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AIDS-Related Services and Training in Outpatient Mental Health Care Agencies in New York

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AIDS-Related Services and Training in Outpatient Mental Health Care Agencies in New York
  PSYCHIATRIC SERVICES  ♦ September 1999 Vol.50 No.9 1225 Directors of 471 outpatient men-tal health settings in New YorkState (82.1 percent of 574 settingslocated in counties with interme-diate to high AIDS case rates) com-pleted a survey about HIV andAIDS services, training needs,and barriers to care. Most of thesites served one to ten personswith HIV infection annually andhad staff members who weretrained in providing at least oneHIV-related service. Nonetheless,84 percent of the respondents re-ported unmet needs for training.The likelihood of providing cer-tain services was significantly in-creased in sites that were in urbanlocations, primarily served clientswith comorbid alcohol or otherdrug use disorders, lacked fundsfor providing condoms, had staff members who were trained inHIV and AIDS services, identifiedparticular HIV training needs, be-lieved clients needed condoms,and viewed HIV-related servicesas very important. (  PsychiatricServices 50:1225–1228, 1999) M ental health care providers nowwork with clients affected byHIV and AIDS and manage an arrayof HIV-related problems in theirwork with these clients. In New York City rates of HIV infection amonghospitalized psychiatric patients varyfrom 4 to 23 percent (1). In semirur-al New York State AIDS is a leadingcause of death among young adultswith psychotic illnesses (2); patientswith comorbid alcohol or other druguse disorders have the highest rates.In some cases, HIV infection occursin the course of a long-standing psy-chiatric illness; in others, HIV infec-tion is followed by adjustment diffi-culties, depression, or neuropsychi-atric complications (3). At least 30percent of all people with HIV re-quire mental health services to treatemotional and cognitive sequelae of the infection (4).HIV falls uniquely within thepurview of mental health care pro-viders. It invades the brain early andcan precipitate or alter the appear-ance of mental illness, and it is spreadby unsafe behaviors that mentalhealth care providers often are in thebest position to address, along withlegal and ethical issues such as duty towarn and duty to protect. In fact, HIVstatus now must be considered in as-sessments of a patient’s dangerous-ness. Finally, adherence to complexantiretroviral regimens may dependon support or enhancement of cogni-tive and other skills.Research findings have supportedthe effectiveness of a variety of ser-vices for prevention of HIV transmis-sion and treatment of HIV-related ill-ness. Cognitive-behavioral interven-tions to reduce risk have been shownto be efficacious with psychiatric out-patients (5). The availability of con-doms has been significantly associat-ed with increased condom use (6).Needle exchange and other harm-re-duction programs have been shown toreduce the likelihood of new HIV in-fections (7). Early intervention withcombination antiretroviral agents canprolong life and delay the onset of HIV-related illnesses.Yet we do not know the extent towhich front-line mental health careproviders are prepared to supplythese services. Even detecting infec-tion is problematic—only 38 percentof infections were recognized acrossstudies that addressed this issue (8).Nor do we know whether certainthreshold conditions must be pre-sent—for example, providers’ havingalready treated a number of patientswith AIDS—before services areviewed as necessary. Only one study,carried out in New York in 1994, hasattempted to document HIV andAIDS preparedness in the mental AIDS-Related Services andTraining in Outpatient MentalHealth Care Agencies in New York Kar   en McKinnon, M.A.Fra   nci   ne Cou   rnos, M   .D.R   ichard Herma   n, M   .A   . James Satriano, Ph.D.Ba   rba   ra J. S   ilv   er, Ph.D.Isela Puel   lo    Ms. McKinnon, Dr. Cournos, Mr. Her- man, and  Ms. Puello are affiliated withthe Columbia University College of Physi-cians and Surgeons and the Washington Heights Community Service of the NewYork State Psychiatric Institute, 1051 Riverside Drive, Unit 112, New York, NewYork 10032 (e-mail, kmm49@columbia.edu).  Dr. Satriano is with the ColumbiaUniversity College of Physicians and Sur-geons and the New York State Office of  Mental Health.  Dr. Silver is affiliated with the Center for Mental Health Ser-vices in Rockville, Maryland.  