Clinical Summary
Clinical Summary: HIV Diagnosis and Preexposure Prophylaxis (PrEP) Prescription Among Commercially Insured Persons With Bipolar Disorder
Patients with bipolar disorder face elevated HIV risk, yet HIV prevention often sits outside routine psychiatric care. In this national claims analysis, HIV diagnoses continued to accumulate while PrEP use remained strikingly low, highlighting a missed prevention opportunity in a population many psychiatrists see regularly.
Design
retrospective cohort study
N
333,867 people with BD
Population
people aged ≥14 years with BD (type I or II) between 2010 and 2022
Duration
between 2010 and 2022
Key Findings
- There were 435 new HIV diagnoses identified within the cohort between 2010 and 2022, and HIV incidence per 100 person-years increased from 0.54% in 2010 to 1.08% in 2022.
- Male sex was strongly associated with incident HIV diagnosis (aOR=5.30 [4.22–6.65], P<.001), and HIV diagnosis was also more likely with a high-risk sexual behavior claim (aOR=2.66 [1.85–3.83], P<.001) and comorbid StUD (aOR=2.40 [1.71–3.39], P <.001).
- PrEP uptake was very low: 1,337 people with BD (0.40%) were prescribed PrEP of any duration between 2010 and 2022, and 909 people with BD (0.27%) were prescribed PrEP for at least 3 months duration between 2010 and 2022.
- Among people with BD who had ≥4 encounters for STIs, 3.53% (n = 246) were prescribed PrEP of any duration, and 2.73% (n = 190) were prescribed at least 3 months of PrEP.
- Male sex was strongly associated with PrEP receipt (aOR=11.6 [10.0–13.5], P < .001); claims for high-risk sexual behavior were associated with greater odds of PrEP prescription (aOR=16.9 [14.7–19.4], P<.001), while comorbid OUD (aOR=0.67 [0.52–0.87], P<.001) and comorbid CUD (aOR=0.69 [0.57–0.83], P< .001) were associated with lower likelihood of PrEP prescription.
Clinical Bottom Line
Among commercially insured people with bipolar disorder, HIV risk was substantial and PrEP use was exceptionally low, including among patients with repeated STI encounters. Bipolar disorder care is a practical setting to identify HIV risk and expand PrEP prescribing rather than relying on primary care alone.
Practice Implications
- Routinely assess HIV prevention needs in bipolar disorder care, especially in patients with male sex, high-risk sexual behavior claims, comorbid stimulant use disorder, or STI encounters, all of which were associated with higher HIV risk or higher PrEP receipt.
- Do not assume STI-related risk is already being addressed elsewhere: among patients with ≥4 STI encounters, only 3.53% (n = 246) received any PrEP and 2.73% (n = 190) received at least 3 months of PrEP.
- Psychiatry-only follow-up should prompt attention to HIV prevention, as people with BD who had outpatient encounters with psychiatrists only had greater odds of HIV diagnosis compared to those who had follow-up encounters with PCPs only (aOR=1.58 [1.11–2.27], P =.01).
- Coordinate PrEP delivery across psychiatry and primary care when possible, since people with BD who had outpatient encounters with both psychiatrists and PCPs had higher odds of PrEP prescription (aOR=1.38 [1.21–1.57], P<.001).
