As we enter the fourth decade of a world of HIV & AIDS, it is clear that the global impact of the virus has been vast. Internationally, an estimated 33.3 million people are living with HIV.⁽²⁾ The burden of the epidemic continues to lie disproportionately heavily within lower- and middle-income contexts. Approximately 15 million people living with HIV who need treatment are in these contexts, and of these, only a third (5.2 million) have access to the necessary facilities and resources.⁽³⁾

Further, in maintaining a critical African eye, it is imperative to note that current estimates suggest that sub-Saharan Africa remains the region most severely affected by the epidemic: Approximately 68% of all people currently living with HIV, 69% of new infections and 72% of AIDS-related deaths occur in sub-Saharan Africa.⁽⁴⁾ Furthermore, HIV has been recognised as a major humanitarian crisis in this context, as well as a significant threat to socio-economic development.⁽⁵⁾

A report by the secretariat of the World Health Organisation (WHO) has drawn attention to the impact of HIV & AIDS as a leading cause of death and disability - one which is linked closely to mental health.⁽⁶⁾ In order to enhance understandings of the nature of this connection, this paper attempts to assess and discuss current findings with respect to the link between HIV & AIDS and mental health, and to craft a more complete understanding of the implications of such a link on the approaches adopted in dealing with these health concerns.
Towards an understanding of mental health

The WHO defines mental health as not just the absence of mental disorder, but also a state of well-being in which every individual is able to work productively, live a fruitful life, make a contribution to his or her community, realises his or her own potential, and feels able to cope with the normal stresses of life.⁽⁷⁾ It is important to note that this definition, consistent with broader understandings of health adopted at an international level, contains within it a multi-faceted conceptualisation of health - personal, social and communal aspects are clearly contained within this definition.

Studies of mental health must take cognisance of the disorders or disordered behaviours arising as a result of psychological or psychiatric conditions. Assessments of the lifetime prevalence of psychiatric conditions in a South African sample, for example, showed that the prevalence of psychological disorders was significant, with 15.8% of the sample having anxiety disorders, 13.4% having substance abuse disorders and 9.8% having mood disorders.⁽⁸⁾ A further 30.3% showed symptoms of a number of other disorders. Mental health and substance abuse problems have been shown to be particularly rife in historically disadvantaged areas.⁽⁹⁾

The reality of an HIV & AIDS – mental health link

An integrated web of influences link and contextualise the phenomena of HIV & AIDS and mental health. This relationship has been described as “intertwined” by Baingana, Thomas and Comblain (2004) who noted that an interdependence exists in the relationship between the two.⁽¹⁰⁾ At the intersection of the mental and physical health of an individual living with HIV is a complex profile. To assign a linear chain of causality would be neither descriptive nor representative. Thus it is essential to maintain at all times an awareness of the multiple levels of influence that foster or inhibit the development of this link.

Studies have consistently shown higher rates of mental health disorders in individuals living with HIV compared with ‘normal’ clinical samples.^(11,12) There are two important facets which form the basis of explanations of this finding. Firstly, mental health disorders, including those related to or arising as a result of substance-abuse, have been shown to be related to an increased risk of HIV & AIDS infection, as well as to have a considerable potential impact on treatment success.⁽¹³⁾ Conversely and concurrently, it is important to note that some mental health conditions can arise as a direct result of HIV infection. Thus, an elevated risk for psychiatric conditions may be directly caused by HIV, be exacerbated by the virus or, in fact, present as a precursor to infection.⁽¹⁴⁾

Notably, psychiatric morbidity with HIV & AIDS was shown early in the epidemic, with a 1996 US study showing that over a year’s screening, 47.9% of participants receiving HIV care presented symptoms of at least one psychiatric disorder.⁽¹⁵⁾ Following the previous example, in South Africa, studies have demonstrated a high prevalence of mental health problems among people living with HIV - one study found that 43.7% of respondents displayed symptoms of a diagnosable mental disorder. The most commonly occurring disorder was depression, followed by alcohol abuse disorder.⁽¹⁶⁾ By way of comparison, a study conducted at approximately the same time found levels of approximately 16.5% of the general population having a diagnosable mental disorder.⁽¹⁷⁾ These findings have been confirmed in further study - evidence suggests that depression, post-traumatic stress disorder and substance abuse were among the most commonly occurring mental disorders in South African HIV positive persons.⁽¹⁸⁾

