United Academy

Mental Health Issues, HIV AIDS, and COVID-19

Dr. Narendra Singh Thagunna

November 29, 2020
Last updated July 15, 2021
KMC Lalitpur


A person infected with HIV is diagnosed with AIDS when he or she has one or more opportunistic infections, such as pneumonia or tuberculosis, and has a dangerously low number of CD4+ T cells (less than 200 cells per cubic millimeter of blood). Despite global progress, millions of people around the world are still at high risk of contracting HIV infection, and AIDS remains a leading cause of death among women of reproductive age and young adolescents. 

Worldwide, 36.9 million people were living with HIV. According to the National Centre for AIDS and STD Control (NCASC), an estimated 29,503 people are currently living with HIV in Nepal since the first HIV case in Nepal was diagnosed in 1988. Four out of every five infections in Nepal have occurred through sexual transmission. Key populations like sex workers, injecting drug users, migrants, prisoners, transgender people, and gay men, and other men who have sex with men are at high risk of acquiring HIV infection. Due to lake of awareness in community people, persons with HIV infection and AIDS are suffering from discrimination and social exclusion makes them more vulnerable. HIV is characterized as a concentrated epidemic in Nepal with an adult (ages 15-49). 

HIV/AIDS and Mental Health:

Anxiety and depression continue to be significant comorbidities for people with human immunodeficiency virus (HIV) infection. One review found that patients tended to experience depression or anxiety as a consequence of being diagnosed with a chronic disease. The study suggested (Niu L et al. 2016; Charlson FJ et al.,2016; Pappin M, Wouters E and Booysen FL, 2012)) that Over half of all HIV-infected individuals suffer from mental health disorders and depression and anxiety disorders are more common in HIV-infected individuals than in the general population. Clinical experience working with women with HIV infection (WLHIV) and a history of psychological trauma suggests that they may have several anxieties linked to the impact of a life-threatening infection on their well-being and that of their children. Stigma and discrimination are associated with poorer health, health disparities, and quality of life for people living with HIV, key populations, and people with mental health conditions.

For people living with HIV, it is important for them to be aware that they have an increased risk of developing mood, anxiety, and cognitive disorders. For example, people living with HIV are twice as likely to have depression compared to those who are not infected with HIV. These conditions may be treatable and many people with mental health conditions recover completely.

An HIV diagnosis may itself aggravate traumatic experiences; many women either relate their HIV diagnosis indirectly to the experience of trauma or acquired HIV during a sexual assault. Interpersonal violence and sexual trauma are highly prevalent among this population. The consequences of these experiences(s) include increased rates of depression and post-traumatic stress disorder and increased likelihood of behavioral avoidance patterns.

People with mental health conditions at greater risk for HIV (injecting drug use, unsafe sex, sexual abuse) and less likely to seek information and health services. People with HIV/AIDS are at a higher risk for mental health disorders like mood, anxiety, and cognitive disorders. Depression and anxiety are the most common mental health conditions among people living with and at risk of HIV. Adolescents and young adults are at the most risk for HIV and the presentation of mental health conditions. People living with HIV are twice as likely to have depression compared to those who are not infected with HIV. Women with HIV infection (WLHIV) have higher psychological trauma, anxiety, depression, and post-traumatic stress disorder (Joska, J.A., Andersen, L., Rabie, S.et al.2020). Psychological stress occurs when an individual perceives that environmental demands tax or exceed his or her adaptive capacity. Forms of stress can contribute to mental health problems for people living with HIV

  • Having trouble getting the services you need
  • Experiencing a loss of social support, resulting in isolation
  • Experiencing a loss of employment or worries about whether you will be able to perform your work as you did before
  • Having to tell others you are HIV-positive
  • Managing your HIV medicines
  • Going through changes in your physical appearance or abilities due to HIV/AIDS
  • Dealing with loss, including the loss of relationships or even death
  • Facing the stigma and discrimination associated with HIV/AIDS

HIV/AIDS and Depression

According to the World Health Organization (WHO), 350 million suffer from depression. Mood disorders, particularly depression, are the most common psychiatric complication associated with HIV disease. Depression can range from mild to severe, and the symptoms of depression can affect individuals' day-to-day life. Both HIV-related medical conditions and HIV medications can contribute to depression. One study estimated depression is the most commonly observed mental health disorder among those diagnosed with HIV, affecting 22% of the population. Depression can also be a consequence of HIV-induced brain injury or antiretroviral medication. Depression can negatively impact your mind, mood, body, and behavior. Unfortunately, more than half of the HIV+ population that suffer from depression have not received an official diagnosis of their depression.

