Since the early years of the HIV epidemic, mental health issues have been prominent. Studies have found that people with mental health issues are vulnerable to behaviours that increase their risk for getting HIV.
Post-exposure prophylaxis (PEP) -- taking anti-HIV medicines for 28 consecutive days after potential exposure to HIV -- is available to help prevent HIV infection among healthcare workers. When PEP is used outside of healthcare settings, such as in cases of sexual exposure, it is sometimes called nPEP (non-occupational PEP).
A team of researchers in Boston has reviewed medical records from a community clinic in that city. The researchers focused on cases where PEP was administered because of potential HIV exposure during consensual intercourse. In reviewing the clinic's medical records (focusing on the years between 1997 and 2013) the researchers found that people who sought PEP had a high rate of mental health issues. The Boston team strongly encourages healthcare providers who prescribe PEP to screen potential patients for mental health issues. Furthermore, the researchers urged PEP prescribers to also provide treatment for mental health issues or at least refer patients to a clinic where they can swiftly receive care for mental health conditions. By treating mental health conditions, PEP providers are likely to improve patients' ability to take PEP and reduce their likelihood of engaging in high-risk behaviour in the future.
All data were collected from adult participants who had tested negative for HIV at or shortly before they sought PEP. All participants requested PEP because of potential sexual exposure to HIV.
The researchers were able to analyse data from 821 participants who sought 1,162 courses of PEP. In other words, some people sought PEP more than once.
The average profile of participants was as follows:
- age -- 33 years
- 96% men, 3% women, less than 1% transgender men and less than 1% transgender women
- major ethno-racial groups were as follows: white -- 72%, Latino -- 11%, black -- 7%, Asian -- 5%
It is striking that researchers found that more than 50% of participants had at least one of the following mental health issues:
- major depression -- 24%
- anxiety -- 22%
- attention deficit hyperactivity disorder -- 8%
- post-traumatic stress disorder -- 3%
- psychotic disorder -- 3%
Furthermore, the researchers stated that "the prevalence of each mental health condition tended to be higher among individuals with substance use disorders than in the overall study ..."
Substance Use and Addiction
Some participants disclosed that they had become addicted to several substances, including alcohol and crystal methamphetamine.
The researchers also found that the simultaneous occurrence of multiple mental health conditions was linked to a statistically increased risk for substance use and exposure to HIV. This finding, they argued, suggests that some factors, such as mental illness, are acting in concert with "risk-taking behaviour" -- intensifying the harmful effects of each factor and amplifying the risk of getting HIV.
Based on their findings, the researchers made several recommendations, as follows:
A need for Comprehensive Interventions
"Comprehensive HIV prevention interventions that address not only sexual risk-taking behaviour but mental health conditions may have the greatest potential to mitigate HIV risk among individuals with co-occurring mental health conditions."
Transitioning to PrEP
In evaluating the sexual milieu of many of the men in the study, the researchers arrived at this conclusion:
"Individuals who seek PEP after engaging in [condomless] receptive anal intercourse should also be considered for pre-exposure prophylaxis [PrEP], particularly if their behavioural patterns suggest recurrent risk, if they remain HIV-uninfected upon completing PEP."
"Prior survey data from this setting demonstrated that patients continued to engage in high-risk behaviour [while taking PEP], emphasizing the importance of combining behavioural and biomedical approaches to patients [who seek] PEP."
The researchers also added that it might be useful for care providers to offer "more intensive behavioural interventions to sexually high-risk patients, including dedicated and more frequent counselling sessions."
The Need for Screening
The researchers also stated: "... it is critical that PEP providers in all settings are trained to screen for mental illness and either begin the indicated treatment while managing PEP with the client, or make prompt referrals upon diagnosis of a treatable [mental health] condition."
A Note on Possible Effectiveness
It is extremely difficult to assess the effectiveness of PEP unless a large, robustly designed clinical trial is undertaken. In the absence of such a trial, a separate analysis was done on the clinic's database to try to estimate the effectiveness of PEP. In taking into account data from 894 PEP users, researchers found that 39 of them (4.4%) subsequently tested positive for HIV within 90 days of receiving their prescription for PEP.
According to the researchers, "The vast majority (89.7%) of [new cases of HIV] were documented at least six months after [participants had initially sought] PEP. The timing of these infections suggests that non-adherence to the initial PEP regimen or PEP failure were not the problem, but rather the MSM had one or more new high-risk exposures [to HIV]."
The report by the Boston researchers underscores future directions that ought to be considered by a wide range of stakeholders, including funders, health policy planners, community clinics, sexual health centres and hospital administrators, as well as doctors, nurses and pharmacists.
Note on Access
PEP is expensive and the monthly cost can range from about $1,000 to $2,000, depending on the regimen chosen. The cost of PEP in cases where HIV exposure has occurred via consensual intercourse is not covered in all regions. Speak to a doctor, nurse or pharmacist to find out more in your region.
A future CATIE News story will discuss the transition from PEP to PrEP in a dedicated HIV prevention clinic in Toronto.
Post-exposure prophylaxis (PEP) -- CATIE fact sheet
Pre-exposure prophylaxis (PrEP) -- CATIE fact sheet
HIV and emotional wellness (CATIE) -- how people with HIV can cultivate their emotional well-being
Canadian Mental Health Association
- Jain S, Oldenburg CE, Mimiaga MJ, et al. High levels of concomitant behavioral health disorders among patients presenting for HIV non-occupational post-exposure prophylaxis at a Boston community health center between 1997 and 2013. AIDS and Behavior. 2015; in press.
- Henderson DK, Gerberding JL. Prophylactic zidovudine after occupational exposure to the human immunodeficiency virus: an interim analysis. Journal of Infectious Diseases. 1989 Aug;160(2):321-7.
- Oldenburg CE, Jain S, Mayer KH, et al. Post-exposure prophylaxis use and recurrent exposure to HIV among men who have sex with men who use crystal methamphetamine. Drug and Alcohol Dependence. 2015 Jan 1;146:75-80.
- Jain S, Oldenburg CE, Mimiaga MJ, et al. Subsequent HIV infection among men who have sex with men who used non-occupational post-exposure prophylaxis at a Boston community health center: 1997-2013. AIDS Patient Care and STDs. 2015 Jan;29(1):20-5.