Influences and implications

Research has indicated that disorders of cognition and personality, as well as those dependent on the abuse of substances can significantly affect an individual’s risk profile, placing them at greater risk of being infected with HIV.⁽¹⁹⁾ Further, substance and alcohol use disorders have been shown to be frequently comorbid with mental ill-health; this includes disorders such as anxiety, panic and depression, as well as other more severe mental illnesses.⁽²⁰⁾ This point therefore gains particular importance when examining the link between mental health and HIV & AIDS, especially when one considers that substance abuse related behaviours, such as the sharing of needles, may predispose an individual to increased risk of HIV infection. It has been estimated that approximately three million injection drug users worldwide may be infected in this way.⁽²¹⁾ Similarly, studies have indicated that alcohol abuse disorders and HIV may interact at both an individual and societal level to impact health. Particularly, the abuse of alcohol has been noted to exacerbate a number of conditions, including HIV. This exacerbation has been attributed to an increase in risk taking behaviours (as a result of disinhibition) coupled with a decrease in adherence to health care regimes and medications, including antiretrovirals (ARVs).⁽²²⁾

Studies have shown that people who are living with HIV & AIDS are increasingly vulnerable to a number of conditions related to their mental well-being; a number of these may even influence an individual’s suicidality profile. These can include, among others, mood disorders such as depression and bipolar disorder, acute stress and anxiety reactions, obsessive-compulsive thought patterns around disease progression, bereavement reactions, personality disorders and psychoses. Cognitive impairment and the use of substances have also been shown to be important factors.⁽²³⁾ Such conditions have been shown to place individuals at a higher risk of contracting HIV as a result of their engaging in risky sexual behaviour, as well as likely misconceptions as to the routes of transmission of the virus.⁽²⁴⁾ Amongst the youth, factors such as depression, rebelliousness and impulsivity have been shown to be indirectly associated with high-risk sexual practices, and thus a higher risk of HIV infection.⁽²⁵⁾

In addition to the above, the following factors have been shown to place individuals with HIV at an increased risk for suicide: premorbid psychiatric conditions, pathophysiology - particularly neuropathology, and the neuropsychiatric effects of psychotropic medication and ARVs. In addition, a number of anxiety reactions, including panic and phobia (even despite negative test results) have been noted as risks.⁽²⁶⁾ Suicidal behaviour, including suicide attempts in the early stages of infection to avoid the eventual consequences of the virus, as well as attempts to become infected as a form of suicidal behaviour are particularly problematic.⁽²⁷⁾ It has been noted that of the approximately one million suicides which occur, 85% of these instances occur in developing countries.⁽²⁸⁾

Structural and social factors are also important to consider. It has been stated that “many who live in settings with few resources for care can only witness the progression of the epidemic in a state of relative helplessness.”⁽²⁹⁾ In such resource limited settings, the psychosocial needs of people living with HIV and often contending with mental illness, too often go unmet.⁽³⁰⁾ For example, poverty has been identified as a specific risk factor and it has been suggested that the burden of the virus has been felt particularly harshly in impoverished communities who have limited resources and capacity to aid their coping with diagnosis and the life circumstances associated with their serostatus.⁽³¹⁾ It has further been noted that HIV is related to both poverty and an increased incidence of mental disorder; however the directionality of this relationship is a matter of debate.⁽³²⁾ It has been suggested that the two facets may, in fact, exacerbate one another.⁽³³⁾

In non-mental health care settings, the health care professionals treating people with HIV may often miss symptoms of mental ill-health as they are also symptomatic of the progression of the virus.⁽³⁴⁾ These may include, for example, weight loss, insomnia, fatigue and a loss of appetite - symptoms concurrently indicative of depression. The realities of limited mental health services in resource poor setting compound the likelihood that HIV positive individuals will receive inadequate mental health care.⁽³⁵⁾

Research has pointed out that people living with HIV and/or AIDS often have complicated histories which impact on their mental health. Such histories can be shaped by the experience of traumatic life-events, including those motivated by HIV-related stigma.⁽³⁶⁾ Stigma and discrimination are another central concern to the mental health status of people living with HIV. The implications of stigma are vast: in some instances people living with HIV feel anxiety and fear relating to disclosing their status, and particularly feel that they risk being excommunicated from family and loved ones as well as being deprived of their livelihoods as a result of their status being disclosed.⁽³⁷⁾ This can certainly influence the mental wellbeing of a person living with HIV and/or AIDS. Research has shown that in most instances, even the process of testing for HIV and the receiving of test results is associated with moderate to intense levels of anxiety and distress for the client.⁽³⁸⁾ Positive results have been conceptualised as ranging from “profoundly distressing”⁽³⁹⁾ to being seen as a death sentence.⁽⁴⁰⁾ Often, these individuals feel bound to experience stigma through the progressive deterioration associated with the prognosis. Also, evidence has shown that seropositive individuals may not disclose their psychological state to health care providers for fear of further stigmatisation.⁽⁴¹⁾ Many individuals who are diagnosed as being seropositive will experience grief and bereavement reactions. The demoralisation often associated with a positive serostatus has been linked to “the strain of chronic illness, social stigma, and the process of accepting mortality”.⁽⁴²⁾

