PrEP Benefits Outweigh Risks in Community Mental Health

Individuals with serious mental illness (SMI; eg, schizophrenia, bipolar disorder) have a greater risk of acquiring HIV compared with the general population and could therefore benefit from preexposure prophylaxis (PrEP) services in the community setting, according to a viewpoint published in Lancet HIV.

Their higher risk is the result of the interaction of several factors, the authors noted, such as sexual behaviors, injection drug use, social determinants, and limited access to preventive health services from structural discrimination. An estimated 6% of persons with SMI live with HIV, which is 10-fold higher vs the general population, the authors pointed out.

According to the CDC, PrEP is close to 99% effective if taken as prescribed. And as part of the Ending the HIV Epidemic plan, PrEP education is encouraged. However, following its approval by the FDA in 2012, PrEP uptake and use remains at suboptimal levels. Of those targeted for PrEP, just one-fifth overall are prescribed the preventive medication, and in New York alone, “only about 20% of mental health clinics serving people with serious mental illness prescribe PrEP.” In addition, many primary care physicians bemoan their lack of up-to-date knowledge on PrEP.

“We seek to show the importance of prioritising access to PrEP for people living with serious mental illness treated in community mental health settings,” the authors stated. “We also address the concerns that community mental health clinic administrators might have about taking on the responsibility of offering PrEP.”

Instead of serving as an addendum to services offered in the HIV care space, PrEP should readily be accessible to HIV-negative individuals. The authors emphasized that for this to happen, PrEP should be a routine part of both preventive care and primary care and that its importance to psychiatry should not be discounted, “considering the high burden of HIV among populations with serious mental illness treated in community mental health settings.”

Among the evidence on risky behaviors that they presented, 45% of individuals with SMI never used condoms, 43% had multiple partners, 65% shared injection equipment, and 32% had a history of a sexually transmitted disease.

The authors noted that there is a current lack of evidence on PrEP adherence among individuals with SMI. However, they presented evidence from previous studies showing higher rates of adherence and therapy continuation, respectively, among persons living with HIV and taking antiretroviral therapy (ART) who receive psychiatric care or who have more than 6 visits in 1 year to a mental health clinic. In addition, they noted that “47% of individuals who inject drugs are interested in taking PrEP.”

Another benefit of providing PrEP services in community mental health settings is to promote health equity, and for this the authors cited that many mental health care providers already include patients’ sexual and drug histories in their care armamentaria, as well that community mental health services are accessed more frequently by persons with SMI compared with primary care.

To make integration altogether easier, the authors noted that several barriers must first be addressed. These are providers’ attitudes and knowledge gaps about PrEP, patients’ attitudes and knowledge gaps about PrEP, and systemic gaps, specifically reimbursement of HIV counseling and preventive services. Truvada (emtricitabine/tenofovir disoproxil fumarate) and Descovy (emtricitabine/tenofovir alafenamide) both average $2000 for a 30-day supply.

The 5 steps they believe are key to PrEP delivery by community mental health providers are:

1. Candidate identification
2. Education
3. Laboratory test initiation (ie, for HIV, creatinine, hepatitis B, sexually transmitted infections), follow-up, and monitoring
4. Prescribing PrEP for HIV-negative individuals
5. Adherence support

Even with these steps, they recommended ongoing efficacy and effectiveness evaluations of any programs created and implemented to promote PrEP use, “to clarify the best ways forward.”

“We believe a unique opportunity exists for community mental health settings to help address the HIV epidemic by facilitating the prescribing of PrEP to the at-risk populations they serve: people with serious mental illness,” the authors concluded. “Although the need to integrate PrEP into these clinics is clear, incorporating PrEP delivery into our public mental health-care system will require leadership buy-in and support for behavioural health providers.”

Reference

Sudler A, Cournos F, Arnold E, et al. The case for prescribing PrEP in community mental health settings. Lancet HIV. Published online January 22, 2021. doi:10.1016/S2352-3018(20)30273-3