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HIV/AIDS and mental health research in sub-Saharan Africa: A systematic review

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Abstract

The relationship between mental illness and HIV/AIDS is complex and bidirectional. A significant amount of research has been performed in high-income countries but less is known about HIV and mental health in sub-Saharan Africa. The objectives of the review were to search the literature for quantitative studies conducted in sub-Saharan Africa on mental health and HIV and to critically evaluate and collate the studies in order to identify research needs and priorities. The databases Ovid, MEDLINE, PsycINFO and the Social Sciences Citation Index (SSCI) were searched for variations of search terms related to HIV/AIDS and mental health and studies limited to the populations of African countries. In addition, we hand-searched indexes of key journals and the databases of academic theses. We included 104 papers or research publications. The majority of these were published after 2005. The major topics covered were: mental-health-related HIV-risk behaviour, HIV in psychiatric populations, and mental illness in HIV-positive populations. The reported prevalence levels of mental illness among people living with HIV or AIDS (PLHIV) was high, with all but one study noting a prevalence of 19% or higher. Neurocognitive changes in adults with HIV were also prevalent, with reported deficits of up to 99% in symptomatic PLHIV and 33% in non-symptomatic PLHIV. Research on HIV in relation to mental health is increasing; however, there is a need for good-quality prospective studies to investigate the bidirectional effects of mental illness and HIV on each other.
African Journal of AIDS Research 2011, 10(2): 101–122
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African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
HIV/AIDS and mental health research in sub-Saharan Africa: a systematic
review
Erica Breuer
1
, Landon Myer
1
, Helen Struthers
2
and John A Joska
3
*
1
University of Cape Town, School of Public Health and Family Medicine, Falmouth Building, Observatory 7925, Cape Town,
South Africa
2
Anova Health Institute, Postnet Suite 242, Private Bag X30500, Houghton 2041, Johannesburg, South Africa
3
Groote Schuur Hospital, Department of Psychiatry and Mental Health, J-Block, Observatory 7925, Cape Town, South Africa
*Corresponding author, e-mail: john.joska@uct.ac.za
The relationship between mental illness and HIV/AIDS is complex and bidirectional. A significant amount of research
has been performed in high-income countries but less is known about HIV and mental health in sub-Saharan Africa.
The objectives of the review were to search the literature for quantitative studies conducted in sub-Saharan Africa
on mental health and HIV and to critically evaluate and collate the studies in order to identify research needs and
priorities. The databases Ovid, MEDLINE, PsycINFO and the Social Sciences Citation Index (SSCI) were searched
for variations of search terms related to HIV/AIDS and mental health and studies limited to the populations of
African countries. In addition, we hand-searched indexes of key journals and the databases of academic theses.
We included 104 papers or research publications. The majority of these were published after 2005. The major
topics covered were: mental-health-related HIV-risk behaviour, HIV in psychiatric populations, and mental illness
in HIV-positive populations. The reported prevalence levels of mental illness among people living with HIV or AIDS
(PLHIV) was high, with all but one study noting a prevalence of 19% or higher. Neurocognitive changes in adults
with HIV were also prevalent, with reported deficits of up to 99% in symptomatic PLHIV and 33% in non-symptomatic
PLHIV. Research on HIV in relation to mental health is increasing; however, there is a need for good-quality
prospective studies to investigate the bidirectional effects of mental illness and HIV on each other.
Keywords: literature reviews,
mental illness, neurocognitive deficits, prevalence, psychiatric disorders, quantitative
research
Background
Mental illness is an increasingly important cause of disability
worldwide. Seven of the 20 leading causes of moderate
to severe disability in the Global Burden of Disease 2004
study by the World Health Organization (WHO) (2008) were
mental illnesses: alcohol abuse, bipolar disorder, schizo-
phrenia, Alzheimer’s disease, panic disorder, drug abuse
and depression. The highest-ranked mental illness was
depression, which is the third-highest cause of disability
worldwide and estimated to become the highest-ranked
cause of disability by 2050 (WHO, 2008).
