Toby Syme, Mark Jeanes
Victorian HIV Mental Health Service, Infectious Diseases Unit, The Alfred Hospital, Melbourne VIC
Last reviewed: October 2019
People with human immunodeficiency virus (HIV) infection suffer high rates of mental illness. Epidemiological studies indicate that the prevalence of mental illness in this population may be as high as 47.9%. Common diagnoses are depressive disorders, anxiety disorders and substance-related disorders. Rates of mental disorder are also reported to be high in resource-limited settings. Why do people living with HIV suffer such high rates of mental illness? Firstly, there is an association between sexual risk-taking behaviours linked to HIV transmission, and mental illness. Secondly, HIV infection impacts on a person’s life and functioning, both directly through neurological injury producing cognitive and behavioural changes and indirectly though the impact of chronic illness on psychological function. Living with a mental disorder has a signiﬁcant impact on a person’s sense of wellbeing and quality of life which may be worsened by the multiple burdens and stigma of living with a mental illness associated with HIV infection. Untreated mental illness can affect a persons’s ability to care for themselves and others, maintain accommodation and employment and to comply with HIV treatment.
People with pre-existing mental illnesses are at a higher risk of contracting HIV infection. The type of predisposing mental disorders can range from cognitive disorders (intellectual disability, dementia and acquired brain injury) to mood disorders (depression and mania), psychotic disorders (especially schizophrenia) and personality disorders (particularly borderline and antisocial personality disorder). In younger people, severe mental illness may be associated with an increased frequency of sexual risk behaviours (higher partner numbers, lower condom use), higher rates of substance use, and an association with social networks that have a higher risk of acquiring and transmitting HIV infection. It is thought that adequately identifying and treating mental illness in young people is likely to reduce HIV acquisition risk behaviours.
The liaison between mental health services and HIV services is important when considering prevention of HIV transmission. With understanding of the increased transmission risk behaviours that may occur in people with HIV infection and mental illness and the challenges that these individuals may encounter accessing preventative treatments, specifically pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), medical and mental health services can work in a synergistic way to reduce transmission  A large percentage of men who have sex with men present unique psychological issues that come from living in a society that is often hostile to gender non-conformity, resulting in personal stigma and shame. While societal attitudes to homosexuality have evolved, the developmental impact of this sense of difference, coupled not infrequently with a history of discrimination and abuse can manifest in adulthood with higher rates of mental illness and substance abuse than in the community in general.
In the Australian context, the majority of people currently living with HIV are men who contracted the infection through sexual contact with other men. Among heterosexuals in Australia diagnosed with HIV infection, migrants, especially those from high-prevalence regions are signiﬁcantly over-represented. This group also presents unique challenges and often has suffered difficult developmental and migration histories, coupled with the challenges of adapting to a new culture and lifestyle. These individuals are thus at high risk of developing a mental disorder which can manifest in differing ways due to the effects of cultural differences. Equally, a diagnosis of HIV infection is often highly stigmatised in communities to which these people belong, resulting in secrecy and social isolation for those with the infection. There is a need for culturally sensitive and appropriate medical practice in order to better engage, educate and treat patients from migrant communities who present with mental illness and HIV infection.
The later stages of HIV infection are commonly associated with the neurocognitive complications of HIV infection and less commonly with severe episodes of psychiatric illness such as manic episodes, psychotic illness and episodes of delirium. These later episodes, though less common, are important to identify and treat early to prevent risks to the patient and potentially others. Antiretroviral medications have also been associated with reported neuropsychiatric symptoms in patients. These can range from mood disturbance to anxiety, sleep disturbance and confusion. The non-nucleoside reverse transcriptase inhibitor (NNRTI), efavirenz, is the antiretroviral agent most frequently associated with neuropsychiatric symptoms including sleep disturbance, vivid dreams, anxiety, agitation, abnormal thinking including suicidal ideation and, less commonly, frank manic or psychotic symptoms.
In people with HIV infection, different types of mental disorders occur with various stages of the infection. There are signiﬁcant illness milestones that can occur, related to phases of disease progression, such as the time of initial diagnosis, commencement of ART), onset of symptomatic illness, ART failure and the need for antiretroviral salvage therapy. The later stages of illness may be associated with the increasing loss of physical functioning combined with the impaired cognitive function. These illness milestones may be associated with periods of stress or normal psychological adjustment. However, if severe they can manifest with psychological symptoms, such as anxiety or mood symptoms that may be better described as an adjustment disorder or if more severe, a major depressive disorder or an anxiety disorder. People with a prior history of mental illness and substance abuse, and those with low social support, are more at risk of suffering from major adjustment difficulties, and more likely to come to the attention of clinicians during these periods of change.
The broad principles of management in this population include a focus on engagement of the person with HIV infection and identiﬁcation and containment of immediate risks. These may be immediate risks to the person (e.g. self-harm and suicidal behaviours), or less directly via self-neglect or disturbed behaviour, and also risks to others through direct violence, neglect (e.g. of children) or problem behaviours (e.g. through unsafe sexual practices). All states and territories of Australia have mental health legislation that allows for involuntary treatment of people if there are immediate safety concerns and the person is unable or unwilling to consent to treatment. It is important to have some knowledge of the legal structures involved. Treatment of mental illness involves a multifaceted bio-psycho-social approach and often requires the resources of a multidisciplinary team (e.g. psychiatrist, mental health trained nurse, psychologist, social worker and occupational therapist) to adequately assess and deliver treatment. Access to such resources are obviously more difficult in rural and remote regions where many of these functions may be provided by a sole clinician such as a general practitioner or nurse practitioner.