are at increased risk of shortened lifespans and medical comorbidity. Expansion of access to HIV/STI testing services for vulnerable and difficult to reach populations aligns with the US Preventive Services Taskforce (USPSTF) recommendation that everyone ages 18-65 should receive HIV testing at least once in their lifetime. The USPSTF also gave its highest rating, Grade A, to its recommendation for use of daily antiretroviral medication for HIV pre-exposure phylaxis in individuals at risk for HIV acquisition. This study’s finding of very low rates of HIV/STI testing in outpatient mental healthcare setting can inform the DHHS, national End the HIV Epidemicplan by targeting this specific population in counties with the highest HIV prevalence.
Findings:
Data from participants in the University of California in San Diego HIV Neurobehavioral Program (HNRP) were used to examine the relationship between 3 frailty measures – the Fried Phenotype, the Rockwood Frailty Index, and the Veterans Aging Cohort Study (VACS) Index – and the presence of HIV-associated Neurocognitive Disorder (HAND). No single measure alone was able to reliably identify symptomatic HAND. However, the Rockwood Frailty Index with its high sensitivity, when combined with the Fried Phenotype’s high specificity, may be able to identify those individuals at highest risk for HAND. Used alone, the Rockwood Frailty Index and Fried Phenotype were more strongly associated with HAND when compared to the VACS Index.
Strengths and limitations:
The data from this study were derived from well-established, longstanding, NIH-funded studies conducted at the UC San Diego HNRP. Participants completed comprehensive neuromedical and neuropsychological evaluations that utilized Frascati criteria to classify diagnoses of HAND. The study was limited by the relatively small number of participants who met criteria for symptomatic HAND and who met the definition of “frail” using the Fried Phenotype. Also, the studies did not include a comparison group of people without HIV. Lastly, the Rockwood Frailty Index components are not identical across studies, thus limiting comparisons in the literature.
Relevance:
The overall prevalence of HAND has not changed significantly since the introduction of antiretroviral therapy almost 30 years ago. Asymptomatic and mildly symptomatic forms of HAND now predominate and have created a need to develop practical tools for early identification and design new therapeutic targets for both clinical as well as research purposes. Although studies have demonstrated an association between frailty and neurocognitive impairment in persons with and those without HIV, this is the first study to report sensitivity and specificity for the Fried Phenotype and Rockwood Index in detecting HAND. This study’s relevance is supported by the aging of the population of people with HIV and evidence suggesting that HIV may accelerate aging and thus increase risk of other neurodegenerative disorders associated with older age such as Alzheimer’s disease. This study also highlights the need for improved resources for and access to neuropsychological testing since frailty alone is a poor proxy for a patient’s neurobehavioral condition.