Key social determinants of mental illness, such as poverty,
conflict, social exclusion and displacement, are common in
sub-Saharan Africa (De Jong, Komproe & Van Ommeren,
2003; Patel & Kleinman, 2003; Patel, 2007; Patel & Kim,
2007; Dobricki, Komproe, De Jong & Maercker, 2010). But
sub-Saharan Africa is also home to more than two-thirds
of the world’s HIV-positive population, in comparison to
the 6% in the United States and in Western and Central
Europe (UNAIDS, 2010). Due to the high prevalence levels
of communicable diseases and nutritional and perinatal
conditions, mental illness has been given a comparatively
low priority in the region. This is despite the fact that the
average number of years of life lost due to disability as a
result of mental illness is comparable to that for the rest of
the world (Abebe, Asfaw, Amare, Almaz, Yared, Ambaye &
Lemma, 2006).
There is growing evidence to suggest strong bidirec-
tional relationships between mental and physical illnesses
(Prince, Patel, Saxena, Maj, Maselko, Phillips & Rahman,
2007). Depression, for example, is both a risk factor and
a consequence of coronary heart disease and stroke
(Hemingway & Marmot, 1999; Jonas & Mussolino, 2000;
Larson, Owens, Ford & Eaton, 2001; Ohira, Iso, Satoh,
Sankai, Tanigawa, Ogawa et al., 2001; Kuper, Marmot &
Hemingway, 2002). Malaria leads to cognitive impairment
and may increase common mental disorders (Dugbartey,
Dugbartey & Apedo, 1998; Kihara, Carter & Newton, 2006),
while maternal psychotic disorders lead to preterm and
low-birth-weight infants (Bennedsen, Mortensen, Olesen &
Henriksen, 1999; Nilsson, Lichtenstein, Cnattingius, Murray
& Hultman, 2001).
Similarly, research from high-income countries suggests
that the relationship between HIV/AIDS and mental illness
is complex and bidirectional. There is evidence from
high-income countries to show that severe mental illness
increases HIV-risk behaviour, such as unprotected sex,
Breuer, Myer, Struthers and Joska102
transactional sex and intravenous drug use (Meade &
Sikkema, 2005).
The effect of HIV/AIDS on common mental disorders,
including depressive disorders, anxiety disorders and
alcohol or substance-related disorders, is less clear. In
a meta-analysis of 10 studies of people living with HIV or
AIDS (PLHIV) from high-income countries, the prevalence of
depression was found to be two-times higher in that popula-
tion group than in the general population (Ciesla & Roberts,
2001). This is thought to be due to a possible direct effect
of HIV on the brain (Treisman & Kaplin, 2002) as well as
the psychological effects of living with a chronic illness.
In addition, HIV or AIDS exerts primary effects, such as
neurocognitive changes, that follow HIV invasion and cause
damage to the central nervous system (Dube, Benton,
Cruess & Evans, 2005); this damage presents as neurocog-
nitive deficits and, in more severe cases, HIV-associated
dementia complex.
Mental illness also has an effect on the treatment of HIV.
The presence of untreated mental illness in HAART-eligible
HIV-positive patients has been shown to decrease the likeli-
hood of HAART initiation (Tegger, Crane, Tapia, Uldall, Holte
& Kitahata, 2008). However, there was no difference in rate
of HAART initiation in participants with treated mental illness
compared to those without mental illness, but evidence
showed decreased adherence in participants with mental
illness (Uldall, Palmer, Whetten & Mellins, 2004).
Although some of the research on mental illness and HIV
in high-income countries can be generalised to sub-Sa-
haran Africa, the nature of the HIV epidemic varies in ways
which could impact differently on mental disorders. Freeman
(2004) proposes several main differences between mental-
health consequences in high-income countries and sub-Sa-
haran Africa. The largest distinction is the difference in the
magnitude of the HIV epidemic. In addition to the size of
the HIV epidemic, the sub-Saharan epidemic is charac-
terised by a predominance of heterosexual HIV spread, in
comparison to the North American and European epidemics
which are characterised by intravenous substance abuse
and homosexual as well as heterosexual spread of HIV.
A significant portion of the literature on mental health and
HIV in high-income countries investigates homosexual men.