HIV positive individuals who have not disclosed their seropositive status, have lost loved ones to HIV, or are themselves in an advancing stage of the illness are at serious risk of Depression. Treatment failure, and even treatment success, should also be considered risk factors for depression.

Many health care professionals believe that an HIV diagnosis will naturally result in depression. Although the diagnosis will certainly trigger anxiety and distress— sometimes so severe it impairs functioning and may even lead to suicide—this kind of situation-specific emotional response is not the same as depression.  Once an HIV patient is diagnosed with clinical depression, the clinician should be mindful that the individual’s risk of suicide is higher than in the general population, and that this is true at all stages of HIV disease. Symptoms of depression come in two categories: affective and somatic.

Affective symptoms include depressed mood, loss of interest in normally pleasurable activities, feelings of guilt or worthlessness, hopelessness or suicidal ideation.

Somatic symptoms include loss of weight or appetite, sleep disturbances, agitation/retardation, fatigue, and loss of concentration. The common symptoms can include:

  • Persistent sadness,
  • Feeling “empty,”
  • Feelings of helplessness,
  • Negativity
  • Loss of appetite
  • Disinterest in engaging with others
  • Overall depressed mood
  • Loss of interest or pleasure
  • Suicidal thoughts
  • Feelings of guilt
  • Appetite and weight changes
  • Sleep disturbance
  • Attention and concentration problems
  • Changes in energy level and fatigue
  • Psychomotor disturbance
  • Severe hopelessness or negativism
  • Persistent agitation
  • Pronounced affective instability
  • Maladaptive social functioning
  • Feeling slow and sluggish
  • Decreased sex drive

HIV and Anxiety

Feelings of anxiety are a normal, healthy response to the diagnosis, onset, or progression of HIV infection. HIV people tend to experience more anxiety than the general population. Certain medications used to treat HIV can also cause anxiety symptoms. People living with HIV can experience symptoms of anxiety across the spectrum of anxiety disorders. Adjustment disorder is the most common psychiatric disorder that manifests as anxiety and is common after receiving an HIV diagnosis.

The other major types of anxiety disorder are panic disorder and agoraphobia, social phobia and other phobias, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), acute stress disorder, and anxiety disorder due to a general medical condition. A person who has anxiety lasting longer than six months, and who has excessive worries is typically diagnosed with a general anxiety disorder. The disorder has been noted in 15.8% of HIV+ persons, compared with only 2.1% of the general population.  Around 10.5% of HIV+ people, compared to 2.5% of the general population, have experienced panic disorder, which can be associated with viral infections, cocaine use disorder, and major depressive disorder.  

HIV positive women experience higher rates of anxiety compared to the general population. One study found 37% of 361 women had high anxiety, mostly related to HIV stigma, reproductive health worries, or having experienced judgment from their family and friends for trying to become pregnant. Anxiety disorders are a serious concern for HIV+ people who don’t have good coping strategies and a strong social support network, such as family, friends, or a faith community. Individuals with a history of abuse like physical, sexual, emotional are more likely to have an anxiety disorder.

Those with a personal or family history of anxiety disorders also are at higher risk for developing them. Individual who have unresolved grief is more risk for anxiety. 

Causes of Mental health problems in HIV/AIDS: 

HIV infection itself does not cause mental health problems, nor does the progression of the disease automatically lead to mental health problems like depression. These common causes and crisis points include:

  • Initial HIV diagnosis
  • Telling friends and family that you have been HIV-infected
  • New medication introductions
  • Recognition of new symptoms and disease progression awareness
  • Hospitalization
  • Physical illness
  • Death of a significant other
  • AIDS diagnosis
  • A return to a higher level of functioning (e.g., going back to work, going back to school)
  • Major life changes (e.g., birth, relocation, change of jobs, loss of a job, pregnancy, end of a relationship)
  • Making end-of-life and permanent planning decisions

HIV/AIDS: Impact on mental health in a time of COVID-19

The recent Covid-19 pandemic has had significant psychological and social effects on the population. COVID-19 is a global health crisis. While the involvement of the respiratory system is the primary cause of transmission and morbidity, there is increasing interest in the individual level mental health consequences of this pandemic. In a recent survey report administered during the Covid-19 pandemic, children and young adults are particularly at risk of developing anxious symptoms (Orgilés et al., 2020). Research has suggested the impact on the psychological well-being of the most exposed groups, including health workers, children, college students, Persons living with a disability, and people infected with HIV and AIDS, who are more likely to develop post-traumatic stress disorder, anxiety, depression, and other symptoms of distress. 

