CATIE News

10 July 2018 

Continuing care needed for HIV-positive people after hospitalization for mental health issues

  • Ontario researchers analysed outcomes of patients hospitalized for mental health issues.
  • Study compared HIV-positive and HIV-negative patients 90 days after hospital release.
  • HIV-positive patients were more likely to seek emergency care for substance use.

Studies have found that mental health issues are relatively common among some HIV-positive people. Unrecognized, untreated or poorly managed mental health issues can degrade quality of life, affect patients’ ability to take HIV treatment (ART) and maintain regular doctor and laboratory appointments. Mental health issues need care and monitoring to minimize their negative impact and risk of recurrence.

Scientists at leading research institutes in Ontario collaborated on a study to analyse some outcomes among people (with and without HIV infection) who sought hospitalization because of severe mental health issues. The researchers were interested in what happened to participants after they were discharged from a hospital. The researchers focused on the period between January 1, 2006 and December 31, 2014. During that time, 1,089 people with HIV infection and 280,888 people without HIV infection were hospitalized due to severe mental health issues.

Results—After a hospital discharge

The researchers found that the proportions of participants who died in the first 30 days after leaving a hospital was similar (around 1%) in both HIV-negative and HIV-positive people. In the first 90 days after hospital discharge, there was no increased risk for being readmitted to a hospital or for visits to an emergency department due to psychiatric illness and HIV infection. However, in the same 90-day period, researchers found that HIV-positive people were at increased risk for visits to the emergency department because of substance use disorders. HIV-positive people were also less likely to receive access to mental health care during this period.

Exploring possible reasons

The present study examined overall trends but did not access highly individualized data, such as extensive medical records, or interview healthcare providers and patients. As a result, it could not directly account for the trends it uncovered. However, based on analysis of other studies, the researchers advanced possible explanations for their findings by gender:

Women

  • “Women with substance use disorders report higher levels of stigma and discrimination from health care workers than men, experiences which may be amplified by HIV-related stigma and deter health-seeking and linkage to care following [hospital] discharge.”
  • “Gender-based violence is up to five times more common among women with substance use disorders relative to the general female population, and may be more severe among women with HIV, relative to HIV-negative women. Gender-based violence limits participation in drug treatment services, access to HIV care and [adherence to HIV treatment].”
  • “Harm-reduction and drug treatment services may be less physically accessible to women, particularly those who engage in sex work, which often occurs in locations remote to those services.”

Men

Studies in the United States have also found that HIV-positive men had higher rates of problematic substance use compared to their HIV-negative counterparts. The researchers stated that gay, bisexual and other men who have sex with men (MSM) represent “over 80% of HIV diagnoses among men in Ontario.” They also stated that intimate partner violence occurs among MSM “at rates similar to those of women and has been associated with substance use and hospitalization among HIV-positive gay and bisexual men.” They made the following statement:

  • “It is therefore conceivable that intimate partner violence is an important determinant of post-discharge emergency department use and hospitalization among men with HIV and that associated screening and support be considered a component of post-discharge care for this population.”

Possible interventions

The researchers proposed that health systems “integrate the [medical] management of substance use disorders and HIV.” Such integration should allow for the continuation of care of mental health issues shortly following discharge from a hospital and should help to decrease re-admission to the emergency department for psychiatric help. The researchers also raised the issue of “further integrating trauma-focused interventions addressing gender-based violence and associated post-traumatic stress disorder.”

The researchers also stated that “HIV imparts an additional layer of stigma to that imposed by mental health illness, which may further compromise access to care.” To provide better connections to care, the researchers suggested the following interventions:

  • post-discharge telephone follow-up
  • home visits by nurses and “transition managers” (for people transitioning to care from a hospital to a non-hospital-based setting)

The researchers noted that such interventions have been found to be useful in other settings and should be assessed with HIV-positive people.

Bear in mind

The present study was imperfect; researchers could not collect individual-level data in great detail, as they did not have access to medical charts and did not interview doctors and patients. However, their findings lead to the conclusion that some HIV-positive people are at increased risk of needing to visit the emergency room because of substance use disorder 90 days after having been previously hospitalized for mental health issues. The researchers called for “the implementation and evaluation of interventions which facilitate post-discharge transition to care for all individuals following hospital discharge for psychiatric illness and the integration of HIV, harm reduction, mental health, and trauma-focused services for people with HIV.”

—Sean R. Hosein

REFERENCE:

Lau C, Kendall CE, Burchell AN, et al. Outcomes among persons with HIV following a mental health admission: A population-based study. AIDS Research and Human Retroviruses. 2018; in press.