To the Editor:
HIV prevalence among people with mental illness has substantially increased in recent years. 1 Advanced brain impairment in people with HIV infection is clinically difficult to manage and usually requires residential care, because the presence of psychiatric illness would negatively affect treatment adherence. 2 We need innovative approaches to increase access and adherence to antiretroviral therapy (ART), especially among these difficult-to-treat populations. Few studies have assessed psychiatric illness as a barrier to adherence to ART. It is not known whether treatment of identified psychologic morbidity leads to an improved antiretroviral medication adherence and a better medical outcome. 3 We evaluated whether psychiatric patients in a residential care facility can reach adequate adherence and virologic response to ART by directly observed therapy (DOT). In Italy, people affected by AIDS who are socioeconomically disadvantaged and living in residential facilities are offered free care (Nonprofit organization). In this study, we report clinical cases assessed in a nonprofit residential care facility (Don Dante Savini, Perugia, Central Italy) designed for patients with late-stage HIV infection and psychiatric disorders. Between January 1999 and December 2003 we cared for 40 consecutive HIV-infected patients (31 men, mean of age 40 ± 7 years) who had severe socioeconomic problems and a chaotic lifestyle (came from mental health services, homeless, marginally housed individuals, or without family support). Thirty-two patients were coinfected with hepatitis C virus. Psychiatric diagnosis (Diagnostic and Statistical Manual of Mental Disorders-IV; DSM-IV criteria) 4 and substance use disorder are reported in Table 1. In this study the diagnostic categories are not exclusive: subjects could screen in with multiple psychiatric diagnoses. All the patients were treatment experienced to HIV therapy, but with previous inadequate adherence. In 4 cases the permanence in the residential care was shorter of 60 days, and in 3 patients ART was not administered because of end-stage liver disease. Therapy was administered and taken under the direct control of a caregiver. The adherence was measured by medication administration records during long-term follow-up, and it was calculated as a proportion of prescribed doses taken. At admission in the residential care facility, the mean CD4+ T-lymphocyte count was 153 ± 127 cells/mm3, 42% of patients (14/33) were on antiretroviral therapy, and just 6/33 (18%) had HIV RNA <50 copies/mL; HIV RNA in the viremic patients was 88.092 ± 157.803 copies/mL. In 11 patients, the therapeutic regimens were selected by genotype resistance test. All these cases showed the presence of pharmacologically resistant strain to the reverse transcriptase and protease inhibitor drugs (mean of viral mutation = 8). In the other cases, the therapeutic regimens were chosen on the basis of the pharmacologic history. We applied integrated approaches in the treatment of these patients including psychopharmacologic therapy, psychotherapy in some cases, and psychosocial and educational support guaranteed by the presence of social health workers. The goal of our evaluation was the number of patients with HIV RNA <50 copies/mL at the last control. The data were analyzed by Epi Info 6.0. 5
The adherence and virologic response to ART were evaluated in 33 patients. Most of them had very complex clinical and behavioral conditions, with more than double diagnoses (advanced HIV infection, liver diseases, psychiatric illness, substance abuse on agonist therapy). Psychiatric conditions were treated before or in tandem with HIV infection. Adherence to therapy and virologic response were observed during a follow-up of 654 ± 610 days. The mean rate of adherence was 98.9 ± 1.7%. The HIV RNA was <50 copies/mL in 28 patients (84.8%) at the last check. There were 25 patients (75.7%) with persistent sustained response (HIV RNA <50 copies/mL. There were 14 treated patients with borderline personality disorder. In these patients, the means of adherence were not different (99%), and 12 obtained good virologic response (HIV RNA <50 copies/mL.
The virologic response to ART administered in residential care compared with ART taken before admission was significantly different (χ2 = 26.75 Yates corrected, P < 0.001). The level of CD4+ T cells increased 144 ± 133 cells/mm3 at the last control. During the follow-up, no AIDS-related deaths were observed.
To our knowledge, this is the first attempt to assess long-term adherence to ART by DOT-provided medication in psychiatric patients housed in residential care facilities. Psychiatric disorders are common in HIV-infected patients, and they may not receive optimal care because their psychiatric disorders are a barrier to medical care, communication with clinicians, and adherence to medical recommendations. 6 We developed clinical interventions by a multidisciplinary team, including both medical and mental health practitioners, to assist psychiatric patients with complex conditions in maintaining high levels of adherence. We obtained 84.8% of patients with HIV RNA not detectable with respect to 18% at the admission in the residential care facilities. Palmer et al 7 reported that borderline personality disorder is significantly associated with lack of adherence to HIV medications in therapy. We obtained good adherence (99%) and response to antiretroviral therapy also in 12 of 14 patients with this condition (85% of these patients with HIV RNA <50 copies/mL). The key for a successful intervention is the combination of clinical and human support by team group and community reinforcement approach. The adherence of DOT-based administration of antiretroviral therapy (measured by electronic monitoring caps) in the correctional setting was not optimal (86%). 8 We obtained encouraging results in psychiatric patients. Patients who are better and more frequently informed about their disease and treatment are likely to increase their trust in the caregivers and their motivation to adhere to therapy. 9 Psychiatric assessment and treatment and social support are crucial to promote appropriate HIV medication adherence, because substance abuse and psychiatric disorders are intertwined with HIV infection. Early recognition and management of depressive comorbidity could be an effective intervention strategy to improve adherence. 10 The relationship with the patient is the most important feature. Our report supports the hypothesis that complex psychiatric patients with HIV infection should be successfully treated in residential care facilities using an integrated multidisciplinary approach.
Giuseppe Vittorio Luigi De Socio, MD*
Luca Fanelli, MD†
Alessandro Longo, MD†
Giuliano Stagni, MD*
*Department of Experimental Medicine and Biochemical Science, Section of Infectious Diseases, University of Perugia, †Residential care facility “D. Dante Savini,” ICOS Perugia, Italy
1. Gray R, Brewin E, Noak J, et al. A review of the literature on HIV infection and schizophrenia: implications for research, policy and clinical practice. J Psychiatr Ment Health Nurs
2. Stephenson J, Woods S, Scott B, et al. HIV-related brain impairment from palliative care to rehabilitation. Int J Palliat Nurs.
3. Sternhell PS, Corr MJ. Psychiatric morbidity and adherence to antiretroviral medication in patients with HIV/AIDS. Aust N Z J Psychiatry
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
, 4th ed. Washington, DC: American Psychiatric Association; 1994.
5. Epi Info
[computer program]. Version 6.0. Atlanta, GA: Centers for Disease Control and Prevention; 1994.
6. Treisman GJ, Angelino AF, Hutton HE. Psychiatric issues in the management of patients with HIV infection. JAMA
7. Palmer NB, Salcedo J, Miller AL, et al. Psychiatric and social barriers to HIV medication adherence in a triply diagnosed methadone population. Aids Patient Care STDS
8. Wohl DA, Stephenson BL, Golin CE, et al. Adherence to directly observed antiretroviral therapy among human immunodeficiency virus-infected prison inmates. Clin Infect Dis
9. Murri R, Fantoni M, Del Borgo C, et al. Determinants of health-related quality of life in HIV-infected patients. AIDS Care
10. Starace F, Ammassari A, Trotta MP, et al. AdI-CoNA Study Group. NeuroICoNA Study Group. Depression is a risk factor for suboptimal adherence to highly active antiretroviral therapy. J Acquir Immune Defic Syndr