Cecilia Makiwane Hospital Psychiatric Ward

[Jason]

Thepsychiatric wards at Cecilia Makiwane were divided into male and female sections, the former staff member said. Both wards were completely closed, and each housed 25 acute patients of varying ages, histories and diagnoses under one roof.

They added that hospital management had not adequately addressed staff concerns after the traumatic incident and ward nurses had embarked on industrial action on 21 July 2017 in protest against the dangerous working conditions.

The unit is the only acute psychiatric facility in the Buffalo City Metro area, serving a population of over 755 000, with the next available facilities two hours away in Queenstown and Fort Beaufort.

The former staff member claimed that firefighters could not enter the ward at the time of the emergency, due to its structural instability and lack of access points. According to documents seen by Spotlight, firefighters on the scene reported that the building was not up to safety standards and should not be in use.

The documents further reveal that in previous years the old hospital building did not acquire fire safety certification, forcing the department to build a new hospital. This information shocked staff, who had only heard rumours of the building being condemned.

Records show that members of hospital management, including the quality assurance manager and a senior manager in the Provincial Department of Health, knew for years that the old hospital was not safe.

Spotlight entered the facility with ease and, according to the source, other unwanted visitors do too. The whistleblower said vagrants were often found in the abandoned wards near the Mental Health Unit, which posed a safety risk to patients and staff.

Kupelo said that security issues would be immediately addressed, including installing security cameras, restricting and controlling access and ensuring that the entire facility is adequately fenced and secured.

IDepartment of Psychiatry and Behavioural Sciences, Faculty of Health Sciences, Walter Sisulu University, East London, South Africa

IIDepartment of Psychiatry, Cecilia Makiwane Hospital, Mdanstane, East London, South Africa

IIIDepartment of Psychiatry and Behavioural Sciences, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa

IVDepartment of Psychiatry, Mthatha Hospital Complex, Mthatha, South Africa

VDepartment of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University, East London, South Africa

VIDepartment of Family Medicine, Cecilia Makiwane Hospital, East London, South Africa

BACKGROUND: The cascade of human immunodeficiency virus (HIV) care in patients with psychiatric disorders is poorly understood

AIM: This study determined the prevalence of HIV and described its cascade of care among patients with psychiatric disorders in the Eastern Cape province, South Africa. The study also examined the correlates of HIV comorbidity with psychiatric disorders in the cohort

METHODS: In this cross-sectional study, a total of 368 individuals attending the Psychiatric Outpatients' Department of Cecilia Makiwane Hospital in Eastern Cape were interviewed with a structured questionnaire. Relevant items on demographics and clinical information were extracted from the medical records. Virologic suppression was defined as viral load

RESULTS: The HIV prevalence after the intervention was 18.8% and a significant proportion of participants already knew their status (n = 320; 87.0%). Linkage to care and antiretroviral therapy initiation occurred in 61 participants, of those diagnosed with HIV (88.4%), with 84.1% being eligible for viral load monitoring (n = 58) and 53.4% having achieved virologic suppression. Being female (AOR = 5.48; 95% CI 2.61-11.51) and black (adjusted odds ratio [AOR] = 3.85; 95% confidence interval [CI] 1.06-14.03) were independent predictors of HIV comorbidity in individuals living with psychiatric disorders

CONCLUSION: This study found a moderately high prevalence (close to 19%) of HIV in individuals with psychiatric disorders, with a significant correlation with being female and being black people. This study also found a significant gap in the linkage to antiretroviral therapy (ART) initiation and a low rate of virologic suppression of 53.4%. Clinicians, therefore, should monitor and provide interventions for patients with concomitant HIV infection along this cascade of care

The cascade of human immunodeficiency virus (HIV) care is defined as the diagnosis of HIV, linkage to care and initiation of antiretroviral therapy (ART), retention in care, and virologic suppression.1 Globally, 37.4 million people were living with HIV by the end of 2018; 79% of them were aware of their serostatus. With increasing access to ART worldwide, 24.5 million people were already on ART (62% of all people living with HIV [PLWHIV]) by June 2019 and 52% had achieved virologic suppression at the end of 2018.2 In South Africa, 7.7 million people were living with HIV by the end of 2018; 90% knew their status, 62% were already initiated on ART and 54% had achieved virologic suppression.2 While the HIV care cascade has been reported for the general population, it is poorly understood among psychiatric patients with HIV infection.

