Psychiatric Context of Acute/Early HIV Infection.
The NIMH Multisite Acute HIV Infection Study: IV
J. Hampton Atkinson Æ Æ Jenny A. Higgins Æ Æ Ofilio Vigil Æ Æ Robert Dubrow Æ Æ
Robert H. Remien Æ Æ Wayne T. Steward Æ Æ Corinna Young Casey Æ Æ
Kathleen J. Sikkema Æ Æ Jackie Correale Æ Æ Chris Ake Æ Æ J. Allen McCutchan Æ Æ
Peter R. Kerndt Æ Æ Stephen F. Morin Æ Æ Igor Grant
Published online: 11 June 2009
? The Author(s) 2009. This article is published with open access at Springerlink.com
risk for HIV transmission. Better understanding of behav-
ioral aspects during this period could improve interventions
to limit further transmission. Thirty-four participants with
acute/early HIV infection from six US cities were assessed
with the Mini International Diagnostic Interview, Beck
Depression Inventory II, State-Trait Anxiety Inventory,
Brief COPE, and an in-depth interview. Most had a pre-
HIV history of alcohol or substance use disorder (85%); a
Acute/early HIV infection is a period of high
majority (53%) had a history of major depressive or bipolar
disorder. However, post-diagnosis coping was predomi-
nantly adaptive, with only mild to moderate elevations of
anxious or depressive mood. Respondents described chal-
lenges managing HIV in tandem with pre-existing sub-
stance abuse problems, depression, and anxiety. Integration
into medical and community services was associated with
adaptive coping. The psychiatric context of acute/early
HIV infection may be a precursor to infection, but not
necessarily a barrier to intervention to reduce forward
transmission of HIV among persons newly infected.
Substance use disorder ? Coping
Acute HIV infection ? Psychiatric disorder ?
Acute HIV infection (AHI)—the weeks to about 2 months
between acquisition of HIV and completion of serocon-
version—is characterized by extremely elevated concen-
trations of HIV RNA (viral load) in blood and genital
secretions, which markedly increases risk of transmission.
Furthermore, although acute HIV shedding is over about
10 weeks post-infection, elevated onward transmission
likely extends through the period of early infection (defined
as the 6 month period after seroconversion) due to ongoing
high risk behaviors, associated sexually transmitted dis-
eases that increase transmission risk, and transmission
amplification through high-risk sexual and drug-use net-
works (for more detailed arguments and references, see
, the first paper of this series in this issue of the jour-
nal). Efforts at secondary prevention aimed toward pre-
venting forward transmission during acute/early infection
may require not only an understanding of the infected
J. H. Atkinson (&) ? O. Vigil ? C. Y. Casey ? C. Ake ?
J. A. McCutchan ? I. Grant
HIV Neurobehavioral Research Center, University of California,
San Diego, 150 West Washington Street, La Jolla,
CA 92103, USA
J. A. Higgins
Center for Health and Wellbeing, Princeton University,
Princeton, NJ, USA
Center for Interdisciplinary Research on AIDS, Yale University,
New Haven, CT, USA
R. H. Remien ? J. Correale
HIV Center for Clinical and Behavioral Studies, New York State
Psychiatric Institute and Columbia University, New York,
W. T. Steward ? S. F. Morin
Center for AIDS Prevention Studies, University of California,
San Francisco, CA, USA
K. J. Sikkema
Duke University, Durham, NC, USA
P. R. Kerndt
Sexually Transmitted Disease Program, Los Angeles County
Department of Public Health, Los Angeles, CA, USA
AIDS Behav (2009) 13:1061–1067
individuals’ awareness, behaviors, and knowledge of AHI,
but also of the mental health context of infection itself.
Although the mental health of individuals with acute/
early infection has not been specifically studied, anxiety
and depressive symptoms lasting for weeks or months after
testing positive for HIV in chronically infected persons are
well-documented (e.g., [16, 19, 20]). Most studies of HIV-
infected persons in the developed world suggest there is an
elevated lifetime and current prevalence of formal psy-
chiatric and substance use disorders compared to the
prevalence observed in population-based community sur-
veys . For example, up to 35–40% of HIV infected
individuals have a lifetime history of major depression [1,
2, 4], compared to around 15% of community controls ,
with the risk of major depression increasing in those with
advanced medical disease [2, 16]. Similarly, lifetime
prevalence of alcohol use disorders (i.e., abuse and
dependence) and non-alcohol substance use disorders (e.g.,
methamphetamine, cocaine, opioids) in infected cohorts
exceeds that in the community: 45–70%  versus 18–30%
for alcohol use disorders  and 50% or more  versus
10% for non-alcohol substance use disorders . Finally,
the so-called ‘‘seriously mentally ill,’’ defined as those with
severe mood disorder (e.g., bipolar disorder) and psychoses
are at heightened risk for acquiring HIV (e.g., ).
