Substance abuse and mental health care. Managed care, access, and clinical outcomes

1. Mental health and substance abuse problems are rapidly growing components of health care premiums and associated costs. 2. Managed care has become as integral factor in the delivery of these services. This trend has elicited concerns about the negative impact of managed care on service access and clinical outcomes. 3. Some managed care designs may actually discourage participation in treatment programs as well as reduce options available to clients. The treatment arena is also shifting from inpatient to outpatient care for most cases. 4. Studies demonstrate the financial efficacy of managed care. However, insufficient data exist about effects on clinical outcomes. 5. The addition of an employee assistance program to the managed care process improves access and may positively affect clinical and financial outcomes.

Fatalism, current life satisfaction, and risk for HIV infection among gay and bisexual men

This study surveyed 430 men at an urban gay pride celebration to assess fatalism, current life satisfaction, and perceived expected years of life among men who have sex with men. Analyses showed that men who engaged in unprotected anal intercourse outside of exclusive relationships reported a greater fatalistic outlook, were more dissatisfied with life, and perceived a shorter life for themselves than men who practiced only safer sex and men who were in exclusive relationships. Gay men in exclusive relationships scored higher than nonexclusively partnered gay men on the measure of current life satisfaction. These results suggest that efforts to prevent HIV infection among gay men should include building personal self-worth, support of long-term relationships, and future goal orientations.

Continued high-risk sex among HIV seropositive gay and bisexual men seeking HIV prevention services

The authors examined HIV risk-related sexual behaviors in an ethnically diverse sample of HIV seropositive gay and bisexual men (N = 86). Measures of sexual behavior, substance use, condom attitudes, behavior change intentions, and engagement in risk-reducing practices were completed. Thirty-nine percent of the men reported engaging in unprotected anal intercourse in the past 3 months. Unprotected anal intercourse was associated with using nitrite inhalants, sex partners who used substances before sex, and low intentions to change risk behavior. These results highlight the difficulties that people living with HIV infection face in maintaining a lifetime of safer sex and the necessity of integrating clinical and prevention interventions for these persons.

Women living with HIV/AIDS: the dual challenge of being a patient and caregiver

More than 60,000 women in the United States have been diagnosed with AIDS, and millions of women worldwide are infected with HIV. Most of these women will die at an early age, leaving their children motherless. During their HIV illness, women confront the challenge of being both patient and family caregiver. Little research has explored this dual challenge. The authors conducted semistructured one-hour interviews with HIV-positive women that focused on the impact of the HIV diagnosis on the women's lives. Significant factors emerging from the interviews included the impact of stigma associated with HIV/AIDS, disbelief of the diagnosis, the lack of a guardian for their children, the paucity of women's support groups, and barriers associated with seeking services. All women exhibited evidence of clinical depression. A model for multidisciplinary intervention is proposed that focuses on women's needs within their family systems.

Active learning: its role in health sciences libraries

Active learning is a method of instruction which involves the students/attendees in the learning process by having them participate and reflect on that experience. It is a process which has received much publicity in the educational literature and is being incorporated in many fields within the health sciences. Health sciences librarians are beginning to incorporate active learning into instruction sessions, and a number of techniques being used in other settings could also be adopted. Examples are offered for using active learning in teaching the use of indexes, end-user database searching, Internet navigation, and problem-based learning.

HIV risk reduction interventions for persons with severe mental illness

Recent seroprevalence studies have shown alarming rates of HIV infection among severely mentally ill men and women in large urban areas, and HIV behavioral epidemiology research indicates that a substantial proportion of seriously mentally ill adults engage in activities that increase their vulnerability to HIV/AIDS. In this paper, the research literature on HIV prevention interventions is reviewed including reports that have described HIV prevention programs, studies that have used uncontrolled pre- and postintervention methods to evaluate risk reduction interventions, and those that have used rigorous randomized designs and examined risk behavior change. Collectively, these studies show that intensive, small-group interventions that target a variety of risk-related dimensions-including knowledge, attitudes, and motivations, and behavioral and cognitive skills-can produce at least short-term reductions in high-risk sexual behavior among the severely mentally ill. A number of gaps in the research literature are identified including the need to: (a) better tailor interventions to risk situations encountered by the mentally ill; (b) develop gender-tailored interventions; (c) examine and implement HIV prevention programs so they help persons sustain behavior change; (d) explore one-on-one counseling and community-level intervention methods; and (e) develop risk reduction interventions for already-seropositive individuals. Implications for service provision are discussed.

