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HIV Testing Policy and Serious Mental Illness

January 2, 2003

"Should seriously mentally ill patients undergo mandatory testing for HIV?" is the question the authors explore in this study. Stating that debate over "the ethical issues raised by the spread of HIV among the seriously mentally ill" has been going on for more than a decade, they examine the issue through opinion data from mental health experts.

They note that when the epidemic first began and there was no effective treatment, many experts felt the benefits of early detection were outweighed by the distress testing caused. Some voiced concerns about confidentiality protections and counseling in the mental health system. Experts in favor of mandatory HIV testing for this population pointed out that knowledge of a patient's HIV status was crucial for differential diagnosis of some psychiatric complaints, and that patients with severe mental disorders were often unaware of their HIV status, and could pass the virus on to others. Many believed the confidentiality rule should be waived in the case of patients deemed dangerous.

A paradigm shift in the attitude toward testing occurred in the mid-90s, according to the report. Targeted prevention, once rejected as too divisive, is now a priority. "This new framework has been put into action with the CDC's SAFE (Serostatus Approach to Fighting the Epidemic) initiative and its 'Know Now' media campaign to encourage testing," the researchers wrote. They also point out that new testing procedures that use urine and saliva instead of blood can provide initial information almost immediately. Such tests can also be performed by persons without specific medical training.

Based on interviews with clinicians and administrators "whose jobs required them to confront clinical and ethical dilemmas associated with the spread of HIV among people with serious mental illness," and their own experience, the authors developed a series of vignettes concerning a hypothetical young man with schizophrenia. The scenarios posed dilemmas regarding HIV testing and confidentiality, asking respondents to rate a clinical decision on a scale of appropriateness from one to nine. Twenty-two mental health professionals completed the survey. Seventy-seven percent were physicians, mainly psychiatrists. Sixty-three percent had direct clinical experience with HIV/AIDS; 68 percent had experience with serious mental illness. On average, participants spent 7.5 years working with HIV/AIDS patients. Nonclinician participants either conducted research or worked on policy issues.

The study found the experts "approached testing with caution but varied their views on the basis of the presence of various indicators" such as high-risk or violent behavior. The respondents showed little enthusiasm for testing patients without their informed consent. However, the authors point out that policy has traditionally allowed and sometimes required exceptional treatment of the mentally disabled. Therefore, they doubt the public would cause an outcry over mandatory HIV testing. Yet, such testing's benefit is questionable. Data show that many physicians, citing concerns about adherence, are reluctant to prescribe HAART to psychiatric patients.

"We therefore propose," the authors concluded, "that more strenuous promotion of voluntary HIV testing programs ... should bepursued by state mental health authorities and hospital associations for all psychiatric admissions and seriously mentally ill individuals seeking or currently receiving outpatient services. ... We believe that, so long as risks and benefits are understood by patients, confidentiality is protected, counseling is provided, and infected patients are guaranteed high-quality HIV treatment, aggressive promotion of voluntary testing is not only ethically acceptable, it is ethically imperative. ..."

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Excerpted from:
American Journal of Public Health
12.02; Vol. 92; No. 21; P. 1931-1939; James Walkup, Ph.D.; James Satriano, Ph.D.; Danielle Barry, M.S.; Pablo Sadler, M.D., M.P.H.; and Francine Cournos, M.D.




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