Organisations prioritise children, pregnant women, sex workers, men having sex with men, transgender people, and people injecting drugs as the key populations for HIV testing.3,4 Yet people with psychiatric disorders seem to be a neglected population, even though their vulnerabilities to HIV are well documented.5,6,7,8,9,10 This is evidenced by the silent treatment meted out to people with psychiatric disorders in many national and international guidelines and policies.3,4 Many authors have reported on the mental health of PLWHIV,11,12,13 yet there is a lack of information regarding people with psychiatric disorders living with HIV.

It is also worth noting that one systematic review and meta-analysis carried out by Hughes et al.,10 found that the prevalence of HIV among people with mental illnesses is higher than the general population in countries with low HIV prevalence and on par in countries with high HIV prevalence. Given that the comorbid diagnosis of HIV and psychiatric disorder tends to attract a stigma,14,15,16 people with these comorbidities need special care. Robust evidence to guide HIV care for people with psychiatric disorders is lacking and controversies exist surrounding the consent for testing in this population. Some clinicians insist on receiving informed consent to perform HIV testing, yet many people with psychiatric disorders are unable to give informed consent because of the severity of their condition.17,18 As such, some patients are not tested for HIV, nor initiated on ART, thus leading to the deterioration and possible fatal outcomes. National recommendations on the treatment of all individuals living with HIV is contingent on HIV testing and linkage to care.4

The bidirectional relationship between HIV and psychiatric disorders has been extensively documented in the literature.6,7,8,9,10 People living with HIV have an increased risk of having a psychiatric disorder. Similarly, people living with a psychiatric disorder have an increased risk of acquiring HIV.6,7,8,9,10 Given that the viral load is the most important determinant of progression of HIV disease,19 evidence suggest that the comorbidity of psychiatric disorder is associated with lower odds of achieving virologic suppression.20

A Swedish study showed that adults with psychiatric disorders have an almost three-fold increased risk of being infected with HIV when compared to the general population.21 Similarly, a report by Singh also showed that individuals with psychiatric disorders are three times more likely to be infected with HIV compared to the general population in South Africa.18 However, a meta-analysis conducted by Breuer et al. reported that PLWHIV are twice more likely to develop depression in comparison to the general population.22 The results of these studies indicate a bidirectional relationship that exists between psychiatric disorders and HIV. Adams et al. reported depression as the predominant comorbid psychiatric disorder (47%) among PLWHIV in London,11 while 17% had adjustment disorders, 15% had anxiety disorders, and 15% were living with substance abuse. Similarly, Chibanda et al., reported that the three most prevalent psychiatric disorders in PLWHIV in low- and middle-income countries, including South Africa, were depression, alcohol use disorders, and neurocognitive disorders.12

The prevalence of HIV ranges from 13% in an inpatient setting in the Western Cape to 50% among first-episode psychosis presentations in KwaZulu-Natal (KZN) or 29.01% among general psychiatric inpatients in KZN among people with psychiatric disorders in South Africa.18,23,24 Studies have reported that women with psychiatric disorders were twice as likely to get infected with HIV than their male counterparts.5,18 Poor adherence to ART, and the resulting increased viral load because of virologic failure, immunological failure, and clinical failure have been documented in individuals with the comorbidity of HIV and psychiatric disorders.25,26,27,28,29 A six-fold higher viral load was found in individuals with severe psychiatric disorders and HIV in comparison to individuals living with HIV and no psychiatric disorder.26

There is a dearth of information on the comorbidity of HIV and psychiatric disorders in the Eastern Cape province, one of the poorest provinces in the country. Uys found an HIV prevalence of 13% among female patients admitted to a regional hospital (the same site for the current study) in the Buffalo City metropolitan municipality (BCMM) in the Eastern Cape province.30 A predominant proportion (53%) of the study participants developed a psychiatric disorder after receiving an HIV diagnosis, while the rest of the patients had a pre-existing primary psychiatric disorder. It should be noted that the small sample size and the sampling from female inpatients did not allow for a broader understanding of the comorbidity of HIV and psychiatric disorders in this population. Therefore, this study aimed to bridge this gap and, to provide relevant epidemiological data to guide the development of integrated psychiatric care services in this region of the province.

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