Nursing Intervention for HIV Regimen Adherence among Serious Mental Illness

描述（由申请人提供）：患有严重精神疾病（SMI）的人感染艾滋病毒/艾滋病的风险增加。在费城，重度精神分裂症患者感染艾滋病毒/艾滋病的相对风险至少是普通医疗补助人群的5倍，我们估计高达7%的重度精神分裂症患者也是艾滋病毒血清阳性。重度精神分裂症患者报告更多的通过异性性接触和注射毒品（IDU）传播，与一般人群相比，重度精神分裂症女性与男男性行为者（MSM）发生的性行为更多。一项成本研究表明，感染艾滋病毒的重度精神残疾者的医疗费用远高于感染艾滋病毒的非重度精神残疾者和感染艾滋病毒的重度精神残疾者。令人关切的是，艾滋病毒阳性的重度精神分裂症患者可能更有可能不坚持治疗，增加较差结果和产生耐药病毒的风险，并使其他人面临更大的风险。药物使用和抑郁已被证明会干扰艾滋病毒治疗的依从性。高级执业护士（apn）的参与已被证明可以改善艾滋病毒/艾滋病患者的预后。由于病例管理人员（CMs）已经参与协调这一人群的心理健康、社会和其他服务，并具有提供这些服务的专业知识，我们认为，将护理和病例管理相结合的综合服务模式将以CD4和病毒载量为指标显著改善艾滋病毒治疗效果，并使用标准化行为自我报告显著降低风险行为。参与者将从费城四家大型城市CMHC之一已经接受重度精神障碍治疗的患者中招募。采用纵向（基线、6、12和24个月）实验组和对照组设计，我们将随机分配300名参与者到干预组或对照组。参与者将被随机筛选是否有药物滥用和抑郁症，实验参与者将接受针对个人沟通和理解量身定制的综合干预，包括记忆辅助设备、有关副作用和其他治疗方面的教育，以及积极的社区外展。对于那些未能坚持使用基本干预措施的人，将实施增加强度的级联治疗。以80%的依从性为目标，级联将包括家庭和重要他人的参与，通过使用传呼机和手机来提示参与者，对于那些仍未达到80%依从性的人，直接观察治疗。

DESCRIPTION (provided by applicant): Persons with serious mental illness (SMI) are at increased risk for HIV/AIDS. The relative risk of HIV/AIDS is at least five times greater in SMI as the general Medicaid population in Philadelphia, and we estimate that up to 7% of the SMI population is also HIV seropositive. SMI persons reported more transmissions through heterosexual contact and injection drug use (IDU), and SMI women have more sex with men who have sex with men (MSM) than in the general population. A cost study showed that SMI with HIV had much higher health care costs than non-SMI persons with HIV and non-HIV persons with SMI. There is concern that HIV positive SMI persons may be a greater risk for poor treatment adherence, increasing risk for poorer outcomes and development of treatment resistant virus, and also placing others at greater risk. Substance use and depression have been shown to interfere with HIV treatment adherence. Involvement of advance practice nurses (APNs) has been previously shown to improve outcomes for persons with HIV/AIDS. Since case managers (CMs) are already involved with coordinating mental health, social, and other services for this population and have specialized expertise in providing those services, we believe that an integrated services model that integrates nursing and case management will result in demonstrably better HIV treatment outcomes using CD4 and viral load as indicators, and significantly reduced risk behaviors using standardized behavioral self-reports. Participants will be recruited from among those already in treatment for SMI in one of four large urban CMHC's in Philadelphia. Using a longitudinal (baseline, 6,12, and 24 months) experimental and control group design, we will randomly assign 300 participants to the intervention or control groups. Participants will be screened for active substance abuse and depression, randomized, and experimental participants will receive an integrated intervention tailored to the communication and comprehension of the individual, and will include memory aid devices, education regarding side effects and other treatment aspects, and active community outreach. For those who fail to adhere using the basic intervention, a treatment cascade that increases in intensity will be implemented. Using 80% adherence as a target, the cascade will include involvement of family and significant others in prompting participants through use of beepers, cellphones, and for those who still fall short of 80% adherence, directly observed therapy.