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Background: People with serious mental illness are at elevated
risk for human immunodeficiency virus (HIV) infection. A small body of
published research has evaluated the efficacy of HIV prevention interventions
that aim to help persons with mental illness modify sexual behaviors that
place them at risk for HIV infection. Additional research has evaluated
the economic efficiency ('cost-effectiveness') of these interventions.
Aims of the Study: We provide a detailed and critical review of
the efficacy and cost-effectiveness of randomized, controlled trials of
HIV prevention interventions for this population. We present a brief overview
of the epidemiology of HIV among men and women with serious mental illness
and describe HIV risk factors for members of this population. The efficacy
literature is critically reviewed, and the results of the available studies
are compared using a common effect size metric. The cost-effectiveness
of HIV prevention interventions for mentally ill adults is then reviewed.
Methods: The efficacy of interventions at reducing risk behaviors
and increasing preventive behaviors was summarized using effect size estimation
techniques. First, we reviewed interventions that have been evaluated
in randomized clinical trials and published in the peer-reviewed scientific
literature so as to summarize the interventions that have been subjected
to the most rigorous evaluation. For each of the five studies that met
the inclusion criteria, we briefly described the methodology and intervention
content, summarized the evidence for intervention efficacy, and calculated
appropriate effect size estimates. A narrative review of two cost-effectiveness
studies published to date was included.
Results: The review of intervention efficacy indicated that the
risk reduction interventions evaluated to date have had only limited success
at helping people with severe mental illness reduce their HIV risk behavior.
Most effect sizes indicating successful condom use increases were in the
small or small to moderate range. Overall, studies with the largest sample
sizes, and presumably the most generalizable results, produced smaller
intervention effect sizes than studies with smaller samples. The cost-effectiveness
literature revealed similarly mixed results: economic efficiency varied
from not cost-effective to highly cost-effective.
Discussion: Limited information is presently available regarding
the efficacy and cost-effectiveness of HIV prevention interventions for
people with severe and persistent mental illness. Encouraging results
were obtained in some, but not all studies. Methodological limitations
will need to be addressed in the next generation of HIV risk reduction
intervention studies for this population.
Implications for Health Care Provision and Use: Persons with severe
mental illness warrant attention from health care providers due to elevated
risk for HIV infection. Interventions discussed herein, focusing on information
and behavioral skills training, can be employed until strategies with
stronger results are developed.
Implications for Health Policies: Effective and cost-effective
HIV risk reduction interventions are available for adults with mental
illness and should be more widely implemented. The cost-effectiveness
of these interventions could be further enhanced by screening potential
participants for high-risk sexual behaviors.
Implications for Further Research: To advance the field, the next
generation of intervention research for people with severe mental illness
will need to improve upon the designs and intervention strategies of the
first generation, include larger samples, and devote increased attention
to the life circumstances and particular mental health issues of intervention
participants.
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