Efficacy and cost-effectiveness of the first generation of HIV prevention interventions for people with severe and persistent mental illness.
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.


OBJECTIVE
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.


CONCLUSIONS
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.


CONCLUSIONS
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.


CONCLUSIONS
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.


CONCLUSIONS
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.
Johnson-Masotti
Ana P
AP
McMaster University, 105 Main Street East, P1., Hamilton, ON L8N 1G6, Canada. johnmas@mcmaster.ca
Weinhardt
Lance S
LS
Pinkerton
Steven D
SD
Otto-Salaj
Laura L
LL
D000163:Acquired Immunodeficiency Syndrome / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control; D000328:Adult; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000191:economics* / Q000592:standards; D028642:Persons with Psychiatric Disorders / Q000523:psychology*; D011314:Preventive Health Services / Q000191:economics* / Q000592:standards; D015397:Program Evaluation; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D012309:Risk-Taking; D012725:Sexual Behavior / Q000523:psychology*; D016896:Treatment Outcome