A major barrier in mental health care is inadequate detection of the comorbid condition, although studies are few and samples are not necessarily representative. This barrier exists to various degrees in both HIV and mental health care settings, but research points to greater problems in the mental health setting. Mental health professionals may not adequately screen for HIV (Brunette et al., 2000; McKinnon et al., 2001), despite the public health recommendations to conduct routine HIV counseling and testing in settings with HIV prevalence of 1 percent or more (CDC, 2001). 7 This cutoff applies to most, if not all, mental health treatment programs, given prevalence figures cited earlier. Researchers at RAND, interviewing 159 treatment providers at 72 mental health and HIV treatment programs in New York City and Los Angeles, found that screening for HIV and risk behaviors in mental health agencies occurs haphazardly, given the range of clients’ nonpsychiatric and other medical needs that compete for the attention of providers. In contrast, HIV treatment agencies tend to place high priority on screening and care for mental illness, as clinicians generally perceive the mental health of clients to be central to successful HIV treatment and adherence. Nevertheless, because research has long established that depression is missed in 40–60 percent of patients in primary care (Hirschfeld et al., 1997; DHHS, 1999), it would not be surprising if depression went undetected in HIV care.
One of the few other studies of this problem found community mental health clinicians in New Hampshire to report lack of specific knowledge about comorbid MI-HIV and to report interest in receiving training (Brunette et al., 2000).
One study that directly focused on the barriers to receipt of HIV care for individuals whose SMI-HIV comorbidity is already known compared nearly 300 SMI-HIV patients in Los Angeles and New York City to patients from the HCSUS cohort from the same geographic region and with HIV alone. It found that people with SMI were more likely to experience barriers to care (Allen M. Fremont, Personal communication, 2002). Barriers to care were measured by a three-item index—not getting needed medical care, going without care because of lack of money, or going without food because they needed the money for care.