However, the sub-Saharan African epidemic is predomi-
nantly among heterosexuals, with the highest adult HIV
prevalence among women. In addition to these factors,
the HIV-1 clades that predominate in sub-Saharan African
countries differ from those in North America and Europe
(Liner, Hall & Robertson, 2007). Clade differences may exert
differential biological effects (Mishra, Vetrivel, Siddappa,
Ranga & Seth, 2008). Therefore, although the literature
from high-income countries can be used as a guide, specific
empirical research from sub-Saharan Africa is clearly
required.
There have been few systematic reviews specific to
mental illness and HIV research in sub-Saharan Africa.
Collins, Holman, Freeman & Patel (2006) reviewed the
literature from developing countries up till 2005 and included
only 16 studies from sub-Saharan Africa. However, a large
amount of research has been published in the interim,
necessitating an update of the systematic review as well
as broadening the scope to portray a more comprehensive
picture of the research on HIV and mental illness. Abubakar,
Van Baar, Van de Vijver, Holding & Newton (2008) investi-
gated a small part of the relationship between mental illness
and HIV in a systematic review focusing exclusively on
paediatric neurodevelopment. Similarly, a review by Brandt
(2009) focused on mental health and quality of life in adults
with HIV. Although more current than the review by Collins
et al. (2006), it remained narrow in its definition of mental
health by not including research on neurocognitive changes
and including only studies on adults. In addition, the review
by Brandt (2009) used few search terms, thus potentially
excluding relevant studies.
In order to inform future research and policy we wanted
to more comprehensively assess the research landscape of
HIV and mental illness. The aim of our review was to identify
and evaluate all quantitative research in sub-Saharan Africa
on HIV and mental illness in order to identify trends. The
review aimed specifically to answer the following questions:
1. What are the main areas of research and their main
findings?
2. What is the methodological quality of the research and
how does this affect its interpretation?
3. What are the needs for research in HIV and mental
health?
4. How does the current body of research impact on policy,
and how can future studies refine this?
Methods
An a-priori search protocol was determined by the research
team prior to the initiation of the literature search. The
databases Ovid, MEDLINE, PsycINFO and the Social
Sciences Citation Index (SSCI) were searched between
September and November 2008, using the following terms:
HIV, AIDS, acquired immunodeficiency syndrome, human
immunodeficiency virus, mental health, mental illness,
dementia, delirium, psychosis, mania, posttraumatic stress
disorder, anxiety, depression, neurocognitive, cognitive,
psychiatric, psychiatry, psychology, psychosocial, alcohol
dependence, alcohol abuse, substance abuse, substance
dependence, and quality of life. The study population was
limited to sub-Saharan African countries. The reference
sections of retrieved articles were hand-searched for
further references. In addition, indexes of key journals were
searched as well as databases of academic theses and
unpublished literature.
The abstracts of the search results were screened by
the first author (EB). Because the aim of this review was
to gauge the quality and types of research, the inclusion
criteria was purposefully broad. Studies were included if
they were: a) performed on a population in sub-Saharan
Africa; and b) used a quantitative measurement instru-
ment to investigate the presence of 1) psychiatric disorder,
psychiatric symptoms, neurocognitive deficits, alcohol
and substance abuse, or the mental-health component of
formally measured quality of life, and 2) HIV-risk behaviour,
HIV status, or relationship with an HIV-positive person as
either a dependent or independent variable. Review articles
or research using only qualitative methods were excluded.
African Journal of AIDS Research 2011, 10(2): 101–122 103
Information from the included articles was abstracted into
a specified template. Methodological appraisal was based
on the STROBE guidelines for reporting observational
studies (see Von Elm, Altman, Egger, Pocock, Gøtzsche &
Vandenbroucke, 2007) and the CONSORT guidelines for
reporting randomised controlled trials (see Hopewell, Clarke,
Moher, Wager, Middleton, Altman & Schulz, 2008). Due to
the expected heterogeneity of the research, a meta-analysis
was not planned and this was confirmed by the disparate
nature of the data given in the retrieved studies.
