A breakthrough approach to identifying at-risk patients and improving treatment outcomes
In the American South, a silent crisis unfolds in HIV clinics and community health centers. Despite representing only 38% of the U.S. population, this region accounted for 52% of all new HIV diagnoses in 2022 4 7 . The statistics reveal a troubling reality: the South has the country's lowest PrEP-to-Need Ratio, with just 12 PrEP users for every new HIV diagnosis, indicating vast unmet prevention needs 4 .
of new HIV diagnoses occur in the South despite having only 38% of population
PrEP-to-Need Ratio in the South, indicating vast unmet prevention needs
Barriers including poverty, limited healthcare access, and stigma
Behind these numbers lie complex stories of poverty, limited healthcare access, stigma, and systemic barriers that make HIV care particularly challenging.
What if a simple screening tool, administered in minutes, could identify which patients are most at risk of falling out of care? Recent research suggests that the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) does exactly that—providing a crucial early warning system that helps clinics support vulnerable patients along their treatment journey 1 5 .
To understand why tools like SAMISS matter, we must first understand the "HIV care cascade"—the sequential steps people with HIV must navigate from diagnosis to successful treatment 6 . This continuum begins with diagnosis, then moves through linkage to care, retention in care, initiation of antiretroviral therapy (ART), and finally, achieving and maintaining viral suppression 6 .
Identification of HIV infection through testing
Connection to HIV medical care within 1 month of diagnosis
Receiving regular HIV medical care
Prescription of antiretroviral therapy
Achieving and maintaining viral load ≤200 copies/mL
The cascade concept reveals where patients disappear from care. Like a sieve, each stage loses some patients. Research from India showed that while 70% of diagnosed patients entered care within three months, only 31% eventually achieved viral suppression after treatment initiation 2 . Similar attrition occurs everywhere, with the greatest losses often happening in the early stages between diagnosis and treatment initiation 2 .
Viral suppression is the ultimate goal—it keeps people healthy and prevents transmission. But the path to this goal is paved with challenges, especially for those dealing with mental health conditions or substance use alongside their HIV diagnosis 1 .
The Substance Abuse and Mental Illness Symptoms Screener (SAMISS) is a brief, validated screening tool specifically designed for people with HIV 8 . Its 16 questions—seven covering substance use and nine addressing mental health—help clinicians quickly identify patients who may need extra support.
Unlike generic screening tools, SAMISS was created specifically for HIV clinics. It asks about alcohol and drug use patterns, mental health symptoms like depression and anxiety, and how these issues affect patients' lives 8 . The screening can be administered by clinic social workers or trained staff in just minutes, making it practical for busy clinical settings.
What makes SAMISS particularly valuable is its ability to prospectively identify patients at risk—giving clinics a chance to intervene before patients miss appointments or stop treatment 1 .
Between 2016 and 2019, researchers in Dallas, Texas, conducted a crucial study that demonstrated SAMISS's real-world value 1 5 . They followed 530 newly diagnosed people with HIV, screening them with SAMISS at their first clinic visit, then tracking their progress through the care cascade for twelve months.
SAMISS questionnaire & demographics
46% started rapid ART
12-month monitoring of key metrics
Statistical modeling of associations
The study population reflected the changing face of the Southern HIV epidemic: predominantly male (79%), with diverse racial backgrounds (46% non-Hispanic Black, 37% Hispanic), and an average age of 35 5 . All patients received care at a safety-net clinic—the kind of institution that serves the most vulnerable populations, regardless of their ability to pay.
The study findings were striking. Among the 530 participants, 34% screened positive for substance use and 41% for mental illness on the SAMISS questionnaire 5 . These high rates confirmed that Southern people with HIV frequently face these concurrent challenges.
Most importantly, these screenings predicted real-world treatment outcomes. The data revealed clear disparities in care retention and viral suppression between those who screened positive versus negative on SAMISS.
| SAMISS Screening Result | Retention Rate | Adjusted Odds Ratio |
|---|---|---|
| Substance Use Positive | Significantly lower | 0.60 (p=0.015) |
| Mental Illness Positive | Significantly lower | Not statistically significant after adjustment |
| Dual Positive | Lowest rates | Not reported |
Understanding and improving the HIV care cascade requires specific methodological approaches and tools:
16-item screener for substance use and mental illness symptoms
Identifies patients at risk of cascade discontinuationStandardized metrics for care engagement
Defined as ≥2 visits 90 days apart in 12 monthsLaboratory measurement of HIV RNA
Determines virologic suppression (<200 copies/mL)Statistical method for imperfect measurement
Validates screening tools against reference standardsMultivariate statistical analysis
Isolates effect of SAMISS scores while controlling for covariatesComprehensive patient data collection
Tracks patient progress through the care cascadeThe Dallas study demonstrates that SAMISS does more than just identify problems—it creates opportunities. As the researchers noted, "SAMISS is a useful tool for prospectively identifying individuals at risk for low retention in care and for not achieving sustained VS" 1 . This early identification allows clinics to:
Allocate support to patients who need them most
Create targeted approaches for substance use and mental health
Enhance long-term results through personalized support
What makes these findings particularly relevant is their timing. With the U.S. government's "Ending the HIV Epidemic" initiative targeting 48 high-burden counties (nearly half in the South), tools like SAMISS could play a crucial role in allocating resources effectively 7 .
The SAMISS story represents a broader shift in HIV care—from focusing solely on viral levels to understanding the whole person. It acknowledges that addressing mental health and substance use isn't separate from HIV treatment; it's essential to its success. As one study concluded, "Future interventions guided by SAMISS may improve HIV care continuum outcomes" 1 —potentially helping thousands of people with HIV in the South and beyond live healthier lives while reducing new infections.
In the challenging landscape of the Southern HIV epidemic, the SAMISS questionnaire offers something precious: hope that comes not from advanced technology, but from better understanding human struggles and addressing them with compassion and precision.