Primary Prevention of HIV in Persons with Severe Mental Illness; A Case Manager Delivered Intervention

Recent studies highlight a disproportionately high incidence of HIV in the population of persons with severe mental illness (SMI) and co-occurring substance abuse. Estimates are that these individuals are between three and seven times more likely to become infected with HIV as compared with other Medicaid recipients. Case managers are the primary providers of services to persons with SMI and in a unique position for potential intervention. Objective: PATH is based on a translation of two HIV prevention programs proven effective in the general population and particularly, among substance users. The RESPECT program was developed by CDC and is the first HIV prevention program to show one-on-one counseling can reduce at-risk sexual behavior in a multi-site demonstration. The NIDA Community-Based Outreach Model (CBOM) was designed to reduce the risk of HIV and other blood-borne infections in drug users. PATH draws on features of both interventions and is tailored to persons with SMI. This effectiveness randomized clinical trial examined the hypothesis that persons with co-occurring severe mental illnesses and substance abuse receiving the Preventing AIDS Through Health (PATH) intervention, will report fewer high-risk sexual behaviors, fewer high-risk substance use related behaviors, improved condom use skills, and use less substances via biological markers. Methods: Two hundred and eighty adults with SMI participated in a cluster randomized design where eighteen case managers delivered the PATH manualized program of education to their respective caseloads and nineteen case managers delivered case management as usual. Participants were eligible if they were actively receiving case management for a mental illness and admitted to substance use. Individuals were interviewed at baseline, three, six and twelve months. Psychometrically sound measures encompassed use of drugs and alcohol, condom-use skills, symptoms of mental illness and sexual risk- taking behaviors. Participants were tested for the presence of drugs via urine specimens at baseline and twelve months. Results: Experimental participants reported using condoms more frequently at six months and had better condom use skills at 12 months. Additionally, experimental participants showed less drug use at 12 months. Conclusions: The PATH intervention has been shown to be effective in reducing HIV risk behaviors related to increased condom use and improvement in condom use skills. Furthermore, recipients of PATH are less likely to use drugs. Findings suggest that case managers are capable of effectively delivering the PATH prevention intervention and that their SMI substance abusing clients have the capacity to learn and adopt new risk reduction behaviors to protect themselves against HIV infection. Implications for social workers working with this high risk population will be discussed.