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DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org

Implementation of HIV Testing in Mental Health Facilities

13 May 2011Ronald D. Wilcox MD FAAP


www.deltaaetc.org 504-903-0788


Please indicate your profession:

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12% 12% 12% 12%12%12%12%12%1. Mental Health Counselor

2. Administrator3. Social Worker4. Primary Care Provider5. HIV Specialist6. Nurse7. Pharmacist8. Other


I am here today because:

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1. I need CEUs2. I thought the topic

interesting3. I was hoping bloody

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CDC Recommendations for HIV Screening and Testing


The CDC recommends routine HIV testing from what age range

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20% 1. 1 year to 13 years2. 13 years to 23 years3. 13 years to 50 years4. 13 years to 64 years5. 24 years to 99 years


HIV Serologic Screening Recommended

• Persons between 13 and 64 years of age routinely offered at entry to care

• Persons with STD’s

• Persons with tuberculosis


HIV Serologic Screening Recommended

• Women considering conception and pregnancy

• All pregnant women

• Women in delivery with undocumented HIV status

• Infants born to mothers of undocumented HIV status


HIV Diagnostic Testing

• Signs or symptoms of HIV infection

• Patients at high risk for HIV based on risk assessment, offered yearly


“Opt-Out Testing”

• Oral or written information given at time of testing at an appropriate health literacy level for the patient– Explaining what HIV infection is– Describing ways to prevent transmission– Meaning of positive and negative results

• Testing is voluntary and never coerced and prior knowledge is still needed. Patient then given the opportunity to decline testing– If refuses, explore reasons. Offer at subsequent visits.– Document refusal in patient record

• General consent for medical care is sufficient for HIV testing• Applies only to medical settings


Per the 2006 CDC recommendations, positive results

of HIV testing can be given at minimum:

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1. Over the loud speaker

2. In person only3. In writing4. To everyone in the

family


Giving results• Negative test results

– Can be conveyed without personal direct contact– High risk patients should be encouraged to get retested

in future• Positive results

– Conveyed in private setting in person– Assure confidentiality. Do NOT use family members as

translators– Discuss partner notification– Document in patient record– Refer for care


Other considerations

• CDC recommendations do not supercede local laws• Facilities and institutions may have their own

requirements• Rapid results reported in 20-30 minutes and

substantially decrease amount of patients not receiving results but positive results MUST be confirmed with Western Blot or other confirmatory test


Testing Options


All of the following are antibody tests for HIV EXCEPT:

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1. ELISA

2. Western Blot

3. Rapid Testing

4. Viral Load


Enzyme-Linked ImmunoSorbent Assay (ELISA)

HIV Enzyme Immunoassay (EIA)1) Apply a sample of HIV antigens

2) Apply patient’s serum containing antibodies

3) Apply second antibody (anti-human immunoglobulins)

4) Apply a color changing substrate

Positive ELISA Negative ELISA


ELISA - EIA

Positive Control

Negative Control

Patient A Patient B Patient C Assay Control

1.689 0.153 0.055 0.412 1.999 0.123


Western Blot (Immunoblot)

• Detects proteins in a given tissue sample

1. HIV infected cells are opened and their proteins placed into a gel

2. Proteins are separated by mass using gel electrophoresis

3. Separated proteins are transferred from gel to a membrane (“blotting”)

Photograph courtesy of Wikipedia Encyclopedia


Structure of HIV

Illustration from SCIENCE & TECHNOLOGYAugust 27, 2001 Volume 79, Number 35 CENEAR 79 35 pp. 37-44


Western Blot4. Procedure continues similar

to ELISA

5. Results are read If no viral bands are present,

the result is negative

If less than the required number of viral bands (p24, gp41, gp120/160) are detected, the result is indeterminate

Controls

+ - Indeterminate+

Samples

-Picture courtesy of www.msichicago.org/ed/AIDS/hivtst5.htm


Interpreting HIV Serology

• HIV Positive = + ELISA AND

+ Western Blot

• HIV Indeterminate = + ELISA AND

1-2 bands on WB


Explanations for HIV Indeterminate

• Early infection, seroconverting• Advanced infection with decreased p24

antibodies• Cross-reactive antibodies or auto-antibodies

from CVD, autoimmune process, or malignancy• HIV-2 infection; O clade HIV-1• Experimental HIV vaccine recipient• Late pregnancy


Interpreting HIV Serology

O b ta invira l load

S erocon vers ionsu sp ec ted

O b ta inH IV -2 W B

H IV -2su sp ec ted

R etes t in3 -4 m on th s

L ow ris kp a tien t

H IV In d e te rm in a te


Rapid Testing• Currently six rapid tests are available in the US

OraQuick® Rapid HIV-1/2 Antibody Test* Reveal™ Rapid HIV-1 Antibody Test Uni-Gold Recombigen® HIV Test* Multispot HIV-1/HIV-2 Rapid Test HIV 1 / 2 Stat Pak* Sure Check HIV 1 / 2 Assay*

• All are interpreted visually

• * CLIA-wavered


Heavy alcohol use can give a false positive for which rapid HIV test?