Recommendations and conclusions

With the increasing influence of HIV on various health care systems being felt internationally and thus becoming increasingly relevant in the field of mental health, the words of G. Stephen Bowen, in his foreword to HIV mental health for the 21st century, issue an important directive. He stated that “[t]hese changes now challenge mental health providers and those in training for HIV/AIDS care in the next century. Above all, providers have learned that compassion is necessary but insufficient; mental health providers must be multifaceted in their skills, creative in their program development, politically aware, and involved in governmental policy-making processes that determine, through such issues as financing, what care clients receive.”⁽⁴³⁾

It is clear that HIV is becoming an increasingly important matter of concern in mental health care, and vice versa. The suggestion has been made that, like developed countries, developing nations (such as South Africa) must strive to include and integrate mental health care and treatment into HIV & AIDS care programmes.⁽⁴⁴⁾ HIV positive individuals often sustain particularly tenuous life-circumstances and the support offered by mental services would likely have a valuable impact in terms of improving and enhancing their lives.

NOTES:

(1) Contact Deanne Goldberg through Consultancy Africa Intelligence's HIV & AIDS Unit ( hivaids@consultancyafrica.com This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
(2) ‘UNAIDS report on the global AIDS epidemic 2010’, UNAIDS, 2010, http://www.unaids.org.
(3) Ibid.
(4) ‘Uniting for universal access: towards zero new HIV infections, zero discrimination and zero AIDS-related deaths’, United Nations, 2011, http://www.who.int.
(5) Kelly, K., Freeman, M., Nkomo, N., & Ntlabati, P., 2008. The vicious circularity of mental health effects of HIV/AIDS: symptom and cause of poor responses to the epidemic. In V. Møller & D. Huschka (Eds.), Quality of life in the new millennium: advances in quality-of-life studies, theory and research. Social Indicators Research Series, 10.
(6) ‘HIV/AIDS and mental health-Report by the secretariat’, WHO, 20 November 2008, http://apps.who.int.
(7) ‘What is mental health?’, WHO, 2011, http://www.who.int.
(8) Stein, D.J., et al.,2008. Lifetime prevalence of psychiatric disorders in South Africa. The British Journal of Psychiatry, 192, pp.112-117.
(9) Havenaar, J.M., et al.,2007. Common mental health problems in historically disadvantaged urban and rural communities in South Africa: prevalence and risk factors. Social Psychiatry and Psychiatric Epidemiology, 43, pp.209-215.
(10) Baingana, F., Thomas, R., & Comblain, C., 2004. Health, nutrition and population (HNP) discussion paper: HIV/AIDS and mental health. Washington: The World Bank.
(11) Kelly, K., Freeman, M., Nkomo, N., & Ntlabati, P., 2008. The vicious circularity of mental health effects of HIV/AIDS: symptom and cause of poor responses to the epidemic. In V. Møller & D. Huschka (Eds.), Quality of life in the new millennium: advances in quality-of-life studies, theory and research. Social Indicators Research Series, 10.
(12) ‘HIV/AIDS and mental health-Report by the secretariat’, WHO, November 2008, http://apps.who.int.
(13) Ibid.
(14) Alegria, M., et al., 2006. Epidemiology of HIV. In F. Fernandez & P. Ruiz. (Eds.) Psychiatric aspects of HIV/AIDS, pp. 3-10. Philadelphia, USA: Lippincott Williams & Wilkins.
(15) Ibid.
(16) Freeman, M., Nkomo, N., Kafaar, Z., & Kelly, K., 2008. Mental disorder in people living with HIV/AIDS in South Africa. South African Journal of Psychology, 38, pp.489–500.
(17) Kelly, K., Freeman, M., Nkomo, N., & Ntlabati, P., 2008. The vicious circularity of mental health effects of HIV/AIDS: symptom and cause of poor responses to the epidemic. In V. Møller & D. Huschka (Eds.), Quality of life in the new millennium: advances in quality-of-life studies, theory and research. Social Indicators Research Series, 10.
(18) Myer,L., et al., 2007. Common mental disorders among HIV-infected individuals in South Africa: prevalence, predictors, and validation of brief psychiatric rating scales. AIDS Patient Care and STDs, 22(2), pp.147-158.
