Scope of the problem

Persons living with HIV/AIDS have many challenges including successfully adhering to treatment recommendations in order to maintain optimal health, negotiating disclosure of HIV status and coping with potential stigma. These are significant challenges; yet, for HIV-infected persons who also have mental health difficulties, these and other, challenges can be amplified. As such, the co-occurrence of HIV and mental illness poses a significant public health problem and represents a difficult challenge for those who treat and care for these persons.

Research studies have shown that there is considerable overlap between HIV infection and several major mental disorders such as major depressive disorder and bipolar disorder. It has been estimated that the prevalence of HIV among individuals with a serious mental illness (SMI) ranges from 1 percent to 24 percent (De Hert et al., 2011), much higher than the rates found among HIV-uninfected persons. Frequently, these individuals are also diagnosed with a substance use disorder (Parry, Blank, & Pithey, 2007), which can make treatment and management of HIV and mental health problems even more challenging.

Negative consequences of HIV and co-occurring mental illness

Below we review some of the particular difficulties that can arise as a result of having both HIV infection and SMI. It is important to note that not all HIV-infected individuals will face these challenges, but for those who have these co-occurring problems, thoughtful and targeted treatment is paramount. 

Health outcomes and medication adherence

SMI is associated with a more rapid and harder-to-treat progression of HIV disease. These worsened disease outcomes can be caused by non-adherence to HIV medication, which can lead to worsened immune response, increased HIV replication, and development of drug-resistant viral mutations. Other, less obvious, connections may also exist. Specifically, there is likely a relationship between stress, depression and immune response such that HIV infection may progress more rapidly in individuals with these symptoms (Leserman, 2003). Given the risk for worse HIV disease outcomes, treatment advocates have used the presence of a coexisting psychiatric illness as a reason to suggest more aggressive and comprehensive clinical management of HIV infection (Angelino & Treisman, 2001).

As indicated above, HIV infection and SMI comorbidity appear to be detrimental for medication adherence. In addition to the problems caused by non-adherence to HIV medications, there may be equally significant difficulties caused by non-adherence to psychotropic medications. Depressive symptoms have long been linked to poor medication adherence among HIV+ persons, and treatment with antidepressant medication appears to improve antiretroviral adherence among those with a current mental health problem, especially those with more complex medication regimens (Kumar & Encinosa, 2009). One can easily imagine a scenario where non-adherence to psychiatric medications leads to disrupted mood or other significant psychiatric symptoms that may then lead to non-adherence to anti-HIV medications. In addition, poorly controlled HIV leads to a higher likelihood of HIV transmission when individuals engage in risk behaviors. In a current study by our group, we have found that HIV+ individuals with comorbid bipolar disorder have significantly worse adherence to their antiretroviral medication than a comparable group of HIV+ individuals without bipolar disorder. The proportion of persons with an ART adherence level above 90 percent was nearly twofold higher in the HIV+ persons without bipolar disorder (Moore et al., in press). 

Risk behavior engagement

Most adults who have been diagnosed with HIV are sexually active (Lansky et al., 2000), and a substantial proportion report engaging in unsafe sexual or drug injection practices (Heckman et al., 1998). Research findings show that SMI clients are highly vulnerable to contracting HIV partly because of the relationship between SMI and low SES, which places this population in contact with high-risk populations (Parry, Blank, & Pithey, 2007). For those who have both HIV and SMI, the risk of transmitting HIV to others may be particularly great, given that individuals with prolonged psychiatric illnesses can exhibit poor judgment, affective instability and impulsivity. These symptoms may increase engagement in higher risk for HIV transmission behaviors.

Suicide risk

One very concerning problem among persons with HIV and SMI is suicidality. Comorbid psychiatric illnesses, especially major depressive disorder and substance use disorders, have been found to be highly predictive of suicidal ideation in HIV+ individuals. A recent study of HIV+ persons in a large multi-site cohort found that individuals with a history of suicidal ideation and suicide attempt reported significantly higher levels of current depressive symptoms and had a significantly higher prevalence of current major depressive disorder, as well as higher levels of plasma HIV RNA (Badiee et al., 2011). Given that prior suicidal ideation and behavior were associated with current depression in this population, it is possible that these individuals may still be at risk for future suicidal ideation and behavior. HIV treating clinicians should be cognizant of past suicidal ideation or behavior, and monitor these patients carefully for current mood disturbances, as these individuals may still be at risk for suicide.

Neurocognitive ability

Neuropsychological impairment is another possible negative consequence of the comorbidity between HIV and SMI, and this impairment may exacerbate other possible outcomes such as increased engagement in risk behaviors and worse medication adherence. It is well known that HIV infection can result in neuropsychological impairment in approximately 50 percent of patients (Heaton, et al., 2010). It is widely recognized that specific mental illnesses can lead to varying levels of neuropsychological impairments too. In one of the few studies of neuropsychological functioning among HIV+ individuals with SMI (specifically bipolar disorder), the authors found that these individuals have worse sustained attention and worse overall daily functioning than HIV-infected individuals without bipolar disorder (Posada et al, 2011).

Treatment recommendations

Given the information summarized above, the question is, “What can we do?” The first step is recognition. Specifically, it is important for practitioners treating HIV-infected individuals to be aware of the high likelihood of co-morbid mental health conditions, have a basic understanding of the diagnosis and treatment of these conditions, and be prepared to partner with mental health professionals in the treatment of affected individuals. Likewise, it is important for individuals with SMI to be tested for HIV, which confers both individual and public health benefits. Individuals who test positive will benefit from medical care; the public benefits because antiretroviral therapy reduces infectiousness, and knowledge of infection status motivates risk reduction (Senn & Carey, 2009).

