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DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Implementation of HIV Testing in Mental Health Facilities 13 May 2011 Ronald D. Wilcox MD.

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Presentation on theme: "DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Implementation of HIV Testing in Mental Health Facilities 13 May 2011 Ronald D. Wilcox MD."— Presentation transcript:

1 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Implementation of HIV Testing in Mental Health Facilities 13 May 2011 Ronald D. Wilcox MD FAAP

2 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org www.deltaaetc.org504-903-0788

3 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

4 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org I am here today because: 1.I need CEUs 2.I thought the topic interesting 3.I was hoping bloody maries would be available 4.My boss forced me to come

5 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org CDC Recommendations for HIV Screening and Testing

6 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org The CDC recommends routine HIV testing from what age range 1.1 year to 13 years 2.13 years to 23 years 3.13 years to 50 years 4.13 years to 64 years 5.24 years to 99 years

7 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

8 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

9 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org HIV Diagnostic Testing Signs or symptoms of HIV infection Patients at high risk for HIV based on risk assessment, offered yearly

10 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org “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

11 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

12 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

13 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

14 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Testing Options

15 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org All of the following are antibody tests for HIV EXCEPT: 1.ELISA 2.Western Blot 3.Rapid Testing 4.Viral Load

16 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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 ELISANegative ELISA

17 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org ELISA - EIA Positive Control Negative Control Patient APatient BPatient CAssay Control 1.6890.1530.0550.4121.9990.123

18 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

19 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Structure of HIV Illustration from SCIENCE & TECHNOLOGY August 27, 2001 Volume 79, Number 35 CENEAR 79 35 pp. 37-44

20 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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 +- Indeterminate + Samples - Picture courtesy of www.msichicago.org/ed/AIDS/hivtst5.htm

21 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Interpreting HIV Serology HIV Positive =+ ELISA AND + Western Blot HIV Indeterminate =+ ELISA AND 1-2 bands on WB

22 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

23 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Interpreting HIV Serology

24 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

25 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Heavy alcohol use can give a false positive for which rapid HIV test? 1.Oraquick Advance 2.Multi-Spot 3.Clearview Stat-Pak 4.SIDA Rapida 5.None of the above

26 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Uni-Gold Recombigen Multispot HIV-1/HIV-2 Reveal G3 OraQuick Advance Clearview Complete HIV 1/2 Clearview HIV ½ Stat Pak

27 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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) Serum/plasma Reveal G3 Multispot 99.8 (99.2 – 100) 100 (99.9 – 100) 99.9 (98.6 – 100) 99.9 (99.8 – 100)

28 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

29 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

30 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

31 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

32 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Reveal G3 CLIA moderate complexity with serum, plasma Store at room temperature Perform test in 5 minutes Shelf life: 1 year

33 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

34 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

35 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Example: Test 1,000 persons HIV prevalence = 10% True positive: False positive: Positive predictive value:100/104 = 96% 1004 Test Specificity = 99.6%(4/1000)

36 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: 100False positive: 4 Positive predictive value: 100/104 = 96% HIV prevalence = 0.4% True positive:4False positive:4 Positive predictive value:4/8 = 50%

37 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

38 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org How does any of this apply to mental health facilities?

39 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Persons with mental illness are at increased risk for: 1.HIV 2.Hepatitis B 3.Hepatitis C 4.1 & 3 5.All of the above

40 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

41 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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):

42 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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)

43 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

44 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

45 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

46 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

47 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

48 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

49 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

50 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

51 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

52 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Reasons for refusal What might be some reasons people would refuse an HIV test?

53 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

54 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

55 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

56 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org Potential Barriers

57 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

58 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

59 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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

60 DELTA REGION AIDS EDUCATION AND TRAINING CENTER deltaaetc.org 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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