Assessing the prevalence of HIV, HBV, and HCV infection among people with severe mental illness

Abstract

People with severe mental illness are at higher risk for HIV infection than the general population. Early studies in New York1Cournos F McKinnon K HIV seroprevalence among people with severe mental illness in the United States: a critical review.Clin Psychol Rev. 1997; 17: 259-269Crossref PubMed Scopus (181) Google Scholar suggested that the prevalence of HIV infection among people with severe mental illness was variable, depending on factors such as homelessness, treatment setting and status, specific psychotic diagnosis, dual diagnosis with substance use disorders, and sampling method (open vs anonymous). General population risk factors for HIV infection also have their expected effects in people with severe mental illness, including high-risk sexual activity (among men who have sex with men, heterosexuals, or injection drug users), injection drug use, ethnicity, gender, age, and viral load at time of exposure. Additional factors directly related to severe mental illness are cognitive impairment and psychotic symptoms that impede the planned use of precautions for risk in sexual activity and injection drug use, which present special difficulties to controlling HIV in this population.2Singh D Goodkin K Psychopharmacologic treatment responses of HIV-infected patients to antipsychotic medications.J Clin Psychiatry. 2007; 68: 631-632Crossref PubMed Google Scholar Thus, the efficacy of antipsychotic treatment and adherence to treatment is relevant to the risk of blood-borne infections in people with severe mental illness.In The Lancet Psychiatry, Elisabeth Hughes and colleagues3Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2015; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar make a major contribution to this subject by examining the prevalences of HIV, hepatitis C virus, and hepatitis B virus infection simultaneously in patients with severe mental illness. They used a well-defined approach to identify relevant articles and to define the studies by specific conditions of testing (although “AIDS” could have been added as a search term and AIDSLine as a database). They included people aged older than 15 years, diagnosed with severe mental illness, and treated in a psychiatric setting. Studies in which prevalence data were obtained only from case notes, self-report, or the grey literature were excluded. They determined the eligibility of studies by a consensus strategy and used the Quality Assessment Tool for Systematic Reviews of Observational Studies4Wong WCW Cheung CSK Hart GJ Development of a quality assessment tool for systematic reviews of observational studies (QATSO) of HIV prevalence in men having sex with men and associated risk behaviours.Emerg Themes Epidemiol. 2008; 5: 23Crossref PubMed Scopus (187) Google Scholar to assess study quality. Hughes and colleagues3Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2015; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar modified the tool to show whether participants were clearly defined as having severe mental illness (yes or no), participation rate (>60%=1, ≤60%=0), whether control variables were used (controlled=1, only descriptive=0), and sample size (≥200 participants=1, <200 participants=0), although the effects of these modifications on reliability and validity are not known. They did a meta-analysis to calculate combined estimates and 95% CIs for each continent. Logistic regression was done to allow for the proportions being unable to have values less than 0, and random effects were assumed because there was clear clinical heterogeneity among the samples.The 373 reports they found included 169 (45%) duplicates and they excluded 41 (11%) because the full-text was not available in English and 74 (20%) because they were deemed ineligible. With the addition of two papers from an updated search, the authors had 91 articles for assessment. This reduction might limit the generalisability of the findings. HIV infection had the largest sample size and was the subject of the most studies: 44 studies assessed HIV (21 071 patients), 19 assessed hepatitis B virus (8163 patients), and 28 studies assessed hepatitis C virus (14 888 patients). Most of the HIV and hepatitis C virus studies were from the USA, and few were from Europe, although the investigators attempted to control for continent. Ultimately, the most important unit for analysis here might be number of studies rather than the cumulative number of participants across studies.5Goodkin K Feaster D Meta-analysis and the need for study quality control.Pain Forum. 