HIV seropositivity in patients with first-episode psychosis

Background. In order to gauge the impact of the HIV epidemic on psychotic disorders, the magnitude and causal direction of the association between HIV infection and psychosis need to be examined closely. Objective. To determine the HIV seropositivity rate among adult patients presenting with first-episode psychosis (FEP) to Town Hill Hospital in Pietermaritzburg, KwaZulu-Natal. Design. A cross-sectional, point-prevalence study was done over a 6-month period. Results. Of the 63 FEP patients in the study, 48 tested HIV- negative and 15 tested positive, giving a seroprevalence rate of 23.8%. Conclusion. The prevalence of HIV seropositivity is high among patients with FEP.


Instruments
The following instruments were used: • A screening document that was used to screen all FEP patients presenting to Town Hill Hospital for suitability to participate in the research project.The instrument was used to determine the patient's past history, duration of illness, and medical and substance history.
• An information leaflet written in English and IsiZulu.
• A consent form.
• A demographic questionnaire.

Methods
A cross-sectional, point-prevalence study was undertaken.The study population comprised patients with FEP admitted to Town Hill Hospital.Town Hill is the largest psychiatric hospital in KwaZulu-Natal.It is a major referral centre for the surrounding regional and district hospitals.The study was conducted over a

Results
Of 378 patients, 63 fulfilled all the inclusion criteria.There were 13 females and 50 males, reflecting the demographic admission patterns at Town Hill Hospital, i.e. more males than females.The demographic characteristics are given in Table I.The remaining group of patients did not participate in the research project for a variety of reasons.Some were lost to follow-up or had a coexisting medical condition; others refused to participate in the study or were deemed not capable of giving informed consent.
The majority of female patients were married, widowed or cohabiting, while the majority of the males were single.Fifteen patients tested seropositive (6 females and 9 males), and 48 were negative.Of those who tested positive, 10 were blacks, 3 were coloured and 2 were Indian.The majority of the patients who tested positive lived in urban areas, were unemployed, and had secondary education (Table I).
The average duration of symptoms before admission was 14 weeks.

Discussion
The study found a high prevalence of HIV seropositivity (23.8%) among patients with FEP.This represents a significant rise in the HIV seroprevalence rates among psychiatric patients admitted to Town Hill Hospital.A previous study found a lower prevalence rate of 2% in 1992 (S D Chetty -unpublished data).Rates in other studies done on new-onset psychosis in patients with HIV-spectrum illness range from 0.2% to 15%. 7In our study, the majority of the females were married, cohabiting or widowed.
It can be reasonably assumed that these individuals had had a regular sexual partner at some stage in their lives.None of the patients had a history of substance use.This was an important factor because substance use is usually related to an increase in risk-taking behaviour and sexual indiscretions.Despite HIV/ AIDS education, substance users continue to engage in HIV risk behaviours.Those who inject drugs, particularly opioids and cocaine, may share or fail to clean injection equipment and often engage in unsafe sex. 9 A study by Susser et al. 10 in 1995 on the sexual behaviour of homeless mentally ill men found an HIV prevalence rate of 19%.The majority of these individuals had sex occasionally or not at all, but many of them had unprotected sex with non-monogamous partners.Added to this, they had comorbid cocaine abuse or dependence that put them at high risk for contracting the virus.
The average duration of psychotic symptoms at the time of recruitment was 14 weeks.It can reasonably be assumed that The majority of patients were diagnosed with schizophreniform disorder.This was an unexpected finding since the researcher had anticipated higher prevalence rates in bipolar patients, due to high risk-taking behaviour because of impaired judgement in this group.There was no conclusive evidence that the HIV itself caused the psychosis, but this aetiology cannot be ruled out.
New-onset psychosis may be, at least in part, a manifestation of an HIV-associated encephalopathy. 5To support this further, none of the participants had a known co-morbid medical condition that could account for the current psychiatric presentation.This finding suggests that the symptoms of psychosis in those infected with HIV are not always related to systemic and cerebral complications of HIV.

Limitations of the study
The main limitation of this study was the sample size.This was due to a variety of reasons: (i) the number of new admissions to Town Hill Hospital dropped significantly after the New Mental Health Act was promulgated; (ii) the pre-and post-test counselling process was time-consuming, and as a result a high number of patients were lost to the study group during their hospital stay; (iii) the recruitment period of 6 months was too short; and (iv) there was no demographic representation for the white population.
Based on all the above limitations, the results of this study cannot be generalised to the general population.Further research needs to be done to explore the aetiological relationship between FEP and HIV seropositivity.

Conclusion and recommendations
This study demonstrated a high prevalence of HIV seropositivity among patients with FEP.This prevalence is in keeping with prevalence figures in South Africa and the rest of the world. 4timates of the frequency of HIV infection in patients with preexisting mental illness range between 0.2% and 7%.Estimates of new-onset psychosis in patients with HIV-spectrum illness range between 0.2% and 15% and may increase as the stage of HIV infection progresses.Regardless of which illness came first, their occurrence together appears to be associated with more morbidity and mortality than would be expected with either illness alone.The high prevalence rate suggests a possible aetiological association between HIV infection and FEP.However, the aetiological link remains to be established.
Based on the above findings, it is highly recommended that HIV testing be considered in patients presenting with FEP.Similarly, it is also reasonable to consider co-morbid HIV infection in psychotic patients.Psychiatrists are in a better position to actively educate their patients on prevention of HIV infection. 11The need for implementation of risk-reduction programmes in psychiatric facilities has to be emphasised because a significant proportion  Further research is recommended on: (i) the prevalence of HIV seropositivity in a large sample of FEP patients; and (ii) the aetiological relationship between HIV seropositivity and FEP.

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month period (1 September 2005 -28 February 2006).The researcher (the principal investigator) requested the assistance of the attending psychiatrists to identify all new admissions with FEP (N = 378).The final diagnosis was made by the multidisciplinary team based on Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria.The patients were managed according to the standard guidelines until they were free of psychotic symptoms and ready to give consent.They were approached individually by the researcher, and written consent was obtained.All participants received pre-test counselling.The blood samples were collected by the researcher and sent to a private laboratory for HIV testing.The results were made available within 48 hours to all patients wanting to know their status.Posttest counselling was provided.Data were analysed using the statistical packages SSPS version 11.5 and Epi-Info version 6.04.Certain data were collapsed into broader categories to facilitate analysis.All primary psychotic disorders were collapsed into one category, viz.functional psychosis.Marital status was divided into two categories, i.e. 'single' and 'other'.The category 'other' included married, widowed and cohabiting individuals.
. 3 August 2007 -SAJP the HIV infection predated the onset of the psychotic symptoms.

articles Volume 13 No. 3
August 2007 -SAJP of patients could be infected with HIV.Particular emphasis should be placed on voluntary counselling and testing (VCT).

Table I . Demographic characteristics and HIV status of the sample (N (%))
*Statistically significant at the 0 05 level.