HIV risk assessment and risk reduction counseling can also occur as part of a routine evaluation and treatment in mental health settings such as Vet Centers and psychiatry clinics.
Veterans with chronic mental illnesses may be at greater risk for HIV because of:
 | deficits in social skills that are needed to negotiate safer sex with partners, |  | | sexual disinhibition, | | | cognitive impairment or poor judgment, | | | hypersexuality or mania, or | | | associated substance use. | |
A 1997 study suggested that U.S. veterans with posttraumatic stress disorder (PTSD) or other mental or emotional problems and substance abuse face a 10-fold increased risk of HIV infection when compared to
veterans without either.(1)
In addition to a link between severe stress exposures and a broad array of diseases,(2) PTSD can also be associated with stress-related risk behaviors that may place veterans at risk for HIV. The relationship between PTSD and substance use is well known. In attempting to cope with, self-manage, or "numb" symptoms of PTSD, a veteran may engage in substance use or abuse or associated unprotected sexual behaviors that may place him or her at risk for HIV. If the PTSD is secondary to sexual assault or trauma, it may be much harder to engage in the self-efficacy and interpersonal skills necessary to negotiate safer sex practices such as consistent condom use with a sexual partner.
The seriously and persistently mentally ill are another population at higher risk for HIV and with a higher prevalence of the disease. A review of studies on HIV risk behavior among seriously mentally ill populations
found lifetime rates of injection drug use from 4-35%, and higher rates of risky sexual behaviors, including such activities with partners known to be at increased risk for HIV.(3) It is likely that psychiatric symptoms, substance abuse, and social vulnerability inadvertently contribute to risk in this population.(3)
While a substance-use history is frequently a part of a mental health intake evaluation, sexual history items can also be integrated into routine questions about social relationships. In asking patients in a mental health setting about their medical history, questions about specific sexual activity, the relationship between substance use and sexual risk, use of condoms, and previous diagnoses of STDs can also be included. Again, it is important to emphasize with the patient that you routinely ask these questions of all your patients as you are concerned with all aspects of their health and emphasize the confidentiality policy of VA.
Should your patient present with risk factors for HIV, you should discuss the possible need for HIV testing and counseling. In addition, you should:
| assess the patient's ability to provide informed consent, | | | refer patients to the HIV test counselor at your facility if they consent to testing and are able to provide informed consent, and | | | determine if the patient wants you to accompany them to the testing or provide a time to see them while they are waiting for their result and immediately after receiving the results of their test. | |
Discussions to evaluate a patient's readiness to adopt behaviors to reduce their risk as well as general HIV prevention counseling can be integrated into other therapeutic goals. Again, it is important to continue to assess risk for HIV on an ongoing basis for veterans who receive mental health services as their risk for HIV may change in response to changes in their psychological functioning and life events. Factors such as depression, hopelessness, manic presentations, and diminished judgment may increase patients' risk status, and may have to be addressed before a patient can change his or her risk behaviors.
Mental health settings in VA can make condoms available to patients by leaving them in areas such as restrooms where patients can pick them up unnoticed. Both male and female condoms can also be prescribed to patients through the VHA National Formulary (listed under "medical supplies").
It may also be helpful to provide educational materials on HIV prevention in clinic waiting rooms and examination rooms. Patients can read the material while they are waiting and it provides a cue to patients that this is a topic they can bring up with their mental health services provider.
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