PSYCHIATRIC SERVICES  ♦ September 1999 Vol.50 No.9 12   26 health workforce, but a low responserate of 35 percent limited the gener-alizability of its results (9).We surveyed outpatient mentalhealth care agencies in New York State about their HIV-related ser-vices to describe the specific servicesprovided, the training already ac-quired by on-site staff and unmetneeds for training, and barriers toservice provision. We then developeda prediction model to identify deter-minants of HIV and AIDS serviceprovision, expecting services to varyby regional AIDS case rate, generalpopulation density, the number of known AIDS cases within a treat-ment site, and the proportion of asite’s clients with alcohol or otherdrug use disorders. Methods We selected licensed outpatient men-tal health treatment sites in countieswith intermediate to high rates of AIDS cases to examine typical servicedelivery in settings where the needfor HIV-related services might havealready influenced providers. Coun-ties with intermediate case rates havebetween 47.81 and 308 cases per100,000 population, and those withhigh case rates have between 308.01and 2,029.6 cases per 100,000 popu-lation (10). An initial listing of 609 el-igible sites was obtained from theNew York State Office of MentalHealth’s licensing bureau in 1997.Thirty-five sites (5.7 percent) hadceased operation before they re-ceived the survey, leaving 574 eligiblesites. Directors or their designees of 471 sites, or 82.1 percent of the 574sites, completed and returned thesurvey after up to three written re-minders.The survey comprised 22 items en-compassing several domains. Sitecharacteristics included populationdensity, identified as rural, suburban,or urban; county AIDS case rates; andnumber of clients served per year.Client characteristics included theproportion with alcohol or other druguse disorders and the number withknown HIV or AIDS treated at thesite annually. Data on training needsincluded whether staff members hadprevious training in HIV test counsel-ing or in any other HIV-related ser-vice and whether the site had currentneeds for training in providing partic-ular HIV-related services.Attitudes toward the importance of HIV-related services were also as-sessed. Respondents were asked wheth-er the site provided a range of HIV-related services, including risk assess-ment, risk reduction interventions,HIV-test counseling, antibody test-ing, and condom distribution. Re-spondents were also asked to describespecific barriers to providing HIV-re-lated services.Multiple logistic regression analy-ses were used to identify factors thatincreased the likelihood that HIV andAIDS services were provided. Wefirst conducted chi square tests to ex-amine differences between charac-teristics of sites that provided HIV-re-lated services and identified barriersand those that did not. For chi squaretests with significant results, we cal-culated unadjusted odds ratios; whenthe unadjusted odds ratios were sig-nificant, we calculated adjusted oddsratios to estimate the likelihood of service provision, simultaneouslycontrolling for the effects of all othervariables entered stepwise into theequation. Results Table 1 shows site characteristicsand the distribution of HIV-relatedservices provided. We found no sig-nificant differences between re-sponding and nonresponding sites incounty AIDS case rates. Of the re-sponding sites, 398 sites, or 84.9 per-cent, were located in counties withhigh AIDS case rates, and 71, or 15.1percent, were located in countieswith intermediate AIDS case rates.A total of 284 of the responding sites,or 60.9 percent, were located in ur-ban areas; 128 sites, or 27.5 percent,were located in suburban areas; and54, or 11.6 percent, were located inrural areas. Adjusted odds ratios, 95percent confidence intervals, and pvalues are presented for significantresults.The likelihood of providing educa-tional materials to clients was signifi-cantly increased when staff weretrained in any other HIV-related ser-vice besides HIV test counseling(OR=6.92, CI=2.27 to 21.53, p=.007)and when sites lacked funds for con-doms (OR=5.53, CI=1.56 to 19.60,p=.008).The likelihood of conducting risk assessment was significantly in-creased when staff were trained inany other HIV-related service (OR=2.27, CI=1.09 to 4.74, p=.03) andwhen condoms were viewed as beingneeded by clients (OR=2.46, CI=1.11to 5.42, p=.03). Routine risk assess-ment was significantly more likelywhen staff were trained in any otherHIV-related service (OR=3.17, CI=1.24 to 8.08, p=.02).HIV test counseling was nearlythree times as likely when staff weretrained to deliver this particular ser-vice (OR=2.96, CI=1.11 to 7.86,p=.03), when staff identified a needfor this training (OR=2.52, CI=1.04to 6.08, p=.04), and when HIV-relat-ed services were viewed as very im-portant or essential (OR=10.39, CI=2.66 to 40.62, p<.001). Antibody test-ing on site was more than three timesas likely when staff had training in anyother HIV-related service (OR=3.08,CI=1.20 to 7.89, p=.02).The likelihood of a site conductingrisk-reduction interventions was in-creased by more than fourfold whensites lacked funds for condoms (OR=4.08, CI=1.37 to 12.14, p=.011).The likelihood of providing supportgroups for HIV-positive clients wasincreased by more than 30-fold whensites were in urban areas (OR=30.49,CI=3.96 to 234.91, p=.001), by more    HIV is spread by unsafe behaviors that mental health care providers often are in the best position to address.  