The impact of psychiatric symptoms on condom self-efficacy among people with serious mental illness.

OBJECTIVE: To determine how psychiatric symptoms affect the self-efficacy of people with serious mental illness to protect themselves and their partners from HIV and other sexually transmitted infections (STIs) by using condoms. METHOD: As part of a National Institute of Mental Health-Funded study, people with serious mental illness (N = 467) were recruited in public psychiatric outpatient clinics in Rio de Janeiro, Brazil for an HIV prevention intervention. We examined the effects of psychiatric symptom severity on condom self-efficacy at baseline across 4 symptom clusters: affect, positive, negative, and activation. RESULTS: Greater activation symptom severity (e.g., elated mood) was related to better condom self-efficacy, whereas greater negative symptom severity (e.g., blunted affect, emotional withdrawal) was related to worse condom self-efficacy. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Our findings suggest that people living with serious mental illness who exhibit more severe negative symptoms are less likely to perceive themselves as capable of using condoms, condom negotiation, and/or condom acquisition, whereas those with more severe activation symptoms are more likely to express confidence in their capabilities. Interventions to prevent HIV and other STIs among people living with serious mental illness should take into account the effects of these symptom clusters on condom skills acquisition and perceptions of self-efficacy in carrying out needed protective behaviors. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Targeted ethnography as a critical step to inform cultural adaptations of HIV prevention interventions for adults with severe mental illness.

As in other countries worldwide, adults with severe mental illness (SMI) in Brazil are disproportionately infected with HIV relative to the general population. Brazilian psychiatric facilities lack tested HIV prevention interventions. To adapt existing interventions, developed only in the US, we conducted targeted ethnography with adults with SMI and staff from two psychiatric institutions in Brazil. We sought to characterize individual, institutional, and interpersonal factors that may affect HIV risk behavior in this population. We conducted 350 hours of ethnographic field observations in two mental health service settings in Rio de Janeiro, and 9 focus groups (n=72) and 16 key-informant interviews with patients and staff in these settings. Data comprised field notes and audiotapes of all exchanges, which were transcribed, coded, and systematically analyzed. The ethnography identified and/or characterized the institutional culture: (1) patients' risk behaviors; (2) the institutional setting; (3) intervention content; and (4) intervention format and delivery strategies. Targeted ethnography also illuminated broader contextual issues for development and implementation of HIV prevention interventions for adults with SMI in Brazil, including an institutional culture that did not systematically address patients' sexual behavior, sexual health, or HIV sexual risk, yet strongly impacted the structure of patients' sexual networks. Further, ethnography identified the Brazilian concept of "social responsibility" as important to prevention work with psychiatric patients. Targeted ethnography with adults with SMI and institutional staff provided information critical to the adaptation of tested US HIV prevention interventions for Brazilians with SMI.

HIV risk behaviors among outpatients with severe mental illness in Rio de Janeiro, Brazil.

We conducted the first study to examine rates of sexual activity, sexual risk behaviors, sexual protective behaviors, injection drug use (IDU), needle sharing, and knowledge about HIV/AIDS among outpatients with severe mental illness (SMI) in Rio de Janeiro, Brazil. Using a measure with demonstrated reliability, we found that 42% of 98 patients engaged in vaginal or anal sex within the past three months. Comorbid substance use disorder was significantly associated with sexual activity. Only 22% of sexually active patients used condoms consistently, despite having better HIV knowledge than those who were sexually abstinent. Overall, 45% of patients reported not engaging in any HIV protective behaviors. There were no reports of drug injection. Adults with SMI in Brazil are in need of efficacious HIV prevention programs and policies that can sustain these programs within mental health treatment settings.

A model for adapting evidence-based behavioral interventions to a new culture: HIV prevention for psychiatric patients in Rio de Janeiro, Brazil.

As in other countries worldwide, adults with severe mental illness in Brazil have elevated rates of HIV infection relative to the general population. However, no HIV prevention interventions have been tested for efficacy with psychiatric patients in Brazil. We conducted participatory research with local providers, community leaders, patient advocates, and patients using an intervention adaptation process designed to balance fidelity to efficacious interventions developed elsewhere with fit to a new context and culture. Our process for adapting these interventions comprised four steps: (1) optimizing fidelity; (2) optimizing fit; (3) balancing fidelity and fit; and (4) pilot testing and refining the intervention. This paper describes how these steps were carried out to produce a Brazilian HIV prevention intervention for people with severe mental illness. Our process may serve as a model for adapting existing efficacious interventions to new groups and cultures, whether at a local, national, or international level.