Department of Health Sciences

1. Department of Health Sciences Systematic review of research of testing psychiatric inpatients for blood borne viruses and scoping project

2. Aims • Background regarding sexual health and serious mental illness (SMI) • To present the findings of a systematic review of prevalence of Blood borne viruses in people with SMI • To present the findings of the systematic review of behavioural interventions to reduce sexual risk taking in people with SMI

3. Definition of Serious Mental health Problems • SMI- chronic and disabling mental health problems such as psychoses- schizophrenia, schizoaffective disorder, bipolar, and severe depressive illness • These usually require ongoing treatment by NHS secondary mental health services • Characterized as chronic relapsing conditions • Often associated with co-morbid substance misuse; at least a 1/3 of people receiving care for some form of psychosis also have a significant drug and/or alcohol problem • Sometimes accompanied by personality disorders as well

4. HIV Risk Behaviour • People with SMI have sex and engage in high risk sexual behaviour (unprotected anal/vaginal intercourse; sex swapping, high risk partner e.g. IVDU) • Carey (1999) 11% reported HIV risk behaviour. • Carey et al (2001) reported that 23% had engaged in risky sexual behaviour. • Davidson et al (2001) found that half of the sample reported being sexually active in the past year; and half of the women and a fifth of the men reported having had sex with causal partners without using a condom. • Carey et al (2004) people with mood disorders had higher rates of sexual risk behaviours, than those with SMI • Meade (2006)41% sexual activity • 29% multiple partners • 32% non-monogamous partners • 15% sex with a stranger • 5% traded sex • 55% never wore condoms

5. Why the increased risk? • Factors associated with sexual risk-taking: • History of childhood sexual abuse • More likely be vulnerable to exploitation and abuse as adults • Active symptoms • Affecting decision-making; hyper-sexuality • Lack of social support • More vulnerable to exploitative and damaging relationships if choices are limited (self-stigma too) • Co-morbid drug and alcohol use • Intoxication • Obtaining drugs via sex work/ swapping • Association with IVDUs

6. Team • ShaanBassi- Biology graduate and research assistant • Dr Fabiola Martin- Consultant in sexual health and sexual health infection researcher University of York/ Hull York Medical School • Dr Simon Gilbody- Professor in mental health and Head of Mental Health Research group, University of York/ Hull York Medical School • Members of the Leeds Dual Diagnosis Expert Group

7. BBV and mental health • People with long term mental health problems are more at risk of BBV than the general population • Mental health services don’t routinely offer sexual health promotion or testing • There is evidence from the USA that having a diagnosis of schizophrenia greatly complicates the treatment adherence and adoption of behavioural interventions in the treatment of HIV. • There is also evidence that people with SMI have co-infection with HIV and Hepatitis C. Hepatitis C is now responsible for more deaths in the USA than HIV. • Hepatitis C is a chronic illness with low grade symptoms (fatigue, malaise, low mood) which can be attributed to MH problem; however if untreated can lead to reduced life expectancy (liver cancer, cirrhosis) and especially problematic if heavy drinking too. • Surprisingly this is an under-researched area in the UK and there is an urgent need for research that would help to inform the development of routine BBV testing and treatment services within mental health inpatient units • Also neglected by policy- mental health and sexual health policy doesn't recognise people with SMI as a key group at increased risk.

8. C2D2: Scoping Project and Systematic Review • C2D2 is a funding stream from Wellcome Trust promoting interdisciplinary research focusing on chronic disease conditions • 6 months • Collaboration between Biology (Centre for Immunology and Infection) York/HYMS, and Department of Health Sciences Mental Health Research Group

9. Aims of the project • Systematic review of prevalence of HIV, Hepatitis B and C in people with serious mental illness • Engagement of key collaborators: service users, NHS services, other academics • Develop further research ideas and proposals

10. Systematic review • Participants: of any age dx with SMI*, treated in any psychiatric setting • Observational studies where tested for HIV, Hep B and/or C • Opt-in or out; consent or anonymous unlinked • Searched Cochrane library, MEDLINE, EMBASE, Psychinfo, CINAHL, and DARE jan 1st 1980-June 5th 2012