PSYCHIATRIC SERVICES  ♦ September 1999 Vol.50 No.9 1227 than tenfold when the majority of clients had comorbid alcohol or otherdrug use disorders (OR=10.18, CI=1.96 to 53.00, p=.006), and by morethan 20-fold when sites identified aneed for staff training in risk inter-viewing (OR=23.64, CI=4.04 to138.52, p<.001).Condom distribution was not sig-nificantly predicted by any of the fac-tors we measured, but the likelihoodthat condoms were distributed anon-ymously was significantly increased,when the majority of clients had alco-hol and other drug use disorders(OR=6.82, CI=1.34 to 6.80, p=.009)and when the need for risk-reductiontraining was identified (OR=3.08,CI=1.44 to 6.58, p=.004).Contrary to our expectations, coun-ty AIDS case rate, annual numbers of clients served, and known HIV andAIDS cases did not predict provisionof HIV-related services. Discussion and conclusions This survey represents one of the firstattempts to describe the response of the outpatient mental health care sys-tem to the AIDS epidemic and toidentify predictors of service provi-sion. We found that 85 percent of sites had identified HIV-positive cli-ents and that 70 percent viewed pro-viding HIV-related services as veryimportant or essential. When boththese conditions were met, 75 per-cent of the sites were providing ser-vices beyond dispensing information.Having received HIV training, identi-fying unmet training needs, and view-ing HIV-related services as very im-portant each contributed to particularaspects of service provision.Making educational materials avail-able to clients was the HIV and AIDSservice most often provided. Suchmaterials are easily disseminated andoften are free of charge. However,studies show that knowledge aboutHIV infection alone has little impacton enacting safer behaviors (6).Lacking funds for condoms result-ed in an increased likelihood that ed-ucational materials and risk-reduc-tion interventions were provided toclients, suggesting that a greater ef-fort to reach clients may result fromboth increasing staff readiness andhaving little recourse to provide con-   Table 1 Characteristics of 471 outpatient mental health care sites in New York State thatparticipated in a survey about HIV and AIDS services CharacteristicN of sites 1 %Total N of clients served per yearOne to 50357.651 to 1005010.8101 to 2009620.7201 to 50012025.9More than 50016235.0Percentage of clients with identified alcohol or other drug use disordersNone81.7One to 2519742.126 to 5012827.451 to 757716.576 to 1005812.4Number of clients known to have HIV or AIDS served annuallyNone7015.2One to 1024352.711 to 509220.051 to 100214.6More than 100357.6Services provided by siteHIV educational material32068.7HIV risk-reduction interventions24553.6HIV risk assessment22248.4HIV test counseling12527.2Support groups for HIV-positive clients8819.2HIV risk assessment is part of routine intake procedureYes14230.4No15232.5Only if client reveals HIV risk behavior17337.0HIV testing of clients who reveal HIV risk behavior on intakeTesting done on site5712.3Client referred to external test site18940.9Client referred to hospital or medical clinic12827.7No procedure in place8819.0Procedures for distribution of condomsNot distributed27358.8Clinician distributes13328.7Anonymous distribution5712.3From a vending machine1.2Primary barrier to condom distributionNo need11934.4Lack of funds to purchase them11031.8Policy due to religious affiliation3510.1Other policy8223.7Previous staff trainingPre- and posttest HIV counseling24953.8Other HIV-related services24654.3Areas in which staff need trainingNeuropsychiatric aspects of HIV and AIDS33473.7Legal, ethical, and policy issues33272.5Providing interventions for HIV risk reduction27061.1HIV risk interviewing25757.2HIV test counseling23252.0Opinion about importance of HIV-related services for clientsEssential18539.8Very important14130.3Somewhat important12126.1Not very important153.2Unimportant3.6 1 Total Ns vary due to missing information.  PSYCHIATRIC SERVICES  ♦ September 1999 Vol.50 No.9 12   28 crete protection to clients in the formof condoms. Respondents at morethan one-third of the sites believedthere was no need to distribute con-doms to clients. Nonetheless, risk-re-duction interventions are unlikely tobe effective if clients lack access tocondoms, which are the most effec-tive sexual risk-reduction tool. Manyoutpatients cannot afford to purchasethem.Among the sites that provided con-doms, the likelihood that they weredistributed anonymously was signifi-cantly increased when a majority of the clients had alcohol or other druguse disorders and when a site identi-fied the need for training in risk-re-duction strategies. Anonymous con-dom distribution may be more likelyto result in clients’ having access tocondoms than if they have to fill aprescription, ask clinicians, or pur-chase them.HIV test counseling was predictedby staff’s having received training toconduct it. We did not obtain enoughdetailed information