‘€œWe were sending mentally ill patients that we had identified HIV in to the general ARV rollout clinics and they weren’€™t getting the treatment that they needed. The reason quoted by some of the doctors was really doctor-bias, I suppose, in some ways. People were feeling that our patients would naturally be non-adherent to their medication and then, cause a whole host of problems in terms of development of resistant strains, transmission of HIV to other patients with mental illness’€, explained Dr Greg Jonsson, head of the Luthando Psychiatric HIV Clinic at Chris Hani Baragwanath Hospital.

Head of the hospital’€™s Psychiarty Department, Professor Yasmien Jeena added that: ‘€œWe found that our patients were being marginalised. Having a mental illness is a stigma in itself and, then, to have mental illness and HIV is, basically, a double stigma’€.

And that led to the formation of Luthando Psychiatrci HIV Clinic in 2008.

‘€œWe needed to make a service that was unique to this very special cohort of patients. We need to run this on a multi-disciplinary level and we also need to run it with staff that is solely dedicated to HIV Psychiatric services. We needed to go about this in a very special way because we needed to make sure that our patients would be adherent to their treatment and prove the rest of the services wrong. So, we decided to bring HIV services into the Psychiatric services’€, Dr Jonsson said.

The clinic offers a full-range of services run by psychiatrists, including screening and treatment for Tuberculosis. There are now over 400 patients receiving treatment at Luthando. These were sourced from the Psychiatric unit’€™s in-patient facility and are being followed up as out-patients.

But Dr Jonsson pointed out that their model is not perfect. In some circumstances, they encounter patients who are so mentally unfit that they cannot even give individual consent to HIV testing, which may prevent many doctors from offering testing services to mentally ill patients.

‘€œIf patients are voluntary and they, maybe, suffer from a minor mental illness, let’€™s say, a minor depressive disorder or something, they often then, do have the capacity to consent to an HIV test and, then, follow the normal route. But if somebody has cognitive impairment, HIV dementia, severe psychosis or an AIDS mania, for example, those patients, then, are identified by us and then, we face a difficult situation because it’€™s now over-riding our patients’€™ autonomy and just going ahead and doing the HIV test or waiting for them to get better before we do the HIV test. So, it’€™s a bit of a grey area’€, he said.

The clinic serves a population that is largely ignored. Studies from all over the world show that mental health disorders are growing faster among people infected with HIV.

In South Africa, a study conducted in 2007 showed that about 16.5% of the general population suffered from some form of mental disorder, while about 43.7% of people living with HIV had a mental illness. Jonsson said the clinic’€™s clients can be grouped into two categories.

‘€œWe have those patients with a pre-existing psychiatric illness that then develop HIV. And I think those patients will develop HIV as a result of their mental illness in that a lot of the patients that are psychotic or cognitively impaired as a result of dementia will have impaired judgment and no insight, and those kinds of patients are then more at risk of transmitting HIV and receiving HIV. Then, we also get those patients that develop psychiatric-symptomatology as a result of the HIV’€.

According to Dr Fatima Laher of Wits University’€™s Peri-natal HIV Research Unit (PHRU), the Luthando Psychiatric HIV Clinic is a model of how AIDS treatment programmes should be in future.

‘€œWe have neglected to look at the mental aspects of what will happen neuro-cognitively, neuro-psychiatrically to these patients as time goes on. Unfortunately, HIV continues persistence in the brain and as yet science has not found a way to remove HIV from the brain. These are the kinds of things that will increasingly affect the incidence of mental health problems in the large, I think at the moment it’€™s a million patients on ART, as time goes on. And I think clinics like this plan for the long-term health of those one million patients in this country’€, Laher said.