1998; 7: 90-94Summary Full Text PDF Google ScholarMost studies used convenience samples from in-patient psychiatric treatment settings; yet, the studies show that data from patients who are not in treatment are needed to best approximate the entire population of patients with severe mental illness.1Cournos F McKinnon K HIV seroprevalence among people with severe mental illness in the United States: a critical review.Clin Psychol Rev. 1997; 17: 259-269Crossref PubMed Scopus (181) Google Scholar It is also important to estimate the number of patients with severe mental illness who are dually diagnosed with substance use disorders to maximise generalisability, because blood-borne infections are much more common in this group.6Devieux JG Malow R Lerner BG et al.Triple jeopardy for HIV: substance using severely mentally ill adults.J Prev Interv Community. 2007; 33: 5-18Crossref PubMed Scopus (28) Google Scholar Another issue not addressed by Hughes and colleagues3Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2015; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar was the percentage of patients with dual and triple co-infections. Hepatitis C virus co-infection occurs in as many as 25% of patients with HIV in the USA.7Strader DB Coinfection with HIV and hepatitis C virus in injection drug users and minority populations.Clin Infect Dis. 2005; 41: S7-13Crossref PubMed Scopus (38) Google Scholar Worldwide, 10% of patients with HIV are co-infected with hepatitis B virus,8Soriano V Labarga P de Mendoza C et al.Emerging challenges in managing hepatitis B in HIV patients.Curr HIV/AIDS Rep. 2015; 12: 344-352Crossref PubMed Scopus (21) Google Scholar with as many as 20% in southeast Asia. The exact number of patients co-infected with hepatitis B virus and hepatitis C virus is unknown; an estimated 9–30% of patients with chronic hepatitis B virus infection are co-infected with hepatitis C virus.9Crockett SD Keeffe EB Natural history and treatment of hepatitis B virus and hepatitis C virus coinfection.Ann Clin Microbiol Antimicrob. 2005; 4: 13Crossref PubMed Scopus (85) Google Scholar Finally, triple infection has been reported in less than 1% of residents in Nairobi, Kenya,10Kerubo G Khamadi S Okoth V et al.Hepatitis B, hepatitis C and HIV-1 coinfection in two informal urban settlements in Nairobi, Kenya.PLoS One. 2015; 10: e0129247Google Scholar and in as many as 12% of patients with HIV infection in central China.11Chen X He JM Ding LS Zhang GQ Zou XB Zheng J Prevalence of hepatitis B virus and hepatitis C virus in patients with human immunodeficiency virus infection in Central China.Arch Virol. 2013; 158: 1889-1894Crossref PubMed Scopus (28) Google Scholar Hence, assessing the proportion of patients with severe mental illness who have these co-infections would be of interest. For patients with HIV, a report of their CD4 cell count and Centers for Disease Control and Prevention clinical disease stage at the time of infection would be useful to gauge the chronicity of infection and relate it to the psychiatric and trauma history of these patients. The distribution of HIV risk factors in this subgroup would also be worthy of examination.Hughes and colleagues3Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2015; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar state that although 30–50% of patients with severe mental illness have substance use disorders, intravenous drug use in this population is rare. Yet, the primary route of transmission of hepatitis B virus and hepatitis C virus is by intravenous drug use (globally roughly 90% for hepatitis C virus), and intravenous drug use is a lesser but significant risk for HIV infection. More than 25% of homeless people with severe mental illness in one study reported the use of intravenous drugs at some time in their lives,12Linn GL Brown M Kendrick L Injection drug use among homeless adults in the southeast with severe mental illness.J Health Care Poor Underserved. 2005; 16: 83-90Crossref PubMed Scopus (9) Google Scholar which is probably generally representative of the USA. Another factor that bears on estimates of the prevalence of these viral infections in people with severe mental illness is the percentage of homeless patients included in these studies. Although all the studies included patients characterised as having severe mental illness, the proportions of specific psychotic diagnoses in each sample varied, and the method of ensuring that patients had severe mental illness rather than simply being psychiatric in-patients was not presented. Furthermore, although the sensitivity analyses showed no effect of study quality on these prevalences, the lack of such an effect does not prove that study quality is irrelevant.In conclusion, Hughes and colleagues' focus on the concomitant estimations of prevalence of HIV, hepatitis B virus, and hepatitis C virus infections in people with severe mental illness is an important first effort to examine the broader issue of this group's medical susceptibility. Future studies should examine the prevalence of co-infections of these three viruses, the relations between risk factors and contracting infection as well as the necessary controls needed in analyses for each of these infections. The generalisability of the risk factor distributions reported should be assessed separately