Preventing HIV/AIDS among high-risk urban women: the cost-effectiveness of a behavioral group intervention

OBJECTIVES

A human immunodeficiency virus (HIV) intervention trial for women at high risk for acquired immunodeficiency syndrome and attending an urban clinic was reported previously. The behavioral group intervention was shown to increase condom use behaviors significantly. This study retrospectively assessed the intervention's cost-effectiveness.

METHODS

Standard methods of cost and cost-utility analysis were used.

RESULTS

The intervention cost was just over $2000 for each quality-adjusted life-year saved; this is favorable compared with other life-saving programs. However, the results are sensitive to changes in some model assumptions.

CONCLUSIONS

Under most scenarios, the HIV prevention intervention was cost-effective.

Predictors of condom use and human immunodeficiency virus test seeking among women living in inner-city public housing developments

BACKGROUND AND OBJECTIVES

To examine prevalence and predictors of condom use and human immunodeficiency virus (HIV) test seeking among women living in inner-city housing developments.

STUDY DESIGN

Between April and June 1994, 671 women living in low-income housing developments in five cities in the United States completed an anonymous self-report questionnaire eliciting information on acquired immune deficiency syndrome (AIDS) risk behavior and characteristics indicative of risk.

RESULTS

Most participants were women of color who were economically disadvantaged. Fifteen percent reported multiple sex partners, and 30% of women with one sex partner believed he had sex with someone else in the past year. Predictors of condom use included increased rates of safe-sex negotiation, stronger risk reduction intentions, absence of condom barrier beliefs, and multiple sex partners. Women tested for HIV in the past year were younger, perceived themselves to be at risk for HIV infection, reported more conversations with other women about AIDS concerns, and had condoms readily available.

CONCLUSIONS

HIV public health prevention interventions are urgently needed for women who live in low-income urban housing developments.

HIV risk behaviors among women living in low-income, inner-city housing developments

OBJECTIVES

This study describes the prevalence and predictors of human immunodeficiency virus (HIV) risk behaviors among women living in low-income, inner-city housing developments.

METHODS

Anonymous questionnaires were administered to 671 women living in 10 inner-city, low-income housing developments in five US cities to determine their levels of HIV risk behavior and predictors of HIV risk practices.

RESULTS

Approximately one third of women were at high risk for HIV because of the risk behavior of their sexual partners. HIV risk was highest among women who accurately perceived themselves to be at increased HIV risk, held strong beliefs about barriers to condom use, and reported weak behavioral intentions to reduce risk. Women at higher risk were also younger and reported higher rates of alcohol and substance use.

CONCLUSIONS

HIV prevention efforts are needed for inner-city women. Interventions should focus on overcoming women's barriers to condom use, strengthening their intentions to change behaviors, and managing the risk related to their use of substances.

Sensation seeking as an explanation for the association between substance use and HIV-related risky sexual behavior

Past research has shown that recreational drug use correlates with sexual behaviors that confer high risk for human immunodeficiency virus (HIV) infection. The present study tested the hypothesis that sensation seeking, a disposition characterized by the tendency to pursue novel, exciting, and optimal levels of arousal, accounts for a majority of the variance in associations between substance use and high-risk sexual behavior. Ninety-nine homosexually active men completed measures of sensation seeking, self-reported sexual behavior, and substance use. Path analysis and hierarchical regression analyses demonstrated that sensation seeking accounts for the observed relationship between substance use and high-risk sexual behavior. We conclude that personality characteristics, often ignored in high-risk sexual episodes, predict risk behavior over and above substance use, and may be useful in tailoring HIV prevention interventions.

Reconciliation of the X-ray and NMR structures of the thrombin-binding aptamer d(GGTTGGTGTGGTTGG)

The thrombin-binding aptamer d(GGTTGGTGTGGTTGG) is one of a family of DNA oligonucleotides that were identified by in vitro selection to bind specifically and with high affinity to thrombin. Two groups independently determined the tertiary structure in solution by NMR and at about the same time, the X-ray crystal structure of the aptamer in complex with thrombin was reported. In all cases, the thrombin-binding aptamer was found to fold into a structure containing two planar guanine quartets as its core. The NMR and crystal structures, however, have fundamentally different folding patterns owing to differences in the way these central bases are connected. We discuss the distinctions between the refined crystal and solution structures and show that the NMR model is consistent with the X-ray diffraction data.

