In this study, the main findings were that 21.5% of patients admitted over the study period with recent-onset psychosis were living with HIV; its seroprevalence was associated with age 25–49 years, female gender, lower educational level, family history of psychosis and current alcohol or cannabis use. There was a very high rate of HIV testing (98%) and care, as all PLWHIV received ART while admitted. Nineteen of the 37 (51.3%) patients with HIV were virologically unsuppressed, with men being less likely to be virally suppressed.

The 21.5% prevalence rate of HIV among patients admitted with recent onset psychosis is slightly higher than the South African general population estimate of 19.0% HIV prevalence in adults aged 15–49 years.¹ The prevalence in this study is also lower than the estimated 26% rate in the recent systematic review of HIV prevalence in FEP in Africa.⁷ Hopefully, the results of this study suggest that HIV prevalence is decreasing in those who are mentally ill and moving towards the general population rates, but this will need to be explored further in larger prospective studies.

In this study, only five patients (1.7%) did not have an HIV test result, which indicates that access to HIV testing was good, and an extremely small proportion were missed or had an unknown HIV status; however, clinicians should endeavour to offer all patients HIV testing and care and document outcomes. This is in stark contrast to earlier studies, which found poor or inadequate access to HIV testing for those with mental illness.⁸ The reported lifetime prevalence of HIV testing among individuals with severe mental illness ranges from 11% to 89%, indicating wide variability in HIV testing in this group.¹⁰ In a retrospective chart review study in Johannesburg, SA, the clinical features, inpatient care and accessibility to ART of mental healthcare users who were admitted to an acute psychiatric unit found that only 17.4% were tested for HIV. The low rates of testing for HIV status were because of ethical considerations about obtaining consent.¹⁸ The reasons for inadequate HIV testing in previous studies may be multifactorial and include concerns on lack of informed consent, stigma and bias.¹⁹ The right of patients to consent or refuse consent to medical treatments is an important right that has developed out of the ethical concepts of freedom, rights and autonomy. It is incorporated into all legal frameworks in most countries around the world and certainly in all Western-style democracies. There are, however, important exceptions to this rule that have ethical, legal and practical reasons. It is acknowledged that some persons do not have the mental capacity to make an informed choice, in which case it is ethical to consider acting in their best interest.²⁰ A study in a Cape Town, SA, examined the relationship between HIV testing history, attitudes towards testing and AIDS stigma and found that compared with people who had been tested, individuals who were not tested demonstrated significantly greater AIDS-related stigmas, ascribing greater shame, guilt and social disapproval to people living with HIV.²¹ As HIV and ART are less stigmatised and health policies and guidelines now encourage routine testing and treatment, there may be improved levels of HIV testing and care in mental health services. This study suggests that the current Department of Health guidelines²² to test all patients at any facility are proving effective, and some clinical facilities may have embraced HIV testing for the mentally ill.

In this study, the HIV risk in people with recent-onset psychosis was associated with the age group 25–49 years, which is also consistent with HIV prevalence rates in the general population in KZN, SA, among people aged 15–49 in 2017, which was at 27%.²³ This suggests that young adults remain very vulnerable, and HIV prevention programmes, including advocacy initiatives, should target this group in those with severe mental illness.

In this study, women contributed 59.7% of the HIV-positive group and had a significantly higher HIV rate than the men (p ≤0.001), which is consistent with the literature.^{18,24,25,26,27} Studies suggest that there is a female preponderance, often in 20–40 year age range, presenting with HIV and psychosis.¹⁸ Another study examined the HIV seroprevalence among psychiatric patients admitted to a public psychiatric institution in KZN between July and November 2003 by conducting anonymous HIV testing among 151 patients and found that 40 (26.5%) were positive, and that women were more likely to be infected than men (aOR = 2.74; 95% CI = 1.25–6.04; p = 0.012).²⁴ In another chart review of patients with psychosis admitted to a psychiatric hospital in Durban, SA, PLWHIV and psychotic disorders were also more likely to be female (74.0%),²⁵ the literature suggesting that they are the more vulnerable to contracting HIV, with prevention strategies needing to target them in particular.

The HIV prevalence was also higher in those without a tertiary education compared with those with, which is supported by other South African studies in people with psychosis.²⁸ It is also important to be cognisant that there has been mixed evidence in studies conducted in sub-Saharan Africa on this subject. In a systematic review that assessed the evidence on the association between educational attainment and risk of HIV infection, it was observed that this relationship may be changing over time in sub-Saharan Africa. It was found that studies conducted before 1996 tended to find no association with education level and HIV-infection risk among the more educated, while a larger proportion of those studies conducted thereafter identified a lower risk of HIV among the more educated.²⁹ This reinforces the need to ensure HIV-prevention measures reach all strata of society and include current approaches that focus primarily on providing information, distributing condoms and treating sexually transmitted infections, with a focus on increasing HIV education in vulnerable populations.²⁹

Individuals who report current substance use were more than three times more likely to have HIV in this study; this is consistent with international literature, which reports that substance use also increases the risk of HIV transmission, as it may contribute to increased risky behaviour.^30,31 Local studies of HIV seropositivity in the mentally ill in KZN have, however, not shown an increase in substance use in PLWHIV and psychosis;^5,25 possibly these studies are limited by sample size and methodology. This finding needs further investigation but does highlight the need for a more comprehensive assessment and holistic care package that encompasses care for medical conditions, such as HIV, while managing comorbid mental illness and substance use.

In this study of those living with HIV, 37 (66.07%) were virologically suppressed; this rate is lower than that reported in the international literature for PLWHIV but higher than that in a recent South African general population.^32,33 A study that assessed the patterns of viral suppression among patients living with HIV across the USA showed an increasing rate of viral suppression, from 32% in 1997 to 86% in 2015.³² A South African cross-sectional survey conducted among 15–49-year old pregnant women attending antenatal care at 1595 nationally representative public facilities found that of 10 052 HIV-positive participants with VL data, 56.2% were virally suppressed.³³

Nineteen (33.93%) of the participants in our study were virologically unsuppressed, which is concerning, as it suggests that the HIV care of patients with psychosis needs to be intensified. These participants were either newly diagnosed with HIV or were re-initiated on ART after defaulting treatment. However, this was difficult to determine from the records available, as anecdotal evidence suggests that patients may not disclose if diagnosed with HIV previously. This suggests a need to consider more active follow-up of those with psychosis and HIV in terms of adherence support to improve outcomes.