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Model Shows Promise in Reducing Harm, Risk for HIV and HCV in Dually Diagnosed Clients

Recent clinical trial of the STIRR model indicated increased rates of testing and immunization and increased knowledge of HCV among participants with severe mental illness and co-occurring disorders.

By Stanley D. Rosenberg

HIV/AIDS and viral hepatitis continue to represent major public health concerns, particularly among individuals at high risk of infection due to injection drug use, homelessness, and severe mental illness. Along with risk for HIV and HCV, co-infection is markedly elevated for persons with severe mental illness, further increasing morbidity and mortality. The largest study to date on this population found an HIV prevalence of 3.1%, approximately eight times the overall U.S. rate, and HCV prevalence was 19.6%, approximately eleven times the overall population rate. The majority of clients who tested HIV-positive (59.1%) were co-infected with HCV (Am J Public Health. 2001, 91(1):31-37. Clients dually diagnosed with both mental illness and substance use disorders were at even greater risk. Early detection and treatment is thus crucial for clients with dual disorders.

The Centers for Disease Control and Prevention, the Veterans Administration and the National Institutes of Health all recommend the following key services for people at elevated risk for Hepatitis and HIV/AIDS:  1) screening for risk, 2) testing those at risk, 3) immunization to prevent hepatitis A and B, 4) risk-reduction counseling, and 5) referral and support for medical care. However, the great majority of clients with dual disorders do not receive these recommended services.

STIRR is a rigorously tested model to overcome identified barriers to providing recommended services for HIV and HCV to dually diagnosed clients. This intervention brings infectious disease services to the clients' usual source of care: publicly funded community mental health providers. It includes: screening for HIV and hepatitis C risk factors, testing for HIV and hepatitis C infection, immunization against hepatitis A and B, and reducing risk and referring for medical treatment for those testing positive for HIV and hepatitis C (STIRR). STIRR is delivered by an external team of specialists with the knowledge, skills, and confidence to deliver these core services. It is brief, requiring about one hour of client contact over three sessions. It employs a health-promotion, empowering approach, recruiting clients as partners and agents in improving their own medical well-being.

Results from a randomized clinical trial in Baltimore, Maryland, indicate that STIRR provided screening for about three-fourths of dually diagnosed clients, greatly increased rates of testing and immunization, increased knowledge of HCV, reduced substance abuse, and appeared to achieve high levels of referral to care, with 81% of STIRR clients and all newly diagnosed HCV clients being referred to care.  While sexual and other risk behaviors did not appear to change after the intervention, the increased rates of blood testing and immunization are of tremendous importance for both primary and secondary prevention of hepatitis. The CDC has stated that immunization for HBV is by far the single most important prevention measure. No other intervention strategy to date has been able to achieve such success in real-world community settings. STIRR's association with evidence of reduced problematic alcohol and substance use may be especially important given the dangers of alcohol for liver function. These findings suggest that linking substance use treatment and information with STIRR may increase its impact on clients' decisional balance with respect to drug and alcohol use. STIRR also appears to be a cost-effective model, with the average cost of delivering STIRR running at $541 per client.

Stanley D. Rosenberg, Ph.D., is a professor of Psychiatry and Community and Family Medicine at Dartmouth Medical School. For further information on the clinical trial of STIRR, see Rosenberg, S.D., Goldberg, R., Dixon, L., Wolford, G., Slade, E., Himelhoch, S., Gallucci, G., Potts, W., Tapscott, S, and Welsh, C. Assessing the STIRR Model of Best Practices for Blood-Borne Infections of Clients with Severe Mental Illness. Psych. Services, 61:885-891, 2010.

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