Studies reported that 17% to 47% of individuals with a SMI were recently tested for HIV, and that 11% to 89% were ever tested for HIV. The variability in estimates reflects variability in many study features including sample size, dates of investigation, sampling (e.g., inpatients vs. outpatients), and policies at the centers from which participants were recruited. Despite these methodological variations, the range of findings indicates that routine HIV testing is not yet a standard practice in most mental health settings.
Studies investigating correlates of testing among individuals with a SMI have reported mixed findings. There was no clear association between HIV testing and either demographic or psychiatric variables; however, many of these findings were based on only one or two studies. The lack of an association between psychiatric symptoms and HIV testing was unanticipated; we expected that individuals with greater distress would be less able to provide informed consent, and would be less likely to be tested for HIV. In a vignette study, clinicians were reluctant to test for HIV if a patient was impaired, even if the patient had a history of risk behavior (Walkup et al., 2002
). The association between testing and psychiatric symptoms or level of functioning merits investigation; it may be important to tailor HIV testing interventions to different levels of functioning.
Engaging in more HIV risk behavior was associated with HIV testing. Thus, among individuals with a SMI, those who are most in need of an HIV test are being tested. Individuals who engage in HIV-risk behaviors may be more concerned about their HIV risk, and therefore seek testing. Clinicians most likely refer patients who report HIV risk behaviors for HIV testing. Although only one study investigated the clinician/patient relationship and HIV testing, a stronger therapeutic alliance was associated with a greater likelihood of testing (Desai et al., 2007
), which suggests that therapists could be a valuable resource to encourage their patients to get tested for HIV.
We located only one well-described intervention to encourage HIV testing among individuals with a SMI (viz., the STIRR program; Rosenberg et al., 2004
). Testing rates for individuals at mental health centers that participated in the intervention were higher than testing rates in other studies; however, because the study employed a post-test only design, firm conclusions cannot be drawn about the efficacy of the intervention.
There are several limitations to this review. First, most of the findings presented in this article were based on only a few studies. More research is needed before firm conclusions about HIV testing rates and correlates can be drawn. Second, because there are few studies, we could not explore the impact of characteristics of study samples or methodology on findings. Finally, the majority of studies reported in this article were conducted in the US; findings may differ in other countries, where HIV rates, SMI or HIV stigma, and access to HIV testing may differ.
HIV testing among individuals with a SMI deserves further study. First, studies investigating the prevalence of HIV testing among individuals with a SMI should determine the overall prevalence of HIV testing as well as the prevalence among individuals engaging in risk behavior (e.g., Meade & Sikkema, 2005b
). Second, it is important to know the timing of HIV diagnosis among individuals with a SMI (Cournos and McKinnon, 1997
). Research has found that a large percentage of individuals are diagnosed late in the course of HIV infection (CDC, 2003b
). Early diagnosis of HIV allows for earlier entry into care, and facilitates risk reduction. It is important to know if individuals with a SMI are diagnosed later than other individuals. Third, research might explore individual (e.g., low risk awareness) and structural (e.g., logistic, policy) barriers to testing, in order to inform intervention development.
Fourth, studies to encourage HIV testing among individuals with a SMI who engage in HIV-risk behavior are needed. To date, no randomized controlled trials (RCTs) to increase HIV testing rates among individuals with a SMI have been conducted. Interventions focusing on service barriers could evaluate the STIRR intervention in a RCT. Alternatively, if attitudinal barriers were targeted, HIV testing interventions that have been efficacious with individuals without a SMI could be adapted and implemented with individuals with a SMI (e.g., Carey et al., in press
Finally, the impact of HIV diagnosis on an individual with a SMI merits study. One reason for trying to increase HIV testing uptake is that individuals infected with HIV reduce their sexual risk behavior (Weinhardt et al., 1999
, Marks et al., 2005
). Given the cognitive and social impairments characteristic of SMI (e.g., social skill deficits), research might determine whether HIV diagnosis in individuals with a SMI results in changes in sexual risk behavior. If not, further intervention may be needed to provide individuals with a SMI who are HIV positive with the information, motivation, skills, and other support they need to adopt safer sexual practices.
To promote the overall health of adults with a SMI, it is important that individuals with a SMI who engage in HIV risk behaviors are tested for HIV. Psychiatric settings may be an opportune venue for HIV testing, for several reasons. First, this is where patients can be found, reducing the need for additional transportation or appointments. Second, mental health clinicians can provide pre- and post-test counseling that is tailored for individuals with a SMI, which other HIV testing sites may be less able to provide (Satriano et al., 2007
). Third, therapists can encourage HIV testing, address patients’ barriers to testing, and allay concerns about testing, confidentiality, and stigma.
Unfortunately, many mental health settings do not encourage HIV testing. In a survey of psychiatric units in hospitals, 53% reported that they encouraged only a few patients to get tested, and 17% reported encouraging almost no patients to get tested (Walkup et al., 1998
). Among outpatient mental health centers in New York state, only 22% provided pre- and post-test counseling, only 16% offered testing on-site, and 13% did not have a procedure to refer patients to other sites for testing (Satriano et al., 2007
Although providers usually agree that HIV-related services are important (Satriano et al., 2007
), there are many barriers to providing HIV services, including lack of training, discomfort with the topic, and competing priorities (Solomon et al., 2007
). Clinicians may be uncomfortable delivering risk reduction counseling, or obtaining consent for or administering HIV tests. Patients may be uncomfortable talking about HIV as well. Additionally, because of resource constraints, HIV testing and counseling in mental settings might take time away from the provision of mental health services.
To reduce barriers to HIV testing in mental health settings, therapists should be provided with training around HIV testing and prevention. Fortunately, the CDC supports technical assistance and training programs. In addition, recent advances have led to the development of rapid HIV testing, which is easy to administer, does not require a venipuncture, can be administered by non-medical personnel, and provides results within 20 minutes, eliminating the need to return for test results.
There are several ethical and legal challenges associated with HIV testing of individuals with a SMI. First, there may be limited benefits if individuals learn they are HIV positive, because some doctors delay the prescription of antiretroviral medication for individuals with a SMI (Fairfield et al., 1999
; Bogart et al., 2000
). This delay in prescribing medication may be due to concerns about interactions among medications, or concerns about HIV-medication adherence (Fairfield et al., 1999
Second, even if HIV-infected individuals are prescribed medication, they may not benefit, because individuals with a mental illness often have difficulty adhering to antiretroviral medication (e.g., Tucker et al., 2003
). Needed are interventions to increase adherence to antiretroviral medications (Simoni et al., 2003
; Uldall et al., 2004
Third, some individuals, because of their mental illness, may not be able to provide informed consent for HIV testing. The laws requiring informed consent for HIV testing for individuals with mental disabilities differ from state to state, and often the need for testing without consent is decided on an individual basis (Haimowitz, 1996
Fourth, the ethical and legal issues associated with testing are complex. Clinicians must balance confidentiality with the duty to warn (particularly if patients are infected and sexually active in an inpatient setting; see Odunsi, 2007
). Such issues require knowledge of state law, and use of clinical judgment (Haimowitz, 1996
In conclusion, individuals with a SMI are at elevated risk for HIV but many have never been tested. Research on testing should include individuals with a SMI, and interventions to promote testing should be evaluated in RCTs. Mental health settings may be opportune venues to test individuals with a SMI for HIV even though clinicians in these settings will face a number of barriers and ethical challenges. These challenges indicate the need for research, continuing professional education, and the commitment of additional resources to this neglected component of comprehensive health care.