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1. Oraquick Advance2. Multi-Spot3. Clearview Stat-Pak4. SIDA Rapida5. None of the above


Uni-Gold Recombigen

Multispot HIV-1/HIV-2

Reveal G3 OraQuick Advance

Clearview Complete HIV 1/2

Clearview HIV ½ Stat Pak


FDA-approved Rapid HIV Tests

Sensitivity(95% C.I.)

Specificity(95% C.I.)

Oral fluid OraQuick Advance Whole blood Un-Gold Recombigen Stat-Pak Sure Check

99.3 (98.4 - 99.7)

100 (99.5 – 100) 99.7 (98.9 – 100)99.7 (98.9 – 100)

99.8 (99.6-99.9)

99.7 (99.0 – 100) 99.9 (98.6 – 100) 99.9 (98.6 – 100)

Serum/plasma Reveal G3 Multispot

99.8 (99.2 – 100) 100 (99.9 – 100)

99.9 (98.6 – 100) 99.9 (99.8 – 100)


OraQuick Advance HIV-1/2

• CLIA-waived for finger stick, whole blood, oral fluid

• Store at room temperature

• Screens for HIV-1 and 2

• Read time 20-40 minutes

• Shelf life: 6 months


Uni-Gold Recombigen

• CLIA-waived for finger stick, whole blood


• Screens for HIV-1


• Shelf life: 1 year


Clearview Complete HIV 1/2

• CLIA-waived for whole blood




• Shelf life: 2 years


Clearview HIV-1/2 Stat-Pak• Clia-waived for whole blood

and fingerstick




• Shelf life: 2 years


Reveal G3

• CLIA moderate complexity with serum, plasma


• Perform test in 5 minutes

• Shelf life: 1 year


Multispot HIV-1/HIV-2• CLIA moderate complexity with

serum, plasma

• Refrigerate reagents

• Distinguishes HIV-1 from HIV-2

• Perform test in 15 minutes

• Shelf life: 1 year refrigerated, 3 months room temperature


Interpreting Rapid Test Results

For a laboratory test:Sensitivity: Probability test=positive if patient=positiveSpecificity: Probability test=negative if patient=negative

Predictive value:PPV is Probability patient=positive if

test=positiveNPV is Probability patient=negative if

test=negative


Example: Test 1,000 persons

HIV prevalence = 10%

True positive:

False positive:

Positive predictive value:

100/104 = 96%

100 4

Test Specificity = 99.6%

(4/1000)


Example: Test 1,000 persons Test Specificity = 99.6%

(4/1000)

HIV prevalence = 10%True positive: 100 False positive: 4

Positive predictive value: 100/104 = 96%

HIV prevalence = 0.4%

True positive:

4 False positive:

4

Positive predictive value:

4/8 = 50%


Rapid Testing

• Appropriate settings– CBO Outreach– Late-Presenting Mothers– Occupational Exposures– Emergency Rooms– Primary Care settings– Mental Health and Substance Abuse Treatment

facilities• Inappropriate setting: right before a date


How does any of this apply to mental health facilities?


Persons with mental illness are at increased risk for:

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1. HIV2. Hepatitis B3. Hepatitis C4. 1 & 35. All of the above


Statistics

• People with Severe Mental Illness are at increased risk for infections with HIV, hepatitis B and C.– Estimated 8-fold incidence of HIV than standard

US population rate– Estimated 5-fold incidence of hepatitis B– Estimated 11-fold incidence of hepatitis C

Rosenberg SD et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 2001; 91: 31-7


Psychiatric Illness and HIV• Prevalence of HIV in psychiatric patients

– Developed countries: 0 – 29.0%– Developing countries: 0 – 23.8%

• Most studies have concentrated on Severe Mental Illness (SMI)– I.e. schizophrenia, schizoaffective disorder,

bipolar disease, major depression with psychotic features

Guimaraes MDC et al. HIV risk behavior of psychiatric patients with mental illness: a sample of Brazilian patients. Rev Bras Psiquiatr 2010; 32 (4):


Psychiatric Illness and HIV

• Risky behaviors in patients with SMI:– 20% of psych patients have a history of IVDU

(range from 15 – 37% lifetime rate and 1 – 8% past year use in developed countries)


Psychiatric Illness and HIV

• Sexually active– Developed countries 51 – 74% in past 12 months

and 32 – 65% in past 3 months• 12 – 68% of those with SMI report inconsistent

condom use with 43 – 78% reporting having unprotected sex in the preceding 3 months

– Developing countries (in Rio de Janeiro) 41.8% sexually active in past three months

• 43.9% of outpatients with SMI reported inconsistent condom use in prior 3 months


Psychiatry and Risk Behavior• National cross-sectional multicenter study in 2006

(PESSOAS Project) of adults with mental illness under care of mostly public inpatient and outpatient mental health settings. Blood tested for HIV, hepatitis B & C, and syphilis.

