HIV, mental health and stigma: a brief survey of current research

HIV Australia | Vol. 11 No. 2 | July 2013

JASON APPLEBY summarises recent research examining the intersection of HIV and mental health.

Introduction

The intersection between HIV, mental health and stigma is a frequent subject for research.

For people living with HIV, issues related to mental health can provide obstacles to accessing care, maintaining good health and may place some people at greater risk of developing other conditions.

In addition, the role of mental health in helping prevent HIV transmission (and the implicit impact of mental health and stigma) have been well described in the literature.

This article summarises some of the recent research in this area, both local and abroad, with a focus on key messages and potential impacts on current health promotion practice.

Do people with HIV have higher rates of depression and other mental illness? Or is it the other way around?

De Hert et al. (2011) investigated potential reasons influencing why people with a serious mental illness (SMI) tend to have a shorter lifespan than the general population.

While it is generally accepted that this excess mortality is due to physical illness, this research attempted to conduct a meta-analysis of the reported prevalence rates of various physical illnesses among people with a serious mental illness, in research from 1966 to 2010.

One of the findings of the analysis was that patients with serious mental illness are at increased risk for a variety of chronic viral infections, including HIV and hepatitis C.

In fact, the researchers reported that: ‘the prevalence of HIV positivity in people with SMI is generally higher than in the general population, but varies substantially (1.3–23.9%).’¹

The authors also noted that ‘the high frequency of substance abuse, sexual risk behaviors (e.g., sex without a condom, trading sex for money and drugs), and a reduced knowledge about HIV-related issues contribute to this high HIV prevalence.’

However, it is important to note that these findings relate to analysis of international research and may not have as much relevance in the Australian context.

In the ‘Primary health care project on HIV and depression’,²researchers from the National Centre in HIV Social Research aimed to describe, measure and compare depression among HIV-positive and HIV-negative gay men.

One of the key findings of this three-year project was that homosexually active men were at high risk of major depression regardless of HIV status.

While HIV-positive men had the highest rates of major depression in the study, HIV status alone was not associated with major depression after controlling for key social, behavioural and psychological factors.

Do interventions designed to improve the mental health of people with HIV have an impact on general health?

It is generally accepted that people with serious mental illness may experience more difficulty in maintaining adherence to antiretroviral medication.

The interplay between mental health and adherence is well described across a range of health conditions (not just HIV). Specifically, depression has a significant impact on adherence to antiretroviral therapy (ART), according to a meta-analysis published in 2011.³ Cross-sectional and longitudinal studies have established clear links between depression and poorer adherence to ART across all populations affected by HIV, in both resource-rich and resource-poor settings.

In addition, it is possible that other connections between mental health and better health outcomes exist for people with HIV.

Some researchers have identified a relationship between stress, depression and immune response which may impact on HIV disease progression.⁴

This hypothesis is consistent with previous studies showing that, even after adjusting for ART adherence, depression is associated with worsened HIV outcomes – including CD4+ count decline, incident of AIDS-defining illness, and AIDS-related mortality.⁵

To this end, several studies have aimed to evaluate the efficacy of various ‘secondary prevention’ models to improve the health of people with HIV who also experience a serious mental illness.

Secondary HIV prevention (or ‘positive prevention’) focuses on reducing risk behaviours associated with HIV transmission and increasing health and quality of life for people with HIV.⁶

Most of these studies evaluated the effectiveness of managing depressive syndrome disorders in the context of antiretroviral adherence, though there is other research on other serious mental illnesses and health outcomes.

In the context of depression and antiretroviral adherence, research findings are incredibly promising – both pharmaceutical (i.e., antidepressant) and psychological (i.e., cognitive behaviour therapy) interventions demonstrated improvement in adherence in people living with HIV and depression.

A 2008 study, which looked at the impact of selective serotonin reuptake inhibitors (SSRIs – a form of antidepressant that boosts serotonin levels in the brain) on adherence and HIV biological markers (like HIV viral load and CD4+ count) concluded that ‘compliant SSRI medication use was associated with improved HAART adherence and HIV laboratory parameters.’⁷

A 2009 randomised control trial aimed to evaluate cognitive-behavioural therapy to enhance medication adherence and reduce depression (CBT-AD) in individuals with HIV. Although this was a relatively small trial (three months outcome assessment) the findings were clear.

Individuals who received cognitive behavioural therapy demonstrated much greater improvements in adherence to treatment, and had reduced levels of depression; these treatment gains were generally maintained at 6 and 12-month followup assessments.

The study investigators noted that: ‘At the acute outcome assessment (3-months), those who received cognitive behavioural therapy evidenced significantly greater improvements in medication adherence and depression relative to the comparison group.

‘Those who were originally assigned to the comparison group who chose to cross over to CBT-AD showed similar improvements in both depression and adherence outcomes. Treatment gains for those in the intervention group were generally maintained at 6- and 12-month follow-up assessments.

‘… By the end of the follow-up period, those originally assigned CBT-AD demonstrated improvements in plasma HIV RNA concentrations, though these differences did not emerge before the cross-over, and hence there were not between-groups differences.’⁸

Conclusion

While the outcomes of the above research appear straightforward, there is a relative paucity of evidence to assist health practitioners in providing specific advice or strategies for people living with HIV and a serious mental illness.

Almost all of the research referenced above quoted the need for further research to identify optimal strategies and evaluate impact on health outcomes such as quality of life or relative morbidity (as opposed to biological markers such as viral load, CD4 count or adherence).

References

1 De Hert, M., Correll, C., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., et. al. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10(1), 52–77.

2 Newman, C., Mao, L., Kidd, M., Saltman, D., Kippax, S. (2009). Primary health care project on HIV and depression: key findings. National Centre in HIV Social Research, University of New South Wales, Sydney. Retrieved from: http://nchsr.arts.unsw.edu.au

3 Gonzalez, J., Batchelder, A., Psaros, C., Safren, S. (2011). Depression and HIV treatment nonadherence. J Acquir Immune Defic Syndr, online edition. DOI:10.1097/QAI.0bo13e31822d490a

4 Leserman, J. (2003). HIV disease progression: depression, stress, and possible mechanisms. Biological Psychiatry, 54(3), 295–306.

5 Tsai, A., Weiser, S., Petersen, M., Ragland, K., Kushel, M., Bangsberg, D. (2010). A marginal structural model to estimate the causal effect of antidepressant medication treatment on viral suppression among homeless and marginally housed persons with HIV. Arch Gen Psychiatry, 67(12), 1282–1290. DOI:10.1001/archgenpsychiatry.2010.160

6 Sikkema, K.,Watt, M., Drabkin, A., Meade, C., Hansen, N., Pence, B. (2010). Mental health treatment to reduce HIV transmission risk behavior: a positive prevention model. AIDS Behav, 14(2), 252–62. DOI: 10.1007/s10461-009- 9650-y

7 Horberg, M., Silverberg, M., Hurley, L., Towner, W., Klein, D., Bersoff-Matcha, S., et. al. (2008). Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIVinfected patients. J Acquir Immune Defic Syndr, 47(3), 384–390.

8 Safren, S., O’Cleirigh, C.,Tan, J., Raminani, S.,Reilly, Otto,M., et. al. (2009). A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals. Health Psychol, 28 (1), 1–10.

Jason Appleby is the Treatments Editor for HIV Australia.