How to Identify Patients With Bipolar Disorder for PrEP Evaluation
How should clinicians identify which patients with bipolar disorder need prompt evaluation for HIV preexposure prophylaxis?
Patients with bipolar disorder face elevated HIV risk, yet PrEP use in this population was under 0.5% in this claims-based study. Clinicians in psychiatric and general medical settings need a practical way to recognize the bipolar disorder patients whose clinical history should trigger HIV prevention assessment rather than waiting for referral from sexual health settings.
-
Start with routine HIV prevention assessment in bipolar disorder care
Do not assume HIV prevention needs are being addressed elsewhere for patients with bipolar disorder. In this cohort, HIV incidence was substantially elevated and PrEP use was very low, so bipolar disorder itself should prompt routine attention to HIV risk and prevention during ongoing care.
-
Screen for CDC PrEP indications from the past 6 months
Ask whether the patient has had at least 1 known HIV-positive partner, an STI diagnosis, sex with 1 or more partners of unknown HIV status, injection drug use with shared needles, or a request to receive PrEP. The article cites these CDC criteria as indications for PrEP prescription and notes that the patient request criterion was added to broaden access.
-
Treat STI history as a strong trigger for PrEP evaluation
Review current and prior STI diagnoses carefully, because any STI encounter was associated with higher odds of HIV diagnosis and with PrEP prescription in this cohort. The study counted STI exposure burden as 0, 1, 2, 3, or 4 or more outpatient STI encounters, and even among those with 4 or more encounters only 3.53% received any PrEP and 2.73% received at least 3 months, highlighting a major missed prevention opportunity.
-
Ask about high-risk sexual behavior explicitly
Elicit sexual risk directly rather than relying only on charted diagnoses. Claims for high-risk heterosexual, homosexual, or bisexual activity were associated with higher odds of HIV diagnosis and were very strongly associated with PrEP prescription, making this a high-yield domain for targeted assessment.
-
Check for comorbid stimulant use disorder and other clinical risk markers
Review comorbid stimulant use disorder because it was associated with greater odds of HIV diagnosis and greater odds of PrEP prescription in this study. Also note whether the patient has had a psychiatric hospitalization, since 1 psychiatric hospitalization during follow-up was associated with greater odds of HIV diagnosis.
-
Pay special attention to patients seen mainly in psychiatry
If the patient's outpatient care occurs primarily in psychiatry, do not defer HIV prevention work automatically to primary care. Compared with primary care-only follow-up, psychiatry-only outpatient care was associated with greater odds of HIV diagnosis, suggesting psychiatric settings may be a critical point for identifying unmet prevention needs.
Clinical Considerations
- This study used administrative claims and could not determine individual-level HIV risk, actual PrEP eligibility, or gaps between eligibility and uptake.
- High-risk sexual behavior diagnosis codes may be underused in clinical practice because of stigma, so absence of such a code does not exclude risk.
- STI diagnosis codes may not perfectly reflect laboratory-confirmed infection, although the authors note that their presence still indicates baseline STI exposure risk.
- The findings come from commercially insured patients with bipolar disorder and may not generalize to uninsured, publicly insured, or more severely impaired populations.
Bottom Line
In bipolar disorder care, STI encounters, high-risk sexual behavior, stimulant use disorder, psychiatric hospitalization, and psychiatry-only follow-up should trigger active PrEP evaluation rather than passive referral.