(19) Baingana, F., Thomas, R., & Comblain, C., 2004. Health, nutrition and population (HNP) discussion paper: HIV/AIDS and mental health. Washington: The World Bank.
(20) Chander, G., Himelhoch, S., & Moore, R.D., 2006. Substance abuse and psychiatric disorders in HIV-positive patients:
epidemiology and impact on antiretroviral therapy. Drugs, 66(6), pp.769-789.
(21) ‘HIV/AIDS and mental health-Report by the secretariat’, WHO, November 2008, http://apps.who.int.
(22) Azar, M.M., Springer, S.A., Meyer, J.P., & Altice, F.L., 2010. A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization. Drug and Alcohol Dependence, 112, pp.178–193.
(23) Schlebusch, L., 2010. HIV-infection as a self-reported risk factor for attempted suicide in South Africa. African Journal of Psychiatry,13(4), 280-283.
(24) Funk, M., et al., 2010. Mental health and development: targeting people with mental health conditions as a vulnerable group. Geneva: WHO Press.
(25) Collins, P.Y., & Freeman, M., 2009. Bridging the gap between HIV and mental health services in South Africa. In P. Rohleder, L. Swartz, S.C. Kalichman & L.C. Simbayi. (Eds.) HIV/AIDS in South Africa 25 Years On, pp.353-372. New York: Springer.
(26) Schlebusch, L., 2010. HIV-infection as a self-reported risk factor for attempted suicide in South Africa. African Journal of Psychiatry,13(4), 280-283.
(27) Ibid.
(28) Ibid.
(29) Collins, P.Y., & Freeman, M., 2009. Bridging the gap between HIV and mental health services in South Africa. In P. Rohleder, L. Swartz, S.C. Kalichman & L.C. Simbayi. (Eds.) HIV/AIDS in South Africa 25 Years On, pp.353-372. New York: Springer.
(30) Ibid.
(31) Baingana, F., Thomas, R., & Comblain, C., 2004. Health, nutrition and population (HNP) discussion paper: HIV/AIDS and mental health. Washington: The World Bank.
(32) Kelly, K., Freeman, M., Nkomo, N., & Ntlabati, P., 2008. The vicious circularity of mental health effects of HIV/AIDS: symptom and cause of poor responses to the epidemic. In V. Møller & D. Huschka (Eds.), Quality of life in the new millennium: Advances in quality-of-life studies, theory and research. Social Indicators Research Series, 10.
(33) Freeman, M., Nkomo, N., Kafaar, Z., & Kelly, K., 2008. Mental disorder in people living with HIV/AIDS in South Africa. South African Journal of Psychology, 38, pp.489–500.
(34) Collins, P.Y., & Freeman, M., 2009. Bridging the gap between HIV and mental health services in South Africa. In P. Rohleder, L. Swartz, S.C. Kalichman & L.C. Simbayi. (Eds.) HIV/AIDS in South Africa 25 Years On, pp.353-372. New York: Springer.
(35) Ibid.
(36) Whetten, K., Reif, S., Whetten, R., & Murphy-McMillan, L.K., 2008. Trauma, ental health, distrust, and stigma among HIV-positive persons: implications for effective care. Psychosomatic Medicine, 70,pp.531–538.
(37) Baingana, F., Thomas, R., & Comblain, C., 2004. Health, nutrition and population (HNP) discussion paper: HIV/AIDS and mental health. Washington: The World Bank.
(38) Worthington, C., & Myers, T.,2003. Factors underlying anxiety in HIV testing: risk perceptions, stigma, and the patient-provider power dynamic. Qualitative Health Research, 13(5), pp.636-655.
(39) Freeman, M., Nkomo, N., Kafaar, Z., & Kelly, K., 2008. Mental disorder in people living with HIV/AIDS in South Africa. South African Journal of Psychology, 38, pp.489–500.
(40) Kelly, K., Freeman, M., Nkomo, N., & Ntlabati, P., 2008. The vicious circularity of mental health effects of HIV/AIDS: symptom and cause of poor responses to the epidemic. In V. Møller & D. Huschka (Eds.), Quality of life in the new millennium: Advances in quality-of-life studies, theory and research. Social Indicators Research Series, 10.
(41) ‘HIV/AIDS and mental health-Report by the secretariat’, WHO, November 2008, http://apps.who.int.
(42) Baingana, F., Thomas, R., & Comblain, C., 2004. Health, nutrition and population (HNP) discussion paper: HIV/AIDS and mental health. Washington: The World Bank.
(43) Bowen, G.S., 1997. Foreword. In M.G. Winiarski (Ed.). HIV mental health for the 21st century, pp.xi-xxiv. USA: New York University Press.
(44) Freeman, M., Nkomo, N., Kafaar, Z., & Kelly, K., 2008. Mental disorder in people living with HIV/AIDS in South Africa. South African Journal of Psychology, 38, pp.489–500.

Written by Deanne Goldberg ⁽¹⁾