While these studies have documented the mental health
status of people chronically infected with HIV, there is a
dearth of knowledge about the mental health status of
persons with acute/early infection. Study of such persons
affords a unique glimpse into people’s mental health
immediately preceding and following HIV transmission
and allows an exploration of their unique mental health
This is the fourth in a series of five papers in this issue of
the journal (see [11, 12, 23, 27]) that describe results from
the National Institute of Mental Health Multisite Acute
HIV Infection Study (see  for the overall aims of the
study). The present research evaluated coping approaches,
current mood, and lifetime prevalence of mood and sub-
stance use disorders in a sample of people diagnosed with
acute/early HIV infection. We believe that this is the first
study of the psychiatric setting for and immediate respon-
ses to such infections.
Participants were 18 years of age or older, had sufficient
English proficiency to complete the study measures, and
had documented evidence of acute or early HIV infection
(see ). Subjects were asked to participate in two study
visits. The first visit was targeted to be held within 4 weeks
of each participant being informed of his or her diagnosis,
and a follow-up visit was targeted for 8 weeks later. At
each visit, participants completed an in-depth qualitative
interview and a structured quantitative survey (see ).
The current study utilized quantitative data from the first
visit, focusing on the mental health status and sexual
behavior sections of the survey, and qualitative data from
The Mini International Neuropsychiatric Interview (MINI;
Plus version 5.0; ), a semi-structured clinician-admin-
istered interview with documented reliability and validity,
was used to ascertain suicidality and lifetime and recent
occurrence of the seven DSM-IV psychiatric and substance
use disorders: Major Depressive Disorder, Bipolar I and II
Disorders, Alcohol Abuse/Dependence, and Substance
Abuse/Dependence. The module on suicide inquires about
recent (past month) suicidal ideation, its frequency and
intensity, and about lifetime suicide plans and attempts. A
‘‘current suicide risk assessment’’ scale is used to derive a
risk score (no, low, moderate, or high risk). Interviewers
were trained to a criterion standard by investigators at the
site responsible for this evaluation (University of Califor-
nia, San Diego). Audio recordings were periodically eval-
uated to ensure adherence to this standard. Interviewers at
each site hand-scored the interview for diagnoses; the San
Diego clinical team reviewed all protocols to confirm
correct scoring procedures.
Participants completed the Beck Depression Inventory-
II (BDI-II; ) and the state scale of the State-Trait Anx-
iety Inventory (STAI, ). Total scores on the Beck II
range from 0 to 63, with higher scores indicating more
depressed mood (i.e., scores from 0 to 13 = minimal
severity;14–28 = mildto
63 = severely depressed mood). The time period assessed
was the past 2 weeks. State STAI scores range from 20 to
80, with higher scores indicating more anxiety. A mean
score of 35.7 (SD = 10.4) has been reported of working
male adults, while mean scores of 47.7 (SD = 13.2) and
42.4 (SD = 13.8) have been reported for neuropsychiatric
and general medical/surgical patients, respectively .
State anxiety was anchored to the present (‘‘right now, right
at this moment’’).
Participants rated their ‘‘recent’’ coping behaviors on the
Brief COPE . The measure yields two summary coping
domain scores: adaptive coping (eight subscales: e.g.,
active coping, planning, positive reframing, acceptance) or
less adaptive coping (six subscales: e.g., self-distraction,
denial, substance use; ). Summary scores were gener-
ated by summing the subscale scores in each domain,
normalized for the number of component subscales. A
1062 AIDS Behav (2009) 13:1061–1067
higher summary score indicates a higher level of adaptive
or less adaptive coping.
We measured sexual behaviors using a structured survey
(see ). To better understand participants’ own articu-
lations of their mental health, HIV diagnosis, and coping
strategies, we utilized data from the qualitative interviews.
We conducted descriptive analyses of lifetime and recent
rates of psychiatric and substance use disorders and suici-
dality, as well as recent mood and coping. We used a
nonparametric approach (Wilcoxon Rank Sums test) to
assess the significance of differences in number of sexual
partners across psychodiagnostic groups. We used paired
t-tests to assess the difference between adaptive and less
Qualitative interviews were coded for themes as
described elsewhere in this series . For the findings
reported here, coding sorts and coding reports focused on
the following themes: substance use before diagnosis;
physical and mental health issues before diagnosis; coping
and emotional response to diagnosis (including emotional/
psychological response to the news, sources of support, and
future thoughts and orientation); behavioral response to the
diagnosis (including substance use); and access of medical
and/or mental health services.
