Making matters worse
Links between HIV/AIDS and mental health

HIV/AIDS sufferers and children whose families are infected with the virus may suffer mental health problems arising directly or indirectly from living with the virus. HIV infected people have to deal with the stigma attached in some communities to being HIV positive. Partners, family and friends, may experience psychological stress from having to nurse sick relatives and deal with multiple deaths.

Mental illness can arise as a direct consequence of HIV infection. For example, HIV enters the central nervous system in the early stages of infection and a significant number of people with HIV develop a reduction or impairment of the brain's cognitive function, such as HIV dementia or minor-cognitive disorder. Impairment increases as the disease progresses. Antiretroviral therapy can reduce the prevalence of HIV related dementia by stopping the spread of infection.

Mood disorders are common in people with HIV/AIDS:

• In three South African studies, major depression was diagnosed in between 35 and 38 percent of HIV/AIDS sufferers.
• In one study, an additional 22 percent were diagnosed with dysthymia - a form of mood disorder characterised by a lack of enjoyment in life.
• 'AIDS mania' (usually featuring inappropriate excitement) appears in the late stages of AIDS and is estimated to occur in around 1.4 percent of cases.

People who abuse substances and suffer from severe mental illness are at increased risk of infection. Moreover some HIV/AIDS sufferers may be at risk of becoming substance abusers or developing severe mental illness. Infected people may turn to alcohol and drugs to psychologically manage their disease. Psychosis may occur in late stage AIDS, though this is rare.

Coping with being HIV positive can be made more difficult by the reactions of communities and even friends and family. People who are rejected or discriminated against may become more depressed. This can result in a more rapid progression of the disease. Even where people have not been discriminated against, fear of rejection and discrimination can lead to them being unable to live a normal life.

Many children will lose their parents to HIV/AIDS. This is not only traumatic in itself but many of these children may not be integrated into new families. This could have devastating consequences for their mental health, both as children and as adults:

• In a Zambian study, 82 percent of people who care for children of AIDS sufferers noted changes in the children's behaviour during their parents' illness. Children stopped playing, became worried, sad and too tired to help at home.
• In Uganda, children were reported to feel despair or anger and were scared their parents would die. Once the parent died, orphans in Uganda and Mozambique suffered more depression.
• In Tanzania, 34 percent of orphans had contemplated suicide.
• In South Africa, AIDS orphans experienced more physical symptoms and were likely to have nightmares. 73 percent suffered from post traumatic stress disorder.
• Because of the ongoing presence of HIV/AIDS within families and communities, these traumatic consequences may occur many times over.

Mental health problems are a critical aspect of the HIV/AIDS epidemic for both infected and affected people. As mental health problems often hinder effective adherence to antiretroviral treatment, it is necessary to include mental health care as part of HIV/AIDS treatment. Equally, mental health practitioners need to understand that patients increasingly have HIV/AIDS related symptoms.

Programmes are needed to deal with mental health in vulnerable or orphaned children. While work with children who have developed mental health problems is vital, the most important thing is preventing children from developing mental health problems. Families should be supported to take in and care for orphans, whilst orphans themselves need help to adjust to new and sometimes difficult situations.

Melvyn Freeman
Social Aspects of HIV/AIDS and Health (SAHA)
Human Sciences Research Council
Private Bag X41
Pretoria
South Africa 0001
mfreeman@hsrc.ac.za

See also

'Psychiatric co-morbidity in South African HIV/AIDS', South African Medical Journal 89(9): 992-995 by C. Els et al, 1999

'A psychological and physical needs profile of families living with HIV/AIDS in Lusaka, Zambia' UNICEF Research brief No 2 by C. Poulter, 1997

'The psychological effect of orphanhood: a study of orphans in Rakai district' Health Transition Review 7 (supplement 1): 105-124 by J. Sengendo and J. Nambi, 1997

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