11. Method • Search was undertaken • Stage 1- after removal of duplicates, all papers were screened by title and abstract against inclusion criteria • Stage 2- full papers were retrieved and if fitted inclusion criteria were included for quality assessment and data extraction • Discussions were had between researchers around exclusion at stage 2 for any papers that were ambiguous • Quality assessment- all papers were assessed using a modifed version of the QATSO- assessed in 4 areas and received a score of max 4 • Was diagnosis clearly established as SMI • Response rate • Control for confounders • Sample size greater than or equal to 200

12. Results • A total of 373 abstracts were initially retrieved and a total of 99 studies were included in the analysis (from 92 papers) • Heterogeneous studies (no meta-analysis) • Many were convenience samples • Selection bias • Only 3/99 scored 4 on modified QATSO • Many papers failed to report rate of participation (e.g. how many eligible people refused to participate from the population?) • 39% did not receive or report gaining consent from participants • 48% reported gaining ethical approval (22% not reporting; 29% being retrospective studies analysing medical records) • Since 2008- this has improved. Out of 29 published studies, 76% reported ethical approval

13. Quality assessment questions (based on QATSO): • If the diagnosis was clearly defined as “SMI” not non-psychotic/primary care setting • If the study reported a response rate? (If the reported response rate was below 60% of the available eligible sample- it received 0) • If the investigator(s) controlled for confounding factors (e.g. stratification/ matching/ restriction/ adjustment) when analyzing the associations (if the study contains purely descriptive results and no association and prediction tests were conducted it received 0), • If the sample size was more than or equal to 200.

14. Range of quality scores

15. Key HIV Prevalence Rates • A third of all studies identified in this review were conducted in the North American continent (USA and Canada) (n=36; 36%) with an average prevalence rate of HIV =2.9%. (gen pop=0.6%) • Africa: the highest HIV prevalence rate 24.2% (n=8). • HIV rates are also higher in the homeless populations, and those who had high risk factors for BBV infection (such as intravenous drug use), 11.5% (n=7) for the former and 12.7% (n=3) for the latter. • Co-morbid substance use may well be a factor of interest- Himelhoch et al. investigated the rates of HIV and HCV in an outpatient urban sample of 153 people with serious mental illness and co-occurring substance abuse and found HIV prevalence rate of 6.1%, USA. • De Hert et al. reported a rate of 0.5% in a sample of 595 schizophrenic and schizoaffective patients in Belgium (11), with Beyer et al. finding a rate of 2.56% in 11,284 bipolar and psychiatric patients in outpatients, USA . • Comparatively, these samples do not offer an adjusted figure however it suggests a higher rate of HIV prevalence in individuals with SMI compared to the general population.

16. Hepatitis B and C • HBV prevalence rates in individuals with mental illness vary considerably, from an overall prevalence rate of 40.7% in a long term psychiatric hospital in Italy (21), 2% in a psychiatric hospital in Greece (22), with a prevalence of 14.7% and 1.64% for active and previous HBV exposure in Brazil (23) . • The use of different serological markers, in which some researchers record current HBV infection (HBsAg positive), whilst others look at prior-exposure (anti-HBc positive) or the overall prevalence of HBV markers, is one of the reasons for such a dispersed prevalence rate. • HCV affects an estimated 20% of people with SMI,with the US having an estimated prevalence of 1.8% (24). • High level of heterogeneity in the prevalence rates of HCV in individuals with SMI, with prevalence figures ranging from 38% in US veterans on a psychiatric ward to 0.7% in Schizophrenic and schizoaffective patients participating in a program in Belgium (25). • Lower rates of HCV can be seen in developing countries, with 1.8% in Iran (26), 2.7% in Eastern Turkey (27) and 2.63% in Brazil (23). • There is a high association between HCV prevalence and drug use and injection, varying on a socioeconomic and geographical basis (24).

17. Discussion of findings • Individuals with severe mental illness appear to be at greater risk of BBVs, than general population. • Data from the studies reviewed in this examination supporting the elevated rates. • There appears to be documented evidence of higher prevalence rates of HIV, HCV and HBV in these individuals than in the general populations • strategies of both examining and reporting such rates needs refining. • Changes in types of studies- earlier ones focused on hep B, then HIV, now recent studies are focusing on Hepatitis C- really concerning rates in psychiatric populations • Not clear what risk behaviours this is associated with- injecting drugs is not common in SMI, the sexual transmission route is not established, possible route via shared household equipment such as toothbrushes and razors?