Structured Psychiatric and Psychological Assessment
The demographic characteristics of the 34 individuals (28
cases of AHI and 6 cases of early HIV infection) who were
enrolled in the study are presented in a companion piece in
this issue . In brief, participants were predominantly
Caucasian or Hispanic gay men in their late 20s or early
30s, who had at least some college education. Psychiatric
history, as assessed by the M.I?N.I. Plus, is described in
Table 1. The vast majority of participants (29 of 34;
85.3%) met criteria for a lifetime history of an alcohol or
other substance use disorder, with more than half (21 of 34;
61.8%) meeting criteria for a recent (within the past
12 months) disorder. Furthermore, a majority of partici-
pants (18 of 34; 52.9%) met criteria for a lifetime diagnosis
of mood disorder, either major depressive disorder or
bipolar disorder. Co-morbidity—the lifetime occurrence of
two of more conditions (e.g., alcohol use disorder and
mood disorder)—was characteristic of the sample, with 18
participants (52.9%) having two or more disorders.
As assessed with the M.I?N.I. Plus, a substantial pro-
portion reported having made a suicide attempt at some
time in their life (11 of 34; 32.4%). As might be expected,
all individuals reporting prior suicide attempts also met
lifetime criteria for alcohol and/or substance use disorders;
likewise a lifetime diagnosis of mood disorder was pre-
valent in those with suicide attempts (7 of 11; 63.6%). A
significant minority of participants (7 of 34; 20.6%)
reported some form of suicidal ideation in the past month.
This consisted of endorsements of thoughts about suicide,
thoughts about being better off dead or wishing one were
dead, and thinking of harming oneself. None reported a
suicide attempt in the past month. Current suicide risk
assessment scores ranged from 0 to 24. The distribution of
risk scores was as follows: no risk, N = 27; low risk,
N = 3; moderate risk, N = 2; high risk, N = 2.
The relationship of mood and substance use disorders to
sexual risk behavior was also assessed. The only finding
that achieved even borderline statistical significance was
that in the 2 months preceding documentation of HIV,
those with a lifetime diagnosis of bipolar disorder (N = 8)
reported more sexual partners than those with no lifetime
mood disorder diagnosis (i.e., no major depression or
bipolar disorder, N = 16) (18.3 ± 19.0 partners vs.
4.4 ± 4.5 partners; P = 0.06).
In terms of the timing of onset of psychiatric condition,
all participants with a lifetime diagnosis of mood or sub-
stance disorder reported onset preceded notification of HIV
infection. The inventories of current mood revealed mild
depressive (mean BDI-II = 12.0 ± 8.9) and anxiety (mean
state scale of the STAI = 36.4 ± 12.4) symptoms. The
vast majority of participants were experiencing minimal
(N = 21; 61.8%) or mild-moderate (N = 11; 32.4%)
Table 1 Lifetime and recent prevalence of DSM-IV disorders in
acute HIV infection (N = 34) compared to US lifetime estimates
from population-based community surveys
N = 34
Major depression (%, No.)
Recent (last 2 weeks) lifetime
Bipolar disorder (%, No.)
Recent (current) lifetime
Alcohol use disorder (%)
Recent (last 12 months) lifetime
Other substance use disorder (%)
Recent (last 12 months) lifetime
Current suicide ideation
Lifetime suicide attempt
Lifetime indicates: ever, recent or past occurrence
aNational Epidemiologic Survey on Alcoholism and Related Con-
ditions [8, 18, 9, 6]
bNational Comorbidity Survey Replication , last 12 months
cNational Comorbidity Survey 
AIDS Behav (2009) 13:1061–10671063
symptoms of depressed mood, while only two (5.9%) were
experiencing severe depressive symptoms. Furthermore,
participants reported greater use of adaptive coping
approaches (summary Brief COPE adaptive domain
score = 5.4 ± 1.1) compared to less-adaptive approaches
to confronting their HIV diagnosis (summary Brief COPE
less-adaptive domain score = 3.4 ± 1.1). This difference
was highly significant (P\0.0001).
In-Depth Interview Findings
Findings from the qualitative in-depth interviews corrob-
orated those from the structured surveys. Respondents
described the challenges of managing an HIV diagnosis in
tandem with pre-existing substance abuse problems,
depression, and anxiety. However, despite these chal-
lenges, several respondents appeared to be coping well,
especially those well integrated into medical and social
services and/or a community of other sero-positive
Although most respondents were coping well, in-depth
interviews also revealed that psychiatric and substance
disorders might have enhanced some individuals’ vulner-
ability to infection and adversely impacted post-diagnosis
coping. For example, one participant described pre-existing
co-morbidity with bipolar disorder and addictive behavior.
‘‘I tend to overdo a lot of things,’’ he said. ‘‘And I think I’m
an addict with lots of different addictions: food, sex, et
cetera.’’ When recounting his infection story, he reported:
I remember fucking this black guy. I remember him
sneezing and stuff, or coughing. I thought perhaps he
might have been sick. And then, you know, [HIV]
crossed my mind, but I’m like, ‘Fuck it, I don’t care.’