The psychological impacts of COVID-19 also pose significant risks to mental-wellbeing as elevated levels of stress and anxiety are further worsened by the ongoing uncertainty of the situation. National lockdowns worsen feelings of loneliness, depression, and anxiety in key populations and people living with HIV. The discrimination and marginalization experienced by young people living with HIV (YPLHIV) place them at heightened risk of experiencing mental health challenges during this time. 

According to UNICEF East Asia Pacific(2020), Assess to mental health service during COVID-19: Among young people who reported needing mental health services, 34% have experienced delays or disruption in access to mental health medications due to COVID-19 and 47% have experienced delays or disruption in accessing psychosocial support as a result of the ongoing pandemic. Approximately 70% of respondents have reported feeling anxious or extremely anxious. 

Treatment and Psychosocial Support:

Treatment for Mental health problems like depression, anxiety, and stress can make a significant difference in the physical and emotional well-being of individuals living with HIV.

Conducting psychological support sessions while complying with physical distancing rules or using modern remote telecommunications, interferes with our efforts to establish a genuine and effective relationship and nurturing empathy. 

Recent research suggests that social support is highly associated with better treatment adherence for individuals with depression or anxiety. Nonpharmacological treatments of HIV-related anxiety include muscle relaxation, behavioral therapies, acupuncture, meditation techniques, self-hypnosis, and individual imagery psychotherapy, cognitive-behavioral therapy, psychoeducation, aerobic exercise, and supportive group therapy. According to Banerjee (2020) The Importance of Psychiatrists and Psychologists during the COVID-19 a) Education of the public about the common psychological effects of a pandemic, b) Motivating the public to adopt strategies for disease prevention and health promotion, c) Integrating their services with available health care, d) Teaching problem-solving strategies to cope with the current crisis, e) Empowering patients with COVID-19 and their caregivers, and f) Provision of mental health care to healthcare workers. 

  • Creating Healthy Routines
  • Connecting with Others
  • Owning Your Feelings
  • Eliminating Toxic Influences
  • Supporting Others

References:

  1. American Psychiatric Association (2000.). Practice guideline for the treatment of patients with HIV/AIDS. American Journal of Psychiatry (suupl). 157(11).
  2. Capaldini, Lisa (1995). Depression and HIV Disease A highly treatable complication of HIV infection. HIV Newsline 1[6].
  3. Gonzalez A, Zvolensky MJ, Parent J, Grover KW, Hickey M (2012). HIV symptom distress and anxiety sensitivity in relation to panic, social anxiety, and depression symptoms among HIV-positive adults. AIDS Patient Care and STDs (epub).
  4. Ivanova EL, Hart TA, Wagner AC, Alijassem K, Loutfy MR (2012). Correlates of anxiety in women living with HIV of reproductive age. AIDS Behavior (epub) .
  5.  Niu L et al. (2016) The mental health of people living with HIV in China, 1998–2014: a systematic review. PLoS ONE 11.
  6.  8. Charlson FJ et al. (2016) The burden of mental, neurological, and substance use disorders in China and India: a systematic analysis of community representative epidemiological studies. Lancet 388, 376–389.
  7. 9. Pappin M, Wouters E and Booysen FL (2012) Anxiety and depression amongst patients enrolled in a public sector antiretroviral treatment programme in South Africa: a cross-sectional study. BMC Public Health 12, 244
  8. Joska, J.A., Andersen, L., Rabie, S. et al.(2020). COVID-19: Increased Risk to the Mental Health and Safety of Women Living with HIV in South Africa. AIDS Behav 242751–2753. https://doi.org/10.1007/s10461...
  9. Banerjee, D., (2020). The COVID-19 outbreak: crucial role the psychiatrists can play. Asian J. Psychiatr. 51, 102014
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