• N = 2475 completed (3255 originally recruited)• Outpatient centers that only treated substance abuse

excluded• Face-to-face interviews of self-reported data and

psychiatric diagnoses obtained from charts


Guimaraes et el

• 64% outpatient, 36% inpatient• 51.6% female, 54.6% > 40 years old, 48.5%

black, 33.2% married or in long-term relat.• Schizophrenia-spectrum diagnoses and

bipolar disease in 56.7%, depression in 12.9%, substance use disorder in 7.0%, and anxiety disorder in 3.6%

• 27% previous STI, >25% previously HIV tested


Guimaraes et al.• Results:

– 61.3% sexually active in prior 6 months• Only 16.3% reported always using condoms

– 80.3% reported unprotected sex at some time– 61.0% had multiple sexual partners– 19.9% had suffered sexual violence– 25.1% had used illicit drugs– 2.9% had history of IVDU– 7.9% had sex while under the influence


Guimaraes et al.• Lifetime unprotected sex

– Two times higher for women, those over 39 years old, those with lower education and income

– Increased risk in those with anxiety problems (four-fold) than those with schizophrenia-spectrum or bipolar, with depression or substance use by three fold

– Increased in those with hx of physical or verbal or sexual violence and those with hix of incarceration


Why should MH facilities offer testing?

• Patients are already seeking care there so should not refer elsewhere for testing

• MH workers can tailor pre- and post-test counseling for those with an SMI

• Therapists can encourage HIV testing, address patient’s barriers to testing , and allay concerns regarding stigma, confidentiality, and testing


Is testing of MH patients being done?

• Homelessness highest chance• Meade and Sikkema – having a non-psychotic

primary diagnosis or border personality disorder increased chance

• Thompson et al – schizophrenics > bipolar for testing

• Voluntary admittance to psychiatric facility increases chance of testing

• Urban services > rural services


Is testing of MH patients being done?

• 200 mentally ill adults receiving outpatient psychiatric services surveyed in Baltimore– 85% had seen a medical provider in previous year– 59% received an HIV test – 41% received a hepatitis test

• Receipt of HIV testing depended on clinic location (urban > suburban) as well as reports of unprotected sexual behavior

• Hepatitis testing not associated with behaviors but was with co-morbid medical condition

Goldberg RW et al. Predictors of HIV and hepatitis testing and related service utilization among individuals with serious mental illness. Psychosomatics 2005; 46: 573-7


Is testing of MH patients being done?• 487 outpatient s from 3 public-sector facilities in Connecticut (one VA and

two state facilities)• 41.9% reported never receiving an HIV test

– 1/3 of these were “very afraid” of getting HIV• Most likely to have received a test:

– Younger age– Felony criminal history– Stronger therapeutic alliance with primary clinician– Increased drug problems and psychological distress

• Only 50% received post-test counseling

Desai MM, Rosenheck RA, and Desai RA. Prevalence and correlates of human immunodeficiency virus testing and posttest counseling among outpatients with serious mental illness. J Nervous Mental Dis. 2007; 195(9):776-80


Reasons for refusal

• What might be some reasons people would refuse an HIV test?


Reasons for testing (or not)

• Patients with SMI more likely to get tested just to know than those without SMI

• No studies in patients with SMI assessing why testing is refused– General population

• Not at risk• Previously tested• Fear of results or subsequent stigma


STIRR Intervention• Screen, Test, Immunize, Reduce risk, Refer• Rosenberg S et al. Psychiatric Services 2004; 55:

660-4• ID specialists visited mental health facilities

– Nurse provided HIV and hepatitis testing, counseling, immunizations against hepatitis, and referrals for HIV positive persons

– Center one: 79% tested– Center two: 66% of dually diagnosed patients tested


Implementing testing• Philadelphia, PA – 11 community-assisted

living facilities • 65 veterans of unknown HIV status with SMI

who refused blood testing within prior 5 years• 64 consented to rapid oral fluid testing

– 3.1% positivity– Offered by nurses working with the patients

Jackson-Malik P et al. Rapid oral fluid testing for HIV in veterans with mental health diagnoses and residing in community-assisted living facilities. JANAC 2011; 22(2): 81-9


Potential Barriers


Barriers to HIV Testing in MH

• Lack of training• Discomfort with topic • Competing priorities• Discomfort giving results and counseling• Discomfort obtaining consent• Resource constraints• Patients may be uncomfortable with subject


Ethical and Legal Challenges• May be limited benefits for patients with SMI to

find out their status because some doctors delay treatment in those with SMI– Drug-drug interactions– Adherence concerns

• Adherence lower in depression• Inability to provide informed consent due to SMI• Duty to warn• Mandatory versus voluntary testing


Summation

• Testing in SMI for HIV should be considered• Routine screening, rather than just risk-

based, is preferred• “Opt-out” testing allowed in LA• Rapid tests still need to have confirmation• Barriers may exist to testing but can be

surmounted


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