HIV Psychiatry

Journal Article Annotations
2017, 4th Quarter

HIV Psychiatry

Annotations by John Grimaldi, MD, and Mary Ann Cohen, MD, FAPM
January 2018

  1. Increasing HIV testing in inpatient psychiatry

Also of interest:

PUBLICATION #1 — HIV Psychiatry
Increasing HIV testing in inpatient psychiatry
Shumway M, Mangurian C, Carraher N, et al


Type of study: A case control study examining the effect of three interventions on HIV testing rates

The finding: This observational study of patients admitted to an acute inpatient psychiatric unit examined the impact of 3 sequential, overlapping interventions intended to increase rates of HIV antibody testing from 2006-2012: 1) advocacy by an administrative champion, 2) an on-site HIV counselor, and 3) advocacy by a clinical champion. Using a general estimating equation model, retrospective analysis of demographic, length of stay and HIV testing data found that rates of HIV testing increased significantly from 6.5% prior to any intervention to 30.1% following full implementation of the 3 interventions, representing an almost 5-fold increase. The largest increase, from 7.2% to 25.1% occurred after a full-time HIV test counselor was added to the inpatient team. Patients who were white or had a longer duration of hospital stay were more likely to receive an HIV test than were black or Asian patients or patients with a shorter length of stay. Over the duration of the study, 1.6% of all patients tested HIV-positive.

Strength and weaknesses: The interventions were tested in a real-world setting and in a population with a significant HIV seroprevalence. The study utilized 2 low-cost interventions thus increasing the applicability to a wide range of settings. The time-limited high-intensity intervention, on-site HIV counseling, was followed by ongoing lower intensity interventions, further demonstrating the feasibility of replicating the interventions in other settings. The study is limited in several respects. No information is provided regarding the patients who tested HIV-positive and efforts to link them to care. The study also did not characterize the 70% of patients who were not tested beyond demonstrating an association between lower testing rates and being black or Asian or having a shorter inpatient stay. This is especially relevant given unequal access for blacks to HIV testing, prevention and treatment services in larger studies. Likewise, a significant proportion of the study population was admitted involuntarily for up to 72 hours of observation, leading to shorter stays and greater likelihood of refusing all bloodwork. Interestingly, few patients specifically refused HIV testing. The study was retrospective in design, relied on administrative data and occurred on a single inpatient psychiatry service in a major urban area. Because interventions overlapped, determining the individual impact of each intervention was not possible.

Relevance: This study is relevant for several reasons. Studies have consistently demonstrated higher than expected HIV prevalence in psychiatric populations, especially dually-diagnosed psychiatric inpatients. Similarly, psychiatric disorders are overrepresented among HV-infected clinical samples. Yet studies also show consistently low rates of HIV testing and HIV-related risk assessment on inpatient psychiatric services. Given this situation, it’s not surprising that the literature and CDC offer clinicians and administrators limited guidance and best practices for HIV testing in psychiatric inpatient as well as ambulatory care settings. This study demonstrates that HIV testing in the inpatient setting can be effective and is feasible with limited investment of resources. This message is even more compelling in light of higher mortality and poorer access to general medical care among individuals with severe mental illness. This vulnerable population should be among the beneficiaries of what is now known about the advantages of early HIV diagnosis and engagement in care.