against those of the entire population for each infection. A random sampling approach would be helpful in future studies of this population. Most importantly, it cannot be concluded that only typical viral risk factors apply to this population when the risk factors specific to patients with severe mental illness have not been taken into account (eg, cognitive impairment and psychotic symptom severity). Patients with severe mental illness often have chronic cognitive impairment, which can impede their adherence to antipsychotic medications, resulting in ongoing psychotic symptoms that prevent access to and implementation of precautions to prevent these infections. Future research should assess the contributions of these factors to the additional risk for these infections in patients with severe mental illness. Health providers in the USA should discuss sexual health and risk for blood-borne viral infections with patients who have severe mental illness and offer HIV testing to all patients aged 13–64 years at least once in their lifetime and offer hepatitis C virus testing once to all adults born between 1945 and 1965 (without previous ascertainment of risk factors for hepatitis C virus), as per guidelines of the Centers for Disease Control and Prevention; screening for hepatitis B virus should be offered only under specific circumstances (continuing risk should result in more frequent testing). Internationally, WHO sets screening guidelines for HIV, hepatitis B virus, and hepatitis C virus.For WHO guidelines on hepatitis B virus testing see http://www.worldhepatitisalliance.org/sites/default/files/resources/documents/Hep%20B%20Guidelines.pdfThis online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on March 2, 2016I declare no competing interests. People with severe mental illness are at higher risk for HIV infection than the general population. Early studies in New York1Cournos F McKinnon K HIV seroprevalence among people with severe mental illness in the United States: a critical review.Clin Psychol Rev. 1997; 17: 259-269Crossref PubMed Scopus (181) Google Scholar suggested that the prevalence of HIV infection among people with severe mental illness was variable, depending on factors such as homelessness, treatment setting and status, specific psychotic diagnosis, dual diagnosis with substance use disorders, and sampling method (open vs anonymous). General population risk factors for HIV infection also have their expected effects in people with severe mental illness, including high-risk sexual activity (among men who have sex with men, heterosexuals, or injection drug users), injection drug use, ethnicity, gender, age, and viral load at time of exposure. Additional factors directly related to severe mental illness are cognitive impairment and psychotic symptoms that impede the planned use of precautions for risk in sexual activity and injection drug use, which present special difficulties to controlling HIV in this population.2Singh D Goodkin K Psychopharmacologic treatment responses of HIV-infected patients to antipsychotic medications.J Clin Psychiatry. 2007; 68: 631-632Crossref PubMed Google Scholar Thus, the efficacy of antipsychotic treatment and adherence to treatment is relevant to the risk of blood-borne infections in people with severe mental illness. In The Lancet Psychiatry, Elisabeth Hughes and colleagues3Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2015; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar make a major contribution to this subject by examining the prevalences of HIV, hepatitis C virus, and hepatitis B virus infection simultaneously in patients with severe mental illness. They used a well-defined approach to identify relevant articles and to define the studies by specific conditions of testing (although “AIDS” could have been added as a search term and AIDSLine as a database). They included people aged older than 15 years, diagnosed with severe mental illness, and treated in a psychiatric setting. Studies in which prevalence data were obtained only from case notes, self-report, or the grey literature were excluded. They determined the eligibility of studies by a consensus strategy and used the Quality Assessment Tool for Systematic Reviews of Observational Studies4Wong WCW Cheung CSK Hart GJ Development of a quality assessment tool for systematic reviews of observational studies (QATSO) of HIV prevalence in men having sex with men and associated risk behaviours.Emerg Themes Epidemiol. 