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Acceptability and necessity of HIV and other blood-borne virus testing in a psychiatric setting

  • Camilla Sanger (a1), Janine Hayward (a2), Gira Patel (a3), Karen Phekoo (a4), Alan J. Poots (a5), Cathy Howe (a5), Owen Bowden-Jones (a5) and John Green (a5)...

Summary

Studies in North America and Europe indicate that the prevalence of blood-borne viruses (BBVs) is elevated in individuals with severe mental illness; there are no comparable data for the UK. We offered routine testing for HIV, and hepatitis B and C in an inner-London in-patient psychiatric unit as a service improvement. Of the patients approached 83% had mental capacity to provide informed consent for testing and 66% of patients offered testing accepted. Although it was not our objective to establish the prevalence of BBVs, 18% of patients had serological evidence of a current or previous BBV infection, we found that offering routine testing in an in-patient psychiatric setting is both practical and acceptable to patients.

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Copyright

Corresponding author

John Green, Department of Clinical Health Psychology, Central and North West London NHS Foundation Trust, 20 Eastbourne Terrace, London W2 6LE, UK. Email: john.green@nhs.net

Footnotes

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Declaration of interest

None.

Footnotes

References

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1 Health Protection Agency. HIV in the United Kingdom: 2011 Report. Health Protection Services, 2011.
2 Meade, CS, Sikkema, KJ. HIV risk behavior among adults with severe mental illness: a systematic review. Clin Psychol Rev 2005; 25: 433–57.
3 Rosenberg, SD, Goodman, LA. Osher, FC, Swartz, MS, Essock, SM. Butterfield, MI. et al Prevalence of HIV. hepatitis B. and hepatitis C in people with severe mental illness. Am J Public Health 2001; 91: 31–7.
4 Meyer, JM. Prevalence of hepatitis A, hepatitis B. and HIV among hepatitis C-seropositive state hospital patients: results from Oregon state hospital. J Clin Psychiatry 2003; 64: 540–5.
5 Carey, MP, Carey, KB, Kalichman, SC. Risk for human immunodeficiency virus (HIV) infection among persons with severe mental illness. Clin Psychol Rev 1997; 17: 271–91.
6 Senn, TE, Carey, MP. HIV testing among individual with a severe mental illness: review, suggestions for research, and clinical implications. Psychol Med 2009; 39: 355–63.
7 Stefan, MD, Catalán, J. Psychiatric patients and HIV infection: a new population at risk? Br J Psychiatry 1995; 167: 721–7.
8 Moser, DJ, Schultz, SK, Arndt, S, Benjamin, ML, Fleming, FW, Brems, CS, et al Capacity to provide informed consent for participation in schizophrenia and hiv research. Am J Psychiatry 2002; 159: 1201–7.
9 Carpenter, WT, Gold, JM, Lahti, AC, Queern, CA, Conley, RR, Bartko, JJ, et al Decisional capacity for informed consent in schizophrenia research. Arch Gen Psychiatry 2000; 57: 533–8.

Acceptability and necessity of HIV and other blood-borne virus testing in a psychiatric setting

  • Camilla Sanger (a1), Janine Hayward (a2), Gira Patel (a3), Karen Phekoo (a4), Alan J. Poots (a5), Cathy Howe (a5), Owen Bowden-Jones (a5) and John Green (a5)...

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Acceptability and necessity of HIV and other blood-borne virus testing in a psychiatric setting

  • Camilla Sanger (a1), Janine Hayward (a2), Gira Patel (a3), Karen Phekoo (a4), Alan J. Poots (a5), Cathy Howe (a5), Owen Bowden-Jones (a5) and John Green (a5)...
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eLetters

Findings of audit of and intervention for routine opt-out psychiatric In-patient HIV Screening in one East London Borough

Keith D. King, Clinical Nurse Specialist
10 September 2013

We read with interest the article by Sanger et al discussing the utility of HIV tests for individuals with serious mental illness (SMI)(Sanger, et al, 2013). We report similar findings from the London Borough of Hackney in East London. The prevalence of HIV in Hackney is oneof the highest in the UK; >8/1000 population with known infection and afurther estimated 2/1000 with undiagnosed HIV (HPA, 2012). Currently little is known about HIV testing related service provision for this vulnerable population in the UK aside from this publication by Sanger et al, (2013).