Reducing barriers to care and improving quality of life for rural persons with HIV

Rural persons living with HIV disease is a patient group rapidly increasing in size and one that will present America's health-care system with daunting challenges. As the HIV epidemic increasingly affects rural America, it is clear there are many significant barriers to providing adequate care for persons with HIV and AIDS in these smaller communities. The study surveyed 57 attendees of the National Rural AIDS Conference held in early 1995, St. Cloud, MN, to assist in the identification of barriers to care and to examine strategies that may improve their quality of life. Health care professionals were more likely to believe the following circumstances made living with HIV/AIDS in a rural community difficult: long distances to medical facilities and personnel, lack of employment opportunities and unsupportive work environments, and a shortage of psychologists, social workers, and mental health counselors. Health care and nonhealth care personnel also showed high levels of agreement regarding ways to improve the quality of life among rural persons with AIDS. Quality of life strategies rated as most promising included ensuring that instrumental support and daily assistance is readily available, teaching HIV-affected persons coping and problem-solving skills, and conducting weekly face-to-face support groups for persons living with HIV/AIDS. These findings provide useful information for strategies to improve the life circumstances of persons living with HIV/AIDS in rural areas.

Lesbian and bisexual women in small cities--at risk for HIV? HIV Prevention Community Collaborative

Objectives.Women who have sex with women are a relatively hidden group that has been overlooked in most AIDS research and prevention efforts, primarily because the efficiency of HIV transmission between female partners is believed to be low. Although data are scant, it is commonly assumed that members of this population are not at high risk for HIV infection. However, a recent study of lesbian and bisexual women living in the San Francisco Bay area reported a relatively high seroprevalence rate and has raised additional questions about this group's HIV risk. The present study, the first to focus on lesbian and bisexual women living outside major AIDS epicenters, provides additional evidence. It describes risk factors for HIV transmission among lesbian and bisexual women living in small cities in four geographic regions of the United States.Methods.On three consecutive evenings in 1992, members of the research team distributed anonymous structured written surveys to women patrons as they entered gay bars in each of 16 small cities.Results.Almost 17% of bisexual respondents and 0.5% of lesbians reported having had unprotected vaginal or anal sex with a male during the two months prior to the survey. Almost 10 percent of bisexual women and 8.8% of lesbians in the sample reported a history of injection drug use. Among those women surveyed who said they had been tested, 1.4% reported they were infected with HIV.Conclusions.Self-identified sexual orientation was highly consistent with recent sexual behavior. HIV risk related to sexual behavior was concentrated among self-identified bisexual women. The prevalence of injection drug use was substantial among both bisexual and lesbians. Developers of HIV risk behavior programs should take the prevalence of these risk behaviors into consideration in the design of effective HIV prevention interventions tailored to the needs of this hidden population.

Increased attention to human sexuality can improve HIV-AIDS prevention efforts: key research issues and directions

Curtailing the human immunodeficiency virus (HIV) epidemic requires the development of effective strategies for helping people reduce high-risk sexual behavior patterns. Because the objective of HIV prevention involves changing how people behave sexually, research findings in human sexuality are extremely pertinent to efforts to promote AIDS risk reduction. Unfortunately, most public health HIV prevention programs rarely reflect findings of human sexuality research. In this article, research is reviewed in the areas of the relationship contexts of sexuality, including variations in monogamy, condom use in affectionate versus casual relationships, sexual communication, and coercion; the modification of sexual behavior repertoires; substance use in relation to sexual intercourse; and sexual schema and scripts relevant to HIV risk. Policy and training issues related to human sexuality may have hindered efforts to incorporate sexuality research findings in HIV prevention programs. Advances and refinements in the success of HIV prevention efforts are likely if research on human sexuality is better integrated in AIDS prevention programs.

