In HATIP 145 (September 17 2009) we reviewed the mental health care needs in people with HIV in resource-limited settings. This follow-up article looks at one particular mental health programme’s approach to integrating HIV care into its service.
People with severe mental illness are at high risk of HIV infection but because of the many disadvantages they face in life, few have access to needed HIV services, especially those within mental health institutions.
“The lives and well-being of psychiatric patients are threatened by the AIDS epidemic, and there is much clinicians can do to minimise the devastating impact of HIV and AIDS on clients in hospitals, clinics, and other psychiatric treatment settings,” according to McKinnon et al, who found a high burden of HIV, and a high frequency of HIV related risk-taking behaviours among people with psychiatric disorders in the US.1
There have been a few similar reports in resource-limited settings.
“All patients can benefit from a sexual health assessment as a part of standard clinical care,” wrote Carey et al after their survey found higher than expected rates of sexually transmitted infections, including HIV, among mental health patients in India.2 “This recommendation may seem obvious. However, research has shown that mental health providers often do not receive training in human sexuality; some providers believe that patients should not be sexually active, or that the mentally ill are too disabled to be sexually active, or that discussion of sexual matters may exacerbate patients' psychopathology... All patients should be encouraged to participate in counselling and testing for HIV and other STIs.”
This pattern of denying that people with mental illness could still be sexually active led Dr Pamela Collins of Columbia University and colleagues to perform an intervention to change this attitude among healthcare workers in South Africa.3 Many of the nurses had HIV themselves, but were extremely reluctant to talk about sex with their clients.
The irony is, according to Joska, Kaliski, and Benatar, that many of the severely disabled are institutionalised without their consent — and yet their consent may be required to provide them with HIV testing services, which could lead to treatment that would save their lives.4 “It is in the best interests of those with severe mental illnesses, who often lack the ability and means to engage in safe sexual practice, to test for HIV infection for prevention and treatment. These patients cannot be denied the opportunity to benefit from treatment,” they wrote.
Gradually, new guidelines for testing and treatment are emerging, however thus far there are not many reports of HIV services being successfully integrated into mental health services.
Integration of HIV into mental health services in Rwanda
This year at the HIV Implementers’ Meeting, when Dr Alfred Ngirababyeyi described the integration of HIV care and treatment services into Ndera Neuropsychiatric Hospital, in Rwanda.5
According to Dr Ngirababyeyi, hospital staff were observing HIV neurological disorders in their patients. Many were in denial of their HIV status or suffered from severe anxiety about HIV — but these patients did not have the same access to ART as other populations in Rwanda.
So last November, the hospital piloted an HIV programme in collaboration with ICAP, and MON through the Treatment Research HIV/AIDS Center (the TRACPlus).
Thirty-one staff members were trained in November on HIV counselling and testing and eight in HIV care and treatment. TRACPlus and ICAP provided on-site training and clinical mentorship to Ndera staff.
In January this year, a workshop was held to discuss key issues that the hospital needed to tackle including obtaining consent for HIV testing among people with mental illness; developing adherence tools, planning for follow-up care of patients leaving the hospital, patient flow, principles of disclosure and the interactions between psychiatric medication and ART. Algorithms and protocols drafted during the workshop have since been finalised.
Structure of HIV services at Ndera
Nurses, psychologists and social workers began providing assessments and individual counselling at the hospital. Pre- and post-test counselling were provided in an HIV clinic that was set up in the hospital, with ART initiation and follow up provided at the clinic. Nurses also provided group education on HIV to clients in the pre-discharge wards. The clinic routinely collects data on demographic variables, HIV serostatus, the uptake of testing, psychiatric diagnosis and medication, the ART regimen prescribed, enrolment onto ART, adherence and retention in care — and reports these data to ICAP and TRACPlus on a monthly basis.
Between January and the end of April 2009, 192 patients received HIV counselling and testing. Eighteen tested positive, and other HIV-positive clients with mental illnesses were referred from other settings. Overall, 31 were enrolled into HIV care (12 men and 19 women). 29% have schizophrenia, 10% mania, 19% bipolar disorder, 10% drug abuse, 22% depression and 10% are currently without a mental health diagnosis.
Eleven have begun ART. One patient with advanced AIDS at the start of the programme has since died. Five have missed follow-up appointments after leaving the facility but they followed them up with phone-calls and home visits.
The next steps
Training of the Ndera staff will continue on HIV/AIDS issues, then expand to all district hospital mental health teams and district hospital HIV care teams on mental health issues. This will be organised with the MoH.
Adherence assessment tools specific to psychiatric settings are being finalised (this includes psychiatric symptom assessments to systematically document mental health status.
Dr Ngirababyeyi say that they plan to develop mentorship and supervision procedures in collaboration with TRACPlus and National Mental Health program, and to renovate facilities to extend the programme.
“We are also planning programme implementation in the district hospitals and peripheral health facilities,” he said. Research protocols are in development to study how HIV interacts with mental health, and for new and improved treatment strategies in people with HIV and mental health problems.
“ The current programme suggests that integration of HIV and mental health services is feasible in a Rwandan tertiary care psychiatric facility,” said Dr Ngirababyeyi. “And with continued training and mentoring; careful monitoring of ethical considerations; development of referral strategies and adherence support; and documentation of challenges and lessons learned accompanied by collaborative problem-solving, Ndera Hospital will be able to successfully integrate HIV services into routine care and can be a model for integration into other settings.”
 McKinnon K, Cournos F, Herman R. HIV among people with chronic mental illness. Psychiatry Quarterly 73:17–31, 2002.
 Carey MP et al. Prevalence of infection with HIV among the seriously mentally ill: review of the research and implications for practice. Prof Psychol Res Pract; 26:262–268, 1995.
 Collins PY et al. Training South African mental health care providers to talk about sex in the era of AIDS. Psychiatric Services 57:1644– 1647, 2006.
 Joska JA, Kaliski SZ, Benatar SR. Patients with severe mental illness: a new approach to testing for HIV. S Afr Med J 98: 630-634, 2008.
 Ngirababyeyi, A et al. Integration of HIV care and treatment services into psychiatric care in Rwanda. HIV Implementers' Meeting, Windhoek, 2009.