2008; 5: 23Crossref PubMed Scopus (187) Google Scholar to assess study quality. Hughes and colleagues3Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2015; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar modified the tool to show whether participants were clearly defined as having severe mental illness (yes or no), participation rate (>60%=1, ≤60%=0), whether control variables were used (controlled=1, only descriptive=0), and sample size (≥200 participants=1, <200 participants=0), although the effects of these modifications on reliability and validity are not known. They did a meta-analysis to calculate combined estimates and 95% CIs for each continent. Logistic regression was done to allow for the proportions being unable to have values less than 0, and random effects were assumed because there was clear clinical heterogeneity among the samples. The 373 reports they found included 169 (45%) duplicates and they excluded 41 (11%) because the full-text was not available in English and 74 (20%) because they were deemed ineligible. With the addition of two papers from an updated search, the authors had 91 articles for assessment. This reduction might limit the generalisability of the findings. HIV infection had the largest sample size and was the subject of the most studies: 44 studies assessed HIV (21 071 patients), 19 assessed hepatitis B virus (8163 patients), and 28 studies assessed hepatitis C virus (14 888 patients). Most of the HIV and hepatitis C virus studies were from the USA, and few were from Europe, although the investigators attempted to control for continent. Ultimately, the most important unit for analysis here might be number of studies rather than the cumulative number of participants across studies.5Goodkin K Feaster D Meta-analysis and the need for study quality control.Pain Forum. 1998; 7: 90-94Summary Full Text PDF Google Scholar Most studies used convenience samples from in-patient psychiatric treatment settings; yet, the studies show that data from patients who are not in treatment are needed to best approximate the entire population of patients with severe mental illness.1Cournos F McKinnon K HIV seroprevalence among people with severe mental illness in the United States: a critical review.Clin Psychol Rev. 1997; 17: 259-269Crossref PubMed Scopus (181) Google Scholar It is also important to estimate the number of patients with severe mental illness who are dually diagnosed with substance use disorders to maximise generalisability, because blood-borne infections are much more common in this group.6Devieux JG Malow R Lerner BG et al.Triple jeopardy for HIV: substance using severely mentally ill adults.J Prev Interv Community. 2007; 33: 5-18Crossref PubMed Scopus (28) Google Scholar Another issue not addressed by Hughes and colleagues3Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2015; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar was the percentage of patients with dual and triple co-infections. Hepatitis C virus co-infection occurs in as many as 25% of patients with HIV in the USA.7Strader DB Coinfection with HIV and hepatitis C virus in injection drug users and minority populations.Clin Infect Dis. 2005; 41: S7-13Crossref PubMed Scopus (38) Google Scholar Worldwide, 10% of patients with HIV are co-infected with hepatitis B virus,8Soriano V Labarga P de Mendoza C et al.Emerging challenges in managing hepatitis B in HIV patients.Curr HIV/AIDS Rep. 2015; 12: 344-352Crossref PubMed Scopus (21) Google Scholar with as many as 20% in southeast Asia. The exact number of patients co-infected with hepatitis B virus and hepatitis C virus is unknown; an estimated 9–30% of patients with chronic hepatitis B virus infection are co-infected with hepatitis C virus.9Crockett SD Keeffe EB Natural history and treatment of hepatitis B virus and hepatitis C virus coinfection.Ann Clin Microbiol Antimicrob. 2005; 4: 13Crossref PubMed Scopus (85) Google Scholar Finally, triple infection has been reported in less than 1% of residents in Nairobi, Kenya,10Kerubo G Khamadi S Okoth V et al.Hepatitis B, hepatitis C and HIV-1 coinfection in two informal urban settlements in Nairobi, Kenya.PLoS One. 2015; 10: e0129247Google Scholar and in as many as 12% of patients with HIV infection in central China.11Chen X He JM Ding LS Zhang GQ Zou XB Zheng J Prevalence of hepatitis B virus and hepatitis C virus in patients with human immunodeficiency virus infection in Central China.Arch Virol. 2013; 158: 1889-1894Crossref PubMed Scopus (28) Google Scholar Hence, assessing the proportion of patients with severe mental illness who have these co-infections would be of interest. For patients with HIV, a report of their CD4 cell count and Centers for Disease Control and Prevention clinical disease stage at the time of infection would be useful to gauge the chronicity of infection and relate it to the psychiatric and trauma history of these patients. The distribution of HIV risk factors in this subgroup would also be worthy of examination. Hughes and colleagues3Hughes E Bassi S Gilbody S Bland M Martin F Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2015; 3: 40-48Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar state that although 30–50% of patients with severe mental illness have substance use disorders, intravenous drug use in this population is rare. Yet, the primary route of transmission of hepatitis B virus and hepatitis C virus is by intravenous drug use (globally roughly 90% for hepatitis C virus), and intravenous drug use is a lesser but significant risk for HIV infection. More than 25% of homeless people with severe mental illness in one study reported the use of intravenous drugs at some time in their lives,12Linn GL Brown M Kendrick L Injection drug use among homeless adults in the southeast with severe mental illness.J Health Care Poor Underserved. 