Implementation of HIV Testing
in Mental Health Facilities
13 May 2011
Ronald D. Wilcox MD FAAP
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www.deltaaetc.org
504-903-0788
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Please indicate your profession:
1. Mental Health
Counselor
2. Administrator
3. Social Worker
4. Primary Care Provider
5. HIV Specialist
6. Nurse
7. Pharmacist
8. Other
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I am here today because:
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CDC Recommendations for
HIV Screening and Testing
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The CDC recommends routine HIV testing from
what age range
20%
20%
20%
20%
20%
1.
2.
3.
4.
5.
1 year to 13 years
13 years to 23 years
13 years to 50 years
13 years to 64 years
24 years to 99 years
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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
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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
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HIV Diagnostic Testing
• Signs or symptoms of HIV infection
• Patients at high risk for HIV based on risk
assessment, offered yearly
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“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
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Per the 2006 CDC
recommendations, positive results
of HIV testing can be given at
minimum:
1. Over the loud
speaker
2. In person only
3. In writing
4. To everyone in the
family
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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
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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
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Testing Options
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All of the following are antibody tests for HIV
EXCEPT:
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1. ELISA
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2. Western Blot
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3. Rapid Testing
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4. Viral Load
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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
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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
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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
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Structure of HIV
Illustration from SCIENCE & TECHNOLOGY
August 27, 2001 Volume 79, Number 35 CENEAR 79 35 pp. 37-44
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Western Blot
4. 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
-
+
Samples
-
+ Indeterminate
Picture courtesy of www.msichicago.org/ed/AIDS/hivtst5.htm
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Interpreting HIV Serology
• HIV Positive =
• HIV Indeterminate =
+ ELISA
AND
+ Western Blot
+ ELISA
AND
1-2 bands on WB
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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
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Interpreting HIV Serology
HIV Indeterminate
Seroconversion
suspected
HIV-2
suspected
Low risk
patient
Obtain
viral load
Obtain
HIV-2 WB
Retest in
3-4 months
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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
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Heavy alcohol use can give a false
positive for which rapid HIV test?
1.
2.
3.
4.
5.
Oraquick Advance
Multi-Spot
Clearview Stat-Pak
SIDA Rapida
None of the above
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Uni-Gold Recombigen
Multispot HIV-1/HIV-2
Reveal
G3
OraQuick Advance
Clearview Complete HIV
1/2
Clearview HIV ½ Stat Pak
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FDA-approved Rapid HIV Tests
Oral fluid
OraQuick Advance
Whole blood
Un-Gold Recombigen
Stat-Pak
Sure Check
Serum/plasma
Reveal G3
Multispot
Sensitivity
(95% C.I.)
Specificity
(95% C.I.)
99.3 (98.4 - 99.7)
99.8 (99.6-99.9)
100 (99.5 – 100)
99.7 (98.9 – 100)
99.7 (98.9 – 100)
99.7 (99.0 – 100)
99.9 (98.6 – 100)
99.9 (98.6 – 100)
99.8 (99.2 – 100)
100 (99.9 – 100)
99.9 (98.6 – 100)
99.9 (99.8 – 100)
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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
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Uni-Gold Recombigen
• CLIA-waived for finger stick,
whole blood
• Store at room temperature
• Screens for HIV-1
• Read time 10-12 minutes
• Shelf life: 1 year
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Clearview Complete HIV 1/2
• CLIA-waived for whole blood
• Store at room temperature
• Screens for HIV-1 and 2
• Read time 15-20 minutes
• Shelf life: 2 years
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Clearview HIV-1/2 Stat-Pak
• Clia-waived for whole
blood and fingerstick
• Store at room temperature
• Screens for HIV-1 and 2
• Read time 15-20 minutes
• Shelf life: 2 years
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Reveal G3
• CLIA moderate complexity
with serum, plasma
• Store at room temperature
• Perform test in 5 minutes
• Shelf life: 1 year
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Multispot HIV-1/HIV-2
• CLIA moderate complexity
with serum, plasma
• Refrigerate reagents
• Distinguishes HIV-1 from HIV2
• Perform test in 15 minutes
• Shelf life: 1 year refrigerated,
3 months room temperature
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Interpreting Rapid Test Results
For a laboratory test:
Sensitivity: Probability test=positive if patient=positive
Specificity: Probability test=negative if patient=negative
Predictive value:
PPV is Probability patient=positive if test=positive
NPV is Probability patient=negative if test=negative
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Example: Test 1,000 persons
Test Specificity = 99.6% (4/1000)
HIV prevalence = 10%
True
positive:
100
False
positive:
Positive predictive value:
4
100/104 = 96%
DELTA REGION AIDS EDUCATION AND TRAINING CENTER • deltaaetc.org
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%
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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
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How does any of this apply to
mental health facilities?
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Persons with mental illness are at increased risk for:
1.
2.
3.
4.
5.
HIV
Hepatitis B
Hepatitis C
1&3
All of the above
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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
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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):
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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)
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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
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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
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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
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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
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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 schizophreniaspectrum 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
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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
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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
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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
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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
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Reasons for refusal
• What might be some reasons people would
refuse an HIV test?
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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
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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
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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
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Potential Barriers
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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
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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
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Summation
• Testing in SMI for HIV should be considered
• Routine screening, rather than just riskbased, 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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I found the information in this presentation:
1. Very informative and
applicable
2. Somewhat informative
and applicable
3. Staid and boring
4. Fascinating because I
got a lot of work done
on my cell phone
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