Consistent with previous clinical research,1, 17, 37
we report that psychiatric disorders are highly prevalent in adults with HIV. Somewhat surprisingly, the increased risk of psychiatric disorders was largely confined to HIV-positive men. Women with HIV were not significantly more likely than HIV-negative women to have psychiatric disorders. HIV status was more strongly associated with psychiatric disorders in men than women. The burden of HIV-associated psychiatric disorders appears to fall disproportionately on men.
The biological and psychological factors that contribute to the association of HIV and psychiatric disorders among men remain poorly defined. HIV can produce neuropsychiatric alterations associated with a variety of psychiatric symptoms.11, 38
At the same time, stress associated with seroconversion may trigger new onset or recurrence of psychiatric disorders. Alternatively, men with pre-existing psychiatric disorders may be more likely to engage in substance use1, 39
and high-risk sexual behavior39, 40
that increase the probability of HIV transmission. In one sample of mentally ill adults,41
25% had multiple sexual partners and condoms were not used in 75% occasions of sexual intercourse. As a result, men with psychiatric disorders may be at high risk for becoming infected with HIV. Consistent with this explanation, higher rates of personality disorders were observed among HIV-positive than -negative men, suggesting that some of the psychopathology among HIV-positive men predates their infection. HIV stigma may also be great in men than in women.
These findings highlight the need for effective interventions to address the convergence of HIV and psychiatric disorders. Services are needed to provide mental health treatment to HIV-positive individuals with psychiatric disorders and to provide HIV prevention services to mentally ill populations, regardless of serostatus. Studies have shown that mental health treatment, whether psychotherapeutic,42
or a combination, can help reduce depressive symptoms among HIV positive patients. Furthermore, a decrease in psychiatric symptoms is associated with slower disease progression,44
improved treatment adherence,12, 45
and a reduction in HIV risk behavior.46, 47
Yet, under diagnosis of depression among HIV-positive patients remains common.48
Routine psychiatric assessments of patients receiving HIV treatment might help to identify psychiatric disorders in HIV-positive individuals which might otherwise pass undetected in community practice.
Although there is extensive evidence for the efficacy of HIV-prevention programs in the general population,49–54
and among drug users,55–62
much less is known about the efficacy of interventions to reduce HIV risk behavior among individuals with other psychiatric disorders.63–68
currently being disseminated focus only on drug use rather than on the full range of common psychiatric disorders. Recent studies72, 73
also demonstrate a paucity of HIV-prevention programs in community mental health centers, where large numbers of high risk populations receive care. Research is needed to develop optimal strategies for HIV prevention among individuals with the common psychiatric disorders.74
In accord with previous clinical studies,1, 6, 17
high rates of psychiatric disorders were reported among HIV-positive women. However, mental disorders were not independently and significantly associated with HIV status among women. Similar results for anxiety and depressive disorders have been reported from a clinical sample.75
Among women, pre-existing psychopathology may not be a strong risk factor for HIV infection. Women are less likely than men to negotiate safe sex and insist on condom use76
and are more likely than men to become infected with HIV from their spouse or partner77–80
or by trading sex for money and drugs.81
It is also possible that for women resiliency or protective factors, such as supportive networks and the quality of their interpersonal attachments, attenuate seroconversion stress related onset or recurrence of psychiatric disorders. As compared with men, women facing adversities related to HIV infection may have a greater capacity to adjust to the environment, tolerate negative affect, seek social support, and cope with adversities of HIV.18
An understanding of how women successfully cope with HIV may offer insights into the mental health care of HIV-positive men following seroconversion.
This study has several limitations. First, information on HIV status was based on self-report and was not independently verified by a physician or laboratory testing. Independent verification is not feasible for a large, nationally representative epidemiological study. However, our self-report HIV rates are consistent with national CDC estimates, suggesting that potential bias in the estimates is likely to be limited. Second, the number of HIV-positive subjects in this sample is relatively small. This is a function of the prevalence of HIV in the general population. To our knowledge, there are no larger epidemiological studies with information on psychiatric diagnoses and HIV status. Nevertheless, even after stratifying by gender, we were able to detect several statistically significant differences between HIV-positive and negative individuals. Third, although the NESARC includes information on age of onset of psychiatric disorders, it does not include information regarding the onset of HIV-positive status, preventing temporal sequencing of psychiatric disorder and HIV onset. Fourth, some HIV-positive individuals diagnosed prior to the 12 months preceding the interview may have misunderstood the question and erroneously responded that they were HIV-negative. However, because our estimates of HIV prevalence closely match those of the CDC, we doubt that such misclassification was widespread and therefore we believe it is unlikely to have significantly altered the findings of this study. Fifth, the survey did not include some groups at high risk for HIV infection and psychiatric disorder including persons in prisons, hospitals, and those without stable housing.
Despite these limitations, the NESARC constitutes the largest nationally representative survey to include information of HIV status and a wide range of psychiatric disorders. Psychiatric disorders are highly prevalent among HIV-positive adults, especially HIV-positive men. Effective evidence-based pharmacological and psychosocial treatments exist for several of the common psychiatric disorders reported by HIV-positive men and women, although information about their efficacy in these populations remains limited. Early mental health treatment could reduce the persistence of these disorders and has the potential to decrease HIV transmission. Increased clinical and public health attention is clearly needed to improve the detection and treatment of psychiatric disorders among HIV-positive adults.