The British HIV Association and National Institute of Clinical Excellence recommend routine HIV testing in all areas where the prevalenceof diagnosed HIV infection is >2/1000 (BHIVA, 2008; NICE, 2011). We conducted a retrospective audit between 01/07/2011-31/12/2011 to identify whether or not these recommendations were being met within the inpatient mental health services in Hackney. We employed a specific HIV/mental health liaison nurse and performed a series of qualitative interviews and utilized these findings to help inform the implementation of routine HIV testing within the inpatient mental health unit. We then re-audited the uptake of HIV testing within the inpatient mental health services between 01/07/2012-31/12/2012. We utilized a retrospective clinical audit methodology to determine period prevalence of HIV and screening rates during the study period.

Between July 1 - December 31, 2011 the HIV period prevalence for the sample (n=505) was 5.9/1000. An HIV test was completed for 4.75% of service users admitted during this period. Barriers identified in qualitative interviews were addressed following the audit, an interventionto improve screening was undertaken in collaboration between the local sexual health services and the mental health services before re-audit occurred. Between July 1- December 31, 2012 the HIV period prevalence for the sample (n=451) was 15.5/1000. An HIV test was completed for 25.5% of service users admitted during this period, which was a substantial improvement. There is evidence that this is part of an upward trajectory. The number of HIV tests requested for service users with SMI rose from 26 in 2010 (pre-intervention) to 258 in 2012 and 115 in the first 3 months of2013 (extrapolating to 460 tests per year.)

We agree with Sanger et al that there is a need to more clearly establish the prevalence of HIV & other blood borne viruses in this population. There is also a need for improved access to screening and prevention services for this vulnerable population. Despite significant barriers, there is an opportunity to improve early detection and improve quality of care with adequate local and national policy and implementationsupport.

References:

British HIV Association (2008) UK National Guidelines for HIV Testing2008. Retrieved from the World Wide Web on May 225th, 2013 from: http://www.bhiva.org/HIVTesting2008.aspx

Health Protection Agency (2012) HIV in the United Kingdom: 2012 Report. London: Health Protection Services, Colindale. Retrieved from the World Wide Web on May 25th, 2013 from: http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1317137200016

National Institute for Clinical Excellence (2011) Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England - Public health guidance, PH33 Retrieved from the World Wide Web on May 25th, 2011 from: http://www.nice.org.uk/guidance/PH33

Sanger, C., Hayward, J., Patel, G., Phekoo, K., Poots, A.J., Howe, C., Bowden-Jones, O., Green, J. (2013)Acceptability and necessity of HIV and other blood-borne virus testing in a psychiatric setting. The British Journal of Psychiatry 202:307-308

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Conflict of interest: None declared

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Routine HIV Testing in Mental Health

David S. Lawrence, Foundation Year 1 Trainee
01 July 2013

We welcome this research and believe it is high time that we have a debate around routine HIV testing in mental health.

At some acute hospitals, such as the Royal Sussex County Hospital in Brighton, routine HIV testing is already offered to all those under the age of 75 admitted through A&E. This may seem a controversial decision however HIV prevalence in Brighton is the largest in England outside London (7.59 per 1000). The Health Protection Agency has recommended Brighton and Hove as an area where wider HIV testing policies should be considered (1). The benefits of early HIV diagnosis are well-recognised.

We work in Older Person's Mental Health on a Dementia Assessment Unitand in Memory Assessment Services in Brighton, therefore we feel well placed to comment further on this short report in question.