to allow us toexamine specificity effects on otherservices provided. Test counselingalso was predicted by holding theview that HIV-related services arevery important. This attitudinal mea-sure did not predict provision of anyother service; it is possible that onceproviders perceive a need for anyHIV services among their clients,they first turn to New York’s widelyavailable free training programs thatlead to certification as an HIV-testcounselor.The factor that predicted provisionof the greatest number of HIV-relat-ed services was training. Providerswho seek training may have greatermotivation to offer services, buttraining also may increase motivationto provide services. Training in-creased the likelihood that risk as-sessment was done routinely. At siteswhere risk assessment was not rou-tine, it was likely to be done only onthe basis of clinicians’ suspicion of risk, which may be highly subject toerror, or after risk behavior becameknown to staff in some other fashionand perhaps too late for the patientto benefit from primary preventioninterventions. In addition to encour-aging routine risk assessment, train-   ing can increase the expertise withwhich a specific service is delivered.Just under one-third of sites pro-vided on-site HIV antibody testing.The presence of this service removesa potential barrier to clients’ follow-ing through with referral to off-sitetesting, which usually requires traveland negotiation of a new system butmay be preferred by clients with con-fidentiality concerns.Contrary to our expectations, theonly demographic predictor of ser-vice provision was urban setting.Even after controlling for AIDS caserate and number of known cases at asite, urban sites were more than 30times as likely as suburban or ruralsites to provide support groups forHIV-positive clients. Having a major-ity of clients with comorbid alcoholor other drug use disorders increasedthe likelihood of having an HIV-posi-tive client support group.We relied on program directors ortheir designees to complete the sur-vey questionnaire and did not assesstheir motivation to do so or validatethe accuracy of their knowledge aboutHIV and AIDS services within theirsites. Programs with staff alreadycommitted to providing HIV-relatedservices may have been more likely tocomplete and return the survey, al-though our high return rate (82.1 per-cent) and the lack of a significant dif-ference in regional AIDS case ratesbetween respondents and nonrespon-dents would reduce the likelihood of this response bias. To increase thecompletion rate, we asked only a lim-ited number and range of questions.Other HIV-related programming—for example, linkages to medicalcare—may have been in place or indevelopment at these agencies. Fu-ture studies that examine the contentof services as well as their impact onclients are needed in New York andother AIDS-endemic areas. ♦  Acknowledgments This study was partly supported by theNew York State Office of Mental Healthand contract 96-MO-2453801D from theCenter for Mental Health Services. Theauthors thank Jeannine R. Guido, M.A.,for conducting part of the data analysis.  References 1.Cournos F, McKinnon K: HIV seropreva-lence among people with severe mental ill-ness in the United States: a critical review.Clinical Psychology Review 17:259–269,19972.Susser E, Colson P, Jandorf L, et al: HIV in-fection among young adults with psychoticdisorders. American Journal of Psychiatry154:864–866, 19973.McKinnon K, Cournos F: HIV and seriousmental illness, in Sexuality and SeriousMental Illness. Edited by Buckley PF. Am-sterdam, Harwood Academic, 19994.Lee HK, Traven S, Bluestone H: HIV-1 ininpatients. Hospital and Community Psy-chiatry 43:181–182, 19955.Kelly JA: HIV risk reduction interventionsfor persons with severe mental illness. Clin-ical Psychology Review 17:293–309, 19976.Guttmacher S, Lieberman L, Ward D, et al:Condom availability in New York City pub-lic high schools: relationships to condomuse and sexual behavior. American Journalof Public Health 87:1427–1433, 19977.Interventions to Prevent HIV Risk Behav-iors. NIH Consensus Statement 15. Wash-ington, DC, National Institutes of Health,19978.Cournos F: Epidemiology of HIV, in AIDSand People With Severe Mental Illness: AHandbook for Mental Health Profession-als. Edited by Cournos F, Bakalar N. NewHaven, Conn, Yale University Press, 19969.Satriano J, Rothschild RR, Steiner J, et al:HIV service provision and training needs inoutpatient mental health settings. Psychi-atric Quarterly 70:73–84, 199910.AIDS Surveillance Quarterly Update, Al-bany, New York State Department of Health, Bureau of HIV/AIDS, 1997 C   ha   nge of A   ddress Authors of papers under peer review or being preparedfor publication in Psychiatric Services are reminded tonotify the editorial office of any changes in address.Please call the editorial office at 202-682-6070, or sendupdated information by fax to 202-682-6189 or by e-mail to psjournal@psych.org.
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