The support of mental health issues within the broader medical management of HIV is a particularly difficult challenge. Currently, mental health problems remain the most common comorbidity for people living with HIV (PLHIV). Some common mental health concerns for PLHIV include:
- Depression – which has a prevalence 2x higher for PLHIV compared to the general population.
- Anxiety disorders and PTSD – which occur for one in four PLHIV.
- Alcohol use disorders – present for roughly 30% of all PLHIV.
Over time there has been both stability and change in the mental health landscape for PLHIV. There is overall stability in the fact that PLHIV are (i) at a greater risk for many mental health issues compared to the general population, and (ii) have a higher general prevalence of mental health issues when compared to the general population.
Although depression and anxiety remain the most common mental health challenges for PLHIV, more recently, adjustment disorders and acute stress responses following a HIV diagnosis are less common. One theory behind this change is that may be a function of improvements in HIV treatments and outcomes. Just a few decades ago a HIV diagnosis had a devastating prognosis, including significant impacts on health, life, relationships, sex, and many other domains. However, given the significant advances in treatment, these outcomes are now far less devastating with HIV now considered a manageable chronic illness. We can therefore see why adjustment to a HIV diagnosis is now potentially less impactful.
The role of stigma
The mental health experiences of PLHIV cannot be discussed without acknowledging the role of HIV stigma. Stigma is getting better, but it’s still prominent and unfortunately as a society we’re not yet past it. Stigma is also important to talk about because it is the mechanism behind so many poorer mental health outcomes for PLHIV. Higher perceived or experienced HIV stigma is associated with poorer mental health, lower medication adherence, increased thoughts of suicide, and a range of other detrimental outcomes.
Of note, however, is that HIV in and of itself does not cause mental health issues. For example, depression is not a symptom of HIV. Rather, there is a moderating or mediating factor between HIV and poorer mental health outcomes. That factor is inevitably stigma. Due to this it remains crucial that we continue talking about, and working to minimize, HIV stigma. If the focus is only on mental health issues and not the root causes of these issues, stigma, then likely we will continue to see poor mental health outcomes for PLHIV. If you’re trying to pull out a weed and you only get the leaves or the stems, but not the roots, that weed will soon grow back.
There are three avenues through which stigma might have influence for a PLHIV. Enacted stigma is when someone has actual, real experiences of discrimination or prejudice based on their HIV status (for example, being rejected by a potential romantic or sexual partner). Next, anticipated stigma occurs when there is a fear about being stigmatized in the future. We might think of this like stigma anxiety. Finally, internalized stigma is when someone has internalized the negative messages (either real messages or perceived messages) and now believes them about themselves.
HIV Stigma is particularly impactful for culturally and linguistically diverse communities in Australia. The impact of stigma within collectivist communities, where the identity and actions of an individual are so closely tied to the family and broader community, can amplify stigma. For example, CALD PLHIV may feel they’ve brought shame to their families and communities through their actions and diagnosis. This has been shown to lead CALD PLHIV to avoiding disclosing their HIV status, which then limits their social supports and potentially their engagement in medical care. Research has also demonstrated that Asian-born MSM who are newly arrived in Australia are at higher risk of acquiring HIV but often delay testing due to continued and extensive internalized stigma.
Seeking support
The fight against HIV stigma, and the support of mental health concerns of PLHIV, are two challenges that are not yet over. Various therapies, such as some described in our Common Treatments information have been shown as particularly effective treatments for mental health concerns for PLHIV.
Regardless of the type of psychological therapy, a HIV informed, aware, and affirming approach is the most important consideration when seeking support for mental health as a PLHIV. Such an approach is about recognising the context of what it means to be a PLHIV. With this in mind, we want to consider the following:
- Does my therapist understand the experiences of stigma still faced by PLHIV?
- Do they understand the lived history of HIV?
- Do they understand the most common psychological issues faced by PLHIV and do they know how to support/treat these?
Peer-support spaces are often incredibly valuable for PLHIV. Various organizations throughout Australia offer support groups and various other programs to support PLHIV, such as Living Positive Victoria, Throne Harbour Health, ACON, and many more. Engagement in peer-support spaces have been shown to improve retention in medical care, improve medication adherence, and are even linked to better viral suppression. Peer support and community-based supports also offer something special that’s above and beyond just psychological therapy and therefore act as a powerful addition to usual care.