Differences in HIV risk characteristics between bisexual and exclusively gay men

Research investigating HIV-risk sexual behaviors of men who have sex with men usually combines gay and bisexual men, treating them as a single, homogeneous group. However, gay and bisexual men may differ in their HIV risk behavior and in psychological characteristics indicative of risk. Exclusively gay (N = 1,180) and bisexual men (N = 136) completed anonymous surveys at gay bars. The surveys assessed demographic, psychological, and behavioral data related to sexual behavior and HIV risk. Relative to exclusively gay men, bisexual men had lower intentions to use condoms in their next intercourse occasion, reported a greater frequency of oral sex with men and more oral-sex partners, knew fewer people who were HIV positive, and perceived weaker peer norms favoring safer sex and risk avoidance. One-third of bisexual men reported engaging in unprotected anal intercourse, and 17% of bisexual men had multiple unprotected anal sex partners in the past two months. Interventions tailored to the needs of bisexual men are urgently needed and should focus on increasing intentions to use condoms, increasing HIV-risk sensitization, and fostering norms favoring safer sex and risk avoidance.

The refined crystallographic structure of a DD-peptidase penicillin-target enzyme at 1.6 A resolution

The D-alanyl-D-alanine peptidase from Streptomyces sp. R61 is a 37,500 dalton exocellular enzyme that has served as a model for membrane-bound peptidases that are involved in bacterial cell wall biosynthesis. Inhibition of these enzymes by beta-lactam antibiotics ultimately leads to bacterial cell death. The X-ray crystal structure of the R61 D-alanyl-D-alanine peptidase has been solved using multiple isomorphous replacement, simulated annealing and least squares refinement. The space group and unit cell parameters are P2(1)2(1)2(1) with a = 51.1 A, b = 67.3 A and c = 102.4 A. The structure has been refined using 2 sigma data to 1.6 A resolution with a crystallographic R-factor of 0.148. The model contains 347 residues (2938 atoms) and 254 solvent molecules. The overall temperature factor is 9.6 A2, and the estimated coordinate error is 0.14 A. The protein consists of a single polypeptide chain organized into two regions. One region contains a nine-stranded antiparallel beta-sheet with helices on both faces; this region includes both the amino and carboxyl termini. The second region is all helical. Sixty percent of the residues occur in helices or beta-sheet. The reactive Ser62 is found between the two regions of the enzyme at the amino end of the protein's longest-helix which begins with one turn of 3(10) helix and continues with four turns of alpha-helix. The active site is an elongated pocket that contains four basic and four aromatic residues. An oxyanion hole is formed by Ser62 NH and Thr301 NH. The pocket also contains the few key residues that are conserved in all penicillin-binding proteins and beta-lactamases. Two of these residues, Lys65 and Tyr159, are among the 16 side-chains that take on multiple conformations in the R61 crystal structure. Three of the 12 proline rings adopt two conformations which we believe has not been previously reported. There is no anionic acid equivalent to the catalytic Glu166 found in Class A beta-lactamases. Two ordered water molecules (O507 and O644) are found buried in the active site and hydrogen-bonded to each other (2.6 A). O507 could potentially act as the hydrolytic water molecule for deacylation.

Multiple partners, risky partners and HIV risk among low-income urban women

A sample of 671 predominantly single, young black women living in 10 low-income housing developments in five cities completed an anonymous questionnaire assessing factors related to their risk of contracting the human immunodeficiency virus, including their sexual behavior and condom use, and their partners' risk-related behaviors. In the two months before the 1994 survey, 17% of the women had sex with multiple partners and 22% had an exclusive partner who either had had other sexual partners in the past year or had a history of injection drug use; 40% had an exclusive partner who they believed had not engaged in these risky behaviors. During the same interval, 26% of women who had multiple partners received treatment for a sexually transmitted disease, compared with 9-11% of those who had an exclusive relationship. Condom use at last intercourse and communications about condom use were less frequent among women with an exclusive, risky partner than among those with multiple partners; attitudinal barriers to condom use did not vary, however, by the characteristics of women's relationships.