2005; 16: 83-90Crossref PubMed Scopus (9) Google Scholar which is probably generally representative of the USA. Another factor that bears on estimates of the prevalence of these viral infections in people with severe mental illness is the percentage of homeless patients included in these studies. Although all the studies included patients characterised as having severe mental illness, the proportions of specific psychotic diagnoses in each sample varied, and the method of ensuring that patients had severe mental illness rather than simply being psychiatric in-patients was not presented. Furthermore, although the sensitivity analyses showed no effect of study quality on these prevalences, the lack of such an effect does not prove that study quality is irrelevant. In conclusion, Hughes and colleagues' focus on the concomitant estimations of prevalence of HIV, hepatitis B virus, and hepatitis C virus infections in people with severe mental illness is an important first effort to examine the broader issue of this group's medical susceptibility. Future studies should examine the prevalence of co-infections of these three viruses, the relations between risk factors and contracting infection as well as the necessary controls needed in analyses for each of these infections. The generalisability of the risk factor distributions reported should be assessed separately against those of the entire population for each infection. A random sampling approach would be helpful in future studies of this population. Most importantly, it cannot be concluded that only typical viral risk factors apply to this population when the risk factors specific to patients with severe mental illness have not been taken into account (eg, cognitive impairment and psychotic symptom severity). Patients with severe mental illness often have chronic cognitive impairment, which can impede their adherence to antipsychotic medications, resulting in ongoing psychotic symptoms that prevent access to and implementation of precautions to prevent these infections. Future research should assess the contributions of these factors to the additional risk for these infections in patients with severe mental illness. Health providers in the USA should discuss sexual health and risk for blood-borne viral infections with patients who have severe mental illness and offer HIV testing to all patients aged 13–64 years at least once in their lifetime and offer hepatitis C virus testing once to all adults born between 1945 and 1965 (without previous ascertainment of risk factors for hepatitis C virus), as per guidelines of the Centers for Disease Control and Prevention; screening for hepatitis B virus should be offered only under specific circumstances (continuing risk should result in more frequent testing). Internationally, WHO sets screening guidelines for HIV, hepatitis B virus, and hepatitis C virus. For WHO guidelines on hepatitis B virus testing see http://www.worldhepatitisalliance.org/sites/default/files/resources/documents/Hep%20B%20Guidelines.pdf For WHO guidelines on hepatitis B virus testing see http://www.worldhepatitisalliance.org/sites/default/files/resources/documents/Hep%20B%20Guidelines.pdf For WHO guidelines on hepatitis B virus testing see http://www.worldhepatitisalliance.org/sites/default/files/resources/documents/Hep%20B%20Guidelines.pdf This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on March 2, 2016 This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on March 2, 2016 This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on March 2, 2016 I declare no competing interests. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysisPeople with serious mental illness are at risk of blood-borne viral infections. However, because of methodological limitations of the studies the prevalence might be overestimated. Serious mental illness is unlikely to be a sole risk factor and risk of blood-borne viral infection is probably multifactorial and associated with low socioeconomic status, drug and alcohol misuse, ethnic origin, and sex. Health providers should routinely discuss sexual health and risks for blood-borne viruses (including risks related to drug misuse) with people who have serious mental illness, as well as offering testing and treatment for those at risk. Full-Text PDF Open AccessCorrectionsGoodkin K. Assessing the prevalence of HIV, HBV, and HCV infection among people with severe mental illness. Lancet Psychiatry 2016; 3: 4–6—The copyright for this comment was incorrect. It should have been Open Access, under the CC-BY-NC-ND licence. This change has been made to the online version as of March 2, 2016. Full-Text PDF