There are interventions, both developed and in process, that may be well suited for individuals with both HIV infection and mental illness. These are often behavioral interventions (e.g., behavioral therapy, integrated case managers, or technological interventions such as text messaging) targeted at improving adherence to HIV and psychiatric treatment regimens, as well as  reducing risk behaviors (e.g., unprotected sex, needle sharing). A recent study showed that individuals with these co-occurring conditions can be successfully treated; and with appropriate supportive services, their adherence to medication can be increased and their HIV viral loads can be reduced (Blank et al., 2011). Another potential intervention that may be appropriate for HIV-uninfected persons with SMI who engage in high-risk behavior is pre-exposure prophylaxis (PrEP) for HIV prevention. This intervention, which involves treatment of uninfected individuals with anti-HIV medications, has shown promise in reducing HIV acquisition in high-risk groups such as men who have sex with men.

In summary, high quality care for HIV infected individuals requires us to be vigilant not only of the medical problems resulting from HIV infection itself, but also the mental health needs of our patients. We have the knowledge that HIV+ persons with a co-occurring mental illness are at risk for several negative outcomes, therefore, the onus is on us as providers to serve our patients well by caring for all of their health needs, both physical and mental.

About the authors

David J. Moore, PhD, received his doctorate from the San Diego State University /University of California, San Diego (SDSU/UCSD) Joint Doctoral Program in Clinical Psychology with a specialization in neuropsychology. Currently, he is an assistant professor in the Department of Psychiatry at UCSD, and a licensed clinical psychologist. Dr. Moore’s research focuses on the neurocognitive and daily functioning abilities (particularly medication adherence) of persons with HIV infection and co-occurring mental illness. With funding from the National Institute of Health and the California HIV/AIDS Research Program, Moore and his research team at the HIV Neurobehavioral Research Program are currently developing text messaging-based interventions to improve medication adherence in these difficult-to-treat populations.

Carolina Posada, BA, recieved her bachelor's in psychology from Pontificia Universidad Javeriana in Bogotá, Colombia. Currently, she is a doctoral student in the SDSU/UCSD Joint Doctoral Program in Clinical Psychology and works under Moore’s supervision. She has a particular interest in the interplay between emotion and cognition in serious mental illness, and how these factors impact daily functioning.

References

De Hert, M., Cohen, D., Bobes, J., Cetkovich-Bakmas, M., Leucht, S., Ndetei, D.M., et al. (2011). Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry, 10, 138-51. Source: http://www.ncbi.nlm.nih.gov/pubmed/21633691

Parry, C.D., Blank, M.B., Pithey, A.L. (2007). Responding to the threat of HIV among persons with mental illness and substance abuse. Current Opinion in Psychiatry, 20, 235–241.

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

Angelino, A.F., Treisman, G.J. (2001). Management of psychiatric disorders in patients infected with human immunodeficiency virus. Clin Infect Dis, 33, 847–56.

Gaynes, B.N., Pence, B.W., PhD, Eron J.J., Miller, W.C. (2008). Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an HIV+ patient population. Psychosomatic Medicine, 70, 505–511.

Kumar, V., Encinosa, W. (2009) Effects of antidepressant treatment on antiretroviral regimen adherence among depressed HIV-infected patients. Psychiatric Quarterly, 80, 131-41.

Moore, D.J., Posada, C., Parikh, M., Arce, M., Gouaux, B., Vaida, F.,Tobin, A., Riggs, K.P., Grant, I., Atkinson, J.H., & the HIV Neurobehavioral Research Center (HNRC). (2011). Medication adherence among HIV infected individuals with comorbid bipolar disorder. AIDS and Behavior, Epub. Oct. 30.

Lansky, A., Nakashima, A.K., and Jones, J.L. (2000). Risk behaviors related to heterosexual  transmission from HIV-infected persons. Supplement to HIV/AIDS Surveillance Study Group. Sexually Transmitted Diseases, 27, 483–489.

Heckman, T.G., Kelly, J.A., and Somlai, A.M. (1998). Predictors of continued high-risk sexual behavior in a community sample of persons living with HIV/AIDS. AIDS and Behavior, 2, 127–135.

Badiee, J., Moore, D.J., Atkinson, J.H., Vaida, F., Gerard, M., Duarte, N.A., et al. (2012). Lifetime suicidal ideation and attempt are common among HIV+ individuals. Journal of Affective Disorders, 136(3), 993-9. doi: 10.1016/j.jad.2011.06.044

Heaton, R.K., Clifford, D.B., Franklin, D.R., Jr., Woods, S.P., Ake, C., Vaida, F., et al. (2010). HIV-associated neurocognitive disorders persist in the era of potent antiretroviral therapy: CHARTER Study. Neurology, 75(23), 2087-2096.

Posada, C., Moore, D.J., Letendre, S.L, Parikh, M., Gouaux, B., Umlauf, A., Grant, I., Atkinson, J.H, & the HIV Neurobehavioral Research Center (HNRC) Group. (2012). Sustained attention deficits among HIV-positive individuals with bipolar disorder (In press). Journal of Neuropsychiatry Clinical Neuroscience, 24(1):61-70. doi: 10.1176/appi.neuropsych.11010028

Senn, T.E & Carey, M.P. (2009). HIV testing among individuals with a severe mental illness: Review, suggestions for research, and clinical implications. Psychol Med, 39, 355–363.

Blank, M.B., Hanrahan, N.P., Fishbein, M., Wu, E.S., Tennille, J.A., Ten Have, T.R., et al. (2011). A randomized trial of a nursing intervention for HIV disease management among persons with serious mental illness. Psychiatric Services, 62(11) Source: http://neuro.psychiatryonline.org/issue.aspx?journalid=18&issueid=4338