The authors point out that psychiatric conditions can be associated with risk taking behaviours which may lead to exposure to bloods borne viruses (BBVs), we would like to highlight that neuropsychiatric symptoms can also be the consequence of BBVs; HIV-related cognitive impairment and neurosyphilis being two such examples. Indeed, HIV related cognitive impairment often responds better to appropriate treatment than dementia ofAlzheimer's type.

Given this, we would argue that testing for BBVs, especially HIV and syphilis, is of high clinical significance to our work.

It is promising to hear the authors' experience that patients were far more amenable to testing than clinical staff anticipated. We agree with this finding in the context of younger patients as learned from personal experience working at RSCH, but also in the context of older patients from experience of testing on the ward.

It would be simple to assume that older patients in a Dementia Assessment Unit may not have the capacity to consent to such a test, remembering that pre-test counselling remains a vital component of the HIVtesting process, but our experience has demonstrated that even patients with advanced dementia still often have capacity to consent to HIV testing. Historically, older patients with dementia have been tested for syphilis and this has never been brought forward as an ethical concern because of it's clinical relevance to their presentation. Similarly, we believe HIV should be thought of in this manner.

It is for the reasons above that we urge mental health service providers to actively encourage testing for BBVs, including HIV, among their patients and not to presume entire patient groups are unable or unwilling to consent on the basis of age or diagnosis.

From this, our team are looking at new ways that we can integrate BBVtesting into our Memory Assessment Service and ward-based work, as well asconducting further research into this field.

References(1) Health Protection Agency. HIV in the UK: 2011 report

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Conflict of interest: None declared

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HIV & other blood borne virus testing in a psychiatric setting

Nirmaljit Kaur, Associate Professor
02 May 2013

The article by Camilla Sanger and others stresses the need for HIV and other blood borne virus (Hepatitis B and Hepatitis C) in an in-patientpsychiatric setting.There are, however, many debatable questions which require answering. Firstly, The implications of the study are limited by the fact that it did not have a control group ( either from another medical setting or control from the family members or general population) to confirm that the prevalence of HIV or other blood borne infections is actually high among psychiatric indoor patients; Secondly, HIV testing cannot be done routinely as it requires informed consent, pre-test and post-test counselling and also, has social and legal implications. In an indoorpsychiatric setting, majority of patients admitted are psychotic patients lacking insight and many of them do not have a relative to give informed consent. Thirdly, there is no use in doing routine screening of these infections unless there is some aetiological correlation between a psychiatric disorder and these viruses. The specific testing in selective patients can be advocated if there is high risk behaviour or presence of symptoms related to infections. Fourthly, in developing countries, where the exposure to some virus infections e.g. Hepatitis A and Hepatitis B is relatively high in the population, routine testing is not feasible either economically and technically.Fifthly, the study did not differentiate between current or previous infection, which is important issue for takingprecautions in drug treatment of psychiatric disorders. Sixthly, source ofinfection has to be determined to develop a preventive programme. The study,however, emphasizes the need to follow Universal Precautions in a psychiatric setting to prevent the spread of these virus infections and also caution to be taken in treating psychiatric disorder as well as virusinfection.In some cases, the symptomatology of psychiatric disorder may become mixed because many of these virus infections lead to high psychiatric morbidity (1,2) and even risk of suicide(2).Some previous studies did not find the prevalence of virus infections higher in institutionalized patients (3).References:1.Lopes et al. Gender, HIV status, and psychiatric disorders: results fromNational Epidemiological Survey on alcohol and related conditions. J Clin Psychiatry 2012;73:384-391.2. Shaefer M et al. Hepatitis C infection, antiviral treatment and mental health:A European expert consensus statement. J Hepatology 2012;57:1379-1390.3. Hung C et al. Prevalence of hepatitis B and hepatitis C in patients with chronic schizophrenia living in institutions.J Chinese Med Assoc 2012;75:275-280.

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Conflict of interest: None declared

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