I was pretty self-destructive. I still am pretty self
destructive. (33-year old gay man, New York).
This respondents’ post-diagnosis coping also was com-
promisedby his experience
I’d called many help lines, searching for help,
searching for help, psychiatrically. When I was in my
lows…thinking about going out and getting a gun. [..]
But there’s no help out there in New York City. So
that’s the reason a lot of people just go ahead and
[commit suicide], and I totally understand that,
Other respondents’ infection and coping narratives were
infused with substance abuse disorders, both as harbingers
of infection and as factors in post-diagnosis coping. One
participant described a long history of methamphetamine
and cocaine use, which he factored into his HIV infection:
When you’re high, you don’t bother to ask anyone
about HIV. [..] Do I think drugs have anything to do
with me having [HIV]? Of course I do. (57-year old
gay man from San Francisco).
Since diagnosis, this respondent had struggled to create
a new, drug-free social network. Highlighting the cycle
between mental illness and substance use, he also worried
that anxiety about his diagnosis could lead him back to
drug use. ‘‘I felt insecure enough without having HIV, he
said. ‘‘Is this going to make me want to go back to past
behavior with the drug use? It very easily could.’’
In a final example of this theme, one respondent
described a history of both depression and methamphet-
amine use (he also reported extreme BDI-II severity on his
structured interview). He expressed anxiety about how to
have sex without methamphetamine and how to access the
help he needed:
I’m trying to get the right help. But I’m not doing it
right…I’m making the wrong choices, you know?
And I need help, but I can’t—I’m—I’m alone with
this. (31-year old gay man, Los Angeles).
In keeping with the structured interview findings, a
number of respondents described highly functional coping
in the aftermath of their HIV diagnosis, despite some of the
mental health challenges mentioned above. Qualitative
data indicated that two factors tended to be most strongly
associated with adaptive coping: good access to clinical
and social services; and integration into a community of
sero-positive people and/or a close relationship with
another HIV-positive person.
One respondent suspected that he became infected
through one of his short-term Internet partners, but his
long-term partner of 7 years was also HIV-positive.
Because of this latter partner, he not only knew what to
expect in the progression of the disease, but he received
immediate referrals to both doctors and support services:
‘‘I’ve gotten a lot information on educational programs and
stuff like that. With [my partner], these things have helped
me get my focus back on reorganizing my life. [..] Until I
talked to them, I didn’t quite focus in on what the positive
aspects of this could be (36-year old gay man, San Diego).
Similarly, another respondent seemed to be faring well
after diagnosis, in large part because of the services
available to him at his testing site, the Gay and Lesbian
Center in Hollywood:
They offered me medical assistance, psychological
assistance, financial assistance, um, moral assistance.
[..] Being newly infected, I’m…I’m eligible for a
whole bunch of stuff. You know, house…assistance
in housing, assistance in medical care, and stuff like
1064AIDS Behav (2009) 13:1061–1067
this. [..] I’m constantly amazed at the medical staff.
(46-year old gay man, Los Angeles).
Perhaps due to this support, the above respondent had
not used methamphetamine since diagnosis, and he was
optimistic about his ability to stay clean.
This study suggests the psychiatric context of acute/early
infection encompasses an elevated prevalence of psychi-
atric disorders exceeding those observed in recent national
community-based epidemiologic surveys [6, 8, 9, 18]
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, 4]. 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, 29].
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 . 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 .
Suicidality in the context of HIV/AIDS has long been a
concern among the medical and general community .
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, 14]) and attempts (5%, ). There
were no reports of suicide attempts among our participants
in the immediate aftermath of testing positive. Those pre-
viously 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 indi-
viduals 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, 10, 28]. 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 . 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 indi-
viduals. 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-
AIDS Behav (2009) 13:1061–10671065
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
the National Institute of Mental Health as supplements to the fol-
lowing AIDS Research Centers: P30MH062246, Center for AIDS
P30MH043520, HIV Center for Clinical and Behavioral Research,
New York State Psychiatric Institute and Columbia University;
P30MH062512, HIV Neurobehavioral Research Center, University of
California San Diego; P30MH052776, Center for AIDS Intervention
Research, Medical College of Wisconsin; P30MH058107, Center for
HIV Identification, Prevention and Treatment Services, University of
California Los Angeles; and P30MH062294, Center for Interdisci-
plinary Research on AIDS, Yale University. Additional funding was
provided by: P30AI42853, Lifespan/Tufts/Brown Center for AIDS
Research and AI43638, Acute Infection and Early Disease Research
Program, University of California San Diego. Complete details about
funding, the study Steering Committee, co-investigators, collaborat-
ing scientists, and project staff are presented in the first paper of this
Primary funding for this study was provided by
of CaliforniaSan Francisco;
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
This article is distributed under the terms of the
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