18. Discussion and recommendations • Review revealed a lack of research in Europe • UK published studies= 0! • Most studies based on convenience samples and potential bias present • Urgent need for rigorously conducted prevalence studies with a representative sample • Maybe even anonymous un-linked? • Need to investigate influence of risk factors and calculate adjusted prevalence

19. Dual Diagnosis Experts Group- Leeds • Group of people (service user led) with an interest in service development and quality for people with both mental health and substance use issues • Consultation meeting: to discuss the idea of universal testing for BBV in mental health settings • Outcomes: • Consensus is that its better to offer to all people rather than targeting certain “risky” people as this normalises and reduces stigma • However, no point in testing unless timely referral and treatment is available (e.g. Hepatology) • Staff attitudes- being non-judgemental about substance use, being knowledgeable.

20. Prevention and Intervention • Infection with HIV, HBV or HCV complicates an already complex mental health problem • Issues of side-effects, neurological effects, treatment adherence • Therefore, prevention is very important • Requires behavioural changes to prevent infection: • Health promotion advice • Access to condoms • Social skills • Motivational work

21. Systematic review of psychosocial interventions to reduce sexual risks • 11 studies (all RCTs) all based in USA • Poor to moderate quality • Heterogeneous in sample, measures, intervention, controls etc (therefore unable to perform meta analysis) • However: some studies showed significant reductions in VEE (Vaginal episode equivalent) up to 6 months post intervention • Demonstrates that it is acceptable and feasible to offer an intervention to people with serious mental health problems related to sexual behaviour

23. Intervention and Follow-up • Kalichman et al 1995 4x 90 mins (waiting control) 1 and 2 mth f/up * reduced unprotected sex • Katz 1996- 4x 2 hr with post test and 2 week f/up (educ and skills) 3 th f/up * improvement in knowledge and confidence • Kelly 1996- 7 session (90mins) CBT + advocacy v CBY vs 1 60min edu session- f/up 3 months * no differences across groups overall • Susser (1998) 15 session CBT skills v 2 session AIDS education 6 and 18mth f/up *mean scores VEE in int group • Weinhardt (1998) 10 session assertive skills, HIV educ v wait list -2 and 4mth follow-up signif increase in condom use sexual assertiveness HIV knowledge • Otto-Salaj (2001) 7 session CBT skills v 7 session “healthy lifestyle” 3,6,9, 12mth f/up varied by gender, more effective for women; men only showed incr in knowledge • Carey (2001) 10 sessions 2x wkly over 5 weeks HIV intervention v SU v Standard 3, 6mth signif reduction in risk behaviours • Berkman (2006) 2x 1 hr sessions total of 6 v 1x 2 hr HIV education f/up to 6 months no significant differences • Berkman (2007) enhanced Sex-G + peer advocacy v 10 sessions social skills and money management 6, 12 mth f/up no differences on risk behaviour • Collins (2001) 10 session female only 10 sessions signif increasedpositive attitude 6 week f/up • Collins 2011- female only 10 sessions v money management reduction not significant but more likely to use female condom at 6 mths • Rosenberg (2010) STIRR immunisation and screening mainly with some counselling and educ, v enhanced standard care 3 sessions over 6 months, 12mth f/up * increased participation in services, but no change on risk behaviour and HIV knowledge 23

25. Implications for Practice-more questions than answers! • Education and prevention work developed with specific needs of people with SMI- need more research on what works. • Screening and testing- definitely, but which service? • Phlebotomy, competence in pre and post test advice • Do mental health nurses see this as a part of their role? • Care pathways to hepatology and HIV specialisms BUT complications of co-morbid drug and alcohol, poor adherence and polypharmacy • What are the workforce needs in treatment settings in adapting care for those with SMI? • Implications for commissioning in the new health and social care landscape

26. Acknowledgements:Dr Chloe Walsh Dr Peter Phillips (City University) and Dr Edward McCann (Trinity College Dublin) for undertaking the systematic reviewing searches, retrieval and data extraction for the interventions reviewand ShaanBassi for his work on the BBV reviewAlso acknowledge the C2D2 funding programme for Chronic Diseases that funded the BBV review project.