Psychosocial differences between recently HIV tested and non-tested gay men who reside in smaller US cities

While a number of studies have examined behavioural and psychosocial correlates of HIV test seeking, most of this research has relied on samples of urban gay men. Less is known about HIV testing rates and factors associated with testing among gay and bisexual men who live in smaller cities. The present research administered surveys to 3969 non-exclusively partnered gay and bisexual men attending gay bars in small American cities to determine (a) rates of HIV test seeking, and (b) how tested and non-tested men differed on a battery of psychosocial indices. A total of 68% of men had been tested for antibodies to HIV--50% in the past year. Men tested for HIV in the past year, compared to men never tested for HIV, knew more people who were HIV positive or were diagnosed with AIDS, had a closer relationship with someone who had died of AIDS, were more likely to be ethnic minorities, reported more conversations with friends about safer sex, and had stronger intentions to use condoms during their next intercourse occasion. Our results indicate that HIV counselling and testing programmes comprise an important component of HIV prevention efforts assisting gay men residing in smaller USA cities.

HIV antibody testing of gay men in smaller US cities

The incidence of new AIDS diagnoses among gay males indicates that risk reduction in smaller communities may be lagging behind that reported in larger cities. Contradictory evidence exists, largely from urban areas, concerning the utility of HIV testing as a means of promoting behavioural change. This study examined the relationship between HIV antibody testing and subsequent high-risk sexual behaviours among gay men in cities of 180,000 or fewer inhabitants. In February and March of 1992, male gay bar patrons in sixteen small US cities were administered an anonymous questionnaire concerning recent sexual behaviour and HIV testing history. Of the 1820 respondents, 28.1% had recently engaged in unprotected anal intercourse and 60.7% had been tested for HIV antibodies. Those who had been tested were more sexually active and reported more protected and safer sexual activities. Analyses at the individual and city levels converged to demonstrate that communities as well as individuals evidence increased self-protection in association with HIV antibody testing.

Group intervention to improve coping with AIDS-related bereavement: model development and an illustrative clinical example

Despite the widespread losses from AIDS, there have been no published evaluations of mental health interventions for people experiencing AIDS-related bereavement. We describe a cognitive behavioural coping model for support group interventions with people who experience an AIDS-related loss. The support group model consists of six primary components to address grief-related responses and the unique features of AIDS bereavement: social support and group cohesion; identification and expression of emotion; identification of AIDS loss specific coping challenges; recognition of current coping; goal setting; and, implementation of adaptive coping to reduce psychological distress. The model integrates theories of cognitive behavioural coping within a social support group context. Results of a pilot study with four men and four women showed that the intervention model cast into eight group sessions significantly reduced depression, intrusive experiences, grief reactions, demoralization, and overall psychological distress immediately following the intervention and at a 3-month follow-up assessment. The intervention appeared to facilitate the adjustment of these bereaved persons and warrants further study.

The aging semantic differential: a confirmatory factor analysis

The Aging Semantic Differential (ASD), which is used to measure attitudes and quantify bias and negative stereotypes toward older people, is a 32-item scale published more than 20 years ago (Rosencranz & McNevin, 1969). Several factor analytic studies failed to replicate the original three-factor structure. Confirmatory factor analyses (CFA) using 100 third-year medical students compared six-factor models derived from the gerontological literature. A modified version of Holtzman, Beck, and Kerber's (1979) four-factor model proved to be the "best" comparative fit based upon a consensus of fit indices.

Predictors of high and low levels of HIV risk behavior among adults with chronic mental illness

OBJECTIVE

Several recent studies confirm elevated rates of human immunodeficiency virus infection among acute and chronic mentally ill adults in large urban areas. This research sought to characterize risk for HIV infection among adults with chronic mental illness and to examine psychosocial factors predictive of risk.

METHODS

Two hundred and twenty-five adults with chronic mental illness who were sexually active in the past year outside of exclusive relationships were individually interviewed in community mental health clinics using a structured HIV risk assessment protocol.

RESULTS

More than 50 percent of the study participants were sexually active in the past month, and 25 percent had multiple sexual partners during that period. Fifteen percent of the men had male sexual partners. In more than 75 percent of occasions of sexual intercourse, condoms were not used. When participants were categorized as at either high or lower risk for HIV infection based on their pattern of condom use, psychosocial factors that predicted risk level included measures of participants' self-reported efficacy in using condoms, perceptions of social norms related to safer sex among peers and sexual partners, and expectations about outcomes associated with condom use, as well as participants' level of objectively assessed behavioral skills in negotiation and assertiveness in sexual situations.

CONCLUSIONS

Interventions aimed at prevention of HIV and AIDS are urgently needed in settings that provide services to persons with chronic mental illness.