This study suggests the psychiatric context of acute/early infection encompasses an elevated prevalence of psychiatric disorders exceeding those observed in recent national community-based epidemiologic surveys [6
] combined with current anxious and depressive symptoms which in the main were not so severe as to interfere with efforts at early intervention. Furthermore, we found that with the right resources, individuals with acute/early HIV infection reported highly adaptive coping strategies.
Our sample’s rates of mood, substance use disorders, and psychiatric co-morbidity, with onset pre-HIV infection, were consistent with studies of “chronically” infected individuals [2
]. One in five of study participants had a bipolar disorder, consistent with evidence that persons with this disorder may be at heightened risk for HIV [24
Current mood symptoms of depression and anxiety were mildly elevated, although within the range of previous studies of individuals seen at voluntary testing centers after notification of seropositivity in the era before modern antiretroviral treatments [21
]. However, almost 40% of our participants did have depression symptom scores in the “clinical” range (BDI-II > 13). In the earlier research of chronically infected individuals studied at the point of notification, those in the clinical range at initial testing were likely to have clinically significant symptoms at 1 year follow-up [21
Suicidality in the context of HIV/AIDS has long been a concern among the medical and general community [17
]. The current prevalence of suicidal ideation in our study of 21% and the lifetime prevalence of suicide attempts of 32% exceeded the community lifetime prevalence of suicidal ideation (14%, [13
]) and attempts (5%, [13
]). There were no reports of suicide attempts among our participants in the immediate aftermath of testing positive. Those previously attempting suicide typically had lifetime histories of mood or substance use disorders, which are known to elevate risk of attempts. In two individuals (5.9%) rated at “high risk” for suicide, it was unclear whether suicidality antedated or resulted from testing positive. These results are consistent with the notion that most suicidal behavior in HIV-infected persons is related to mood or substance use disorder rather than HIV.
Our findings suggest implications for development of interventions for primary or secondary HIV prevention. The mild current mood symptoms, lack of acute suicidal behavior, and predominant reliance on adaptive coping approaches indicate that a substantial proportion of individuals diagnosed with acute/early HIV infection remain generally hopeful and forward-looking despite the stress of notification of positive testing, suggesting that appropriate prevention interventions would have a high probability of success. Behavioral interventions for people living with HIV might be adapted to apply to the period of acute/early infection [7
]. However, ongoing intervention may be needed for persons with conditions associated with episodic difficulties with impulse control (e.g., bipolar disorder), since reductions in risky sexual behavior after testing positive may be difficult to sustain. With regard to primary prevention, individuals with mood disorders may be especially vulnerable, given the nature of the depressive illness and the likelihood of co-existing substance use disorders. Therefore public mental health centers might particularly be brought into the network of sites promoting testing and education about AHI.
There are several important limitations to this research that may impact on its generalizability. First, our sample size was very small. Next, we only included individuals who were diagnosed in the stage of acute/early infection, whereas most infected persons are diagnosed at a later stage [22
]. It is possible that persons diagnosed with AHI in particular have specific characteristics that make them more likely to be identified and
more likely to have the mental health characteristics observed in our sample. The small sample makes our estimates of the prevalence of psychiatric disorders imprecise; for bipolar disorder, for example, the difference of a few cases would markedly alter our proportions. It may also be the case that by recruiting from sites offering testing and treatment we sampled for individuals already involved in other systems of care, including mental health or substance abuse care systems. Recruiting a population with a high base rate of psychopathology would overestimate rates of mood and substance use disorders in persons with acute/early HIV infection. Another limitation is that we did not determine whether people diagnosed with acute/early infection experience greater distress than chronically infected individuals. Knowing if episodes of mental disorder or distress tends to be more likely during the time surrounding acute/early infection would help inform interventions. Finally, our sample consisted of predominantly gay men from major urban areas with well-organized gay communities. This may account for the high level of adaptive coping observed in our sample, with the concomitant access to clinical and social services and integration into an HIV-positive “community.”
Despite these limitations it is possible that including mental health considerations into behavioral prevention perspectives may help expand and advance development of interventions aimed at reducing risk of HIV transmission and acquisition.