Psychiatric Disorders and HIV/Hepatitis Coinfectio
By Jacques Baillargeon, PhD, David P. Paar, MD, and Joseph V. Penn, MD, CCHP
Posted on September 8, 2008 – This article is a synopsis of Baillargeon, Jacques, et al., Psychiatric Disorders, HIV Infection and HIV/Hepatitis Co-infection in the Correctional Setting. AIDS Care 20(2008): 124-129.
Numerous epidemiologic studies have shown that the percentage of U.S. prisoners infected with HIV, hepatitis C virus (HCV), or hepatitis B virus (HBV) is significantly higher than that for the general population. Patients infected with both HIV and hepatitis present a number of challenges to health care providers. Because coinfected patients tend to have a more rapid progression to end-stage liver disease, timely diagnosis and treatment are crucial. Coinfected patients also are more difficult to treat since the complex regimen requiring administration of multiple drugs increases the risk of hepatotoxicity and other serious side effects. These challenges are compounded in the presence of serious mental illness, which—like HIV and hepatitis—has an elevated prevalence in the U.S. prison population. Although several investigators have reported an association between psychiatric disorders and HIV infection in correctional populations, the relationship between serious mental illness and the risk of HIV/hepatitis coinfection has not been studied. Since the vast majority of these individuals will eventually be released into the community, the degree to which correctional health care providers are able to control and manage these infectious diseases has enormous public health implications.
We conducted a study to determine if there was an association between psychiatric disorders and the presence of HIV monoinfection, HIV/HCV coinfection, and HIV/HBV coinfection among the population of one of the nation’s largest prison systems. The study cohort included 370,511 inmates incarcerated in the Texas Department of Criminal Justice (TDCJ) prison system for any duration from January 1, 2003, through July 1, 2006. Using a prison-wide electronic medical record database, the prevalence of six categories of psychiatric disorders (major depressive disorder, dysthymia, bipolar disorders, schizophrenia, schizoaffective disorders and non-schizophrenic psychotic disorders) was compared among inmate cohorts with any of four categories of infectious disease (all HIV infection combined, HIV monoinfection, HIV/HCV coinfection, and HIV/HBV coinfection). Unadjusted prevalence odds ratios and corresponding 95% confidence intervals were generated for each estimate.
Our analyses showed that inmates in all four infectious disease cohorts had an elevated prevalence of all six categories of psychiatric disorders under study when compared to inmates without HIV or HIV/hepatitis coinfection. With the exception of two outcomes (i.e., schizophrenia and schizoaffective disorder) in the HIV/HBV cohort, these associations persisted across all of the disorders under study and were statistically significant even after adjusting for age, gender, and race. Moreover, in comparison to the cohort with HIV only, the inmate cohort with HIV/HCV-coinfection had a statistically significant increased risk of having any psychiatric disorder (odds ratio=1.2, 95% confidence interval=1.1-1.4) after adjusting for demographic characteristics.
Our findings of statistically significant associations between psychiatric disorders and both HIV and hepatitis infections are relevant to both clinicians and public health officials. Because the presence of psychiatric disease is an important obstacle to adherence to treatment regimens for HIV and hepatitis infection, the identification and treatment of mental illness is particularly important. It is plausible that psychiatric disorders such as schizophrenia and bipolar disorder may represent important contributing factors to the high rates of HIV and hepatitis observed in prison populations by way of behavioral factors such as high-risk sexual activity and injection drug use. To elucidate the causal mechanism underlying the high prevalence of psychopathology in prisoners with HIV and hepatitis infection will require future investigations to prospectively assess the temporal association of psychiatric disorders, risk behaviors, and disease transmission in these individuals. Our findings suggest that HIV-infected inmates, particularly those coinfected with HCV, may benefit from targeted interventions that integrate mental health, prevention, and pharmacotherapy adherence programs.