Results
The initial search retrieved 381 studies, of which 104 studies
met the inclusion criteria. Most of the excluded studies were
not performed in Africa or did not quantitatively measure
mental illness. Included studies were grouped into four
major categories: 1) the effect of mental illness on HIV-risk
behaviour; 2) HIV in psychiatric patients; 3) mental illness
in HIV-positive populations; and 4) the mental illness effects
of HIV on non-infected individuals. The studies included are
outlined in Appendix 1.
Research trends
There was a sharp increase in the number of studies
published after 2003, reaching a peak in 2006. Fifty-four
percent of the research was conducted in South Africa
and another 25% in Uganda. The distribution of studies
varied according to topic (see Figure 1). The majority of the
research regarding HIV in psychiatric populations and mental
illness in HIV-positive populations was from South Africa; the
majority of neurocognitive studies in adults and children were
conducted in Nigeria and Uganda (see Table 1).
The most researched topic has been the prevalence of
mental illness in populations with HIV and the relationship
between HIV and psychiatric disorders (see Figure 1),
comprising 25% of the included literature. In addition,
there were a number of studies on neurocognitive changes
in adults and children with HIV, as well as HIV-related
orphanhood and mental health. There has been little
research on mental illness in relation to HIV, other than
alcohol abuse leading to HIV-risk behaviour, or the effect on
others affected by HIV or AIDS.
A high proportion of studies involved international collab-
oration, with 40% of the authors affiliated to institutions
in non-African countries, particularly the United States.
The majority of affiliations in both African and non-African
countries were with universities and university teaching
hospitals, with some representation from research institutes,
international governmental organisations as well as
non-governmental organisations. Although some institutions
had supported several studies, the research was performed
across many institutions and by different authors: of the 364
authors involved, only 20% of the authors were involved in
two or more articles, and 7% were involved in three or more
articles.
Approximately one-third of the papers explicitly acknowl-
edged funding sources. These ranged from large govern-
mental research funders, particularly the National Institutes
of Health (United States), the National Institute of Mental
Health (United States) and the Medical Research Council
(South Africa), to various universities, charitable trusts,
research funds and pharmaceutical funding.
Major findings
Mental health and HIV-risk behaviour
Seven studies were included that investigated the influence
of mental illness on HIV-risk behaviour, with six of these
exclusively investigating the effects of alcohol and/or
substance abuse. The most common measure of alcohol
Figure 1: Distribution of studies of HIV/AIDS and mental illness by topic, with South Africa compared with the rest of sub-Saharan Africa (n
= 104 studies)
South Africa
Other sub-Saharan African countries
TOPICS
NUMBER OF STUDIES
18
16
14
12
10
2
4
6
8
Mentally ill populations
at risk of HIV
Psychiatric populations
Mental illness in people
living with HIV
Neurocognitive changes
in adults with HIV
Neurocognitive changes
in children with HIV
Pregnancy
Quality of life
Measurement
(validity, prevalence)
Treatment
Effects of HIV on others
Breuer, Myer, Struthers and Joska104
Author Study site
Sample
size (HIV
serostatus)
Diagnostic/
screening
measures
Any mental
illness (%)
Depression Anxiety Dependence
Schizophrenia
(%)
Bipolar disorder
(%)
Psychotic
disorders (%)
Any
depression
(%)
Major (%)
Previous
major (%)
Minor (%)
Generalised
anxiety (%)
PTSD (%)
Panic
disorder (%)
Agoraphobia
(%)
Social
phobia (%)
Specific
phobias (%)
OCD (%)
Alcohol (%)
Drug (%)
Bganya (1999) South
Africa
n = 115 HIV+ BDI (if BDI >17,
then DSM-IV)
50.4 38 5.2
Brandt (2007) South
Africa
n = 130 HIV+
n = 50 HIV-
CES-D, Brief COPE,
MOSSS-rev, SSAI
12.3
6
Els et al. (1999) South
Africa
n = 100 HIV+ HAS, MINI, SAS
(Zung)
35 321637915103 6
Freeman et al.
(2008)
South
Africa
n = 900 HIV+ WHO CIDI 43.7 11 29.1 0.4 4.9 0.1 0.9
Moosa et al. (2005) South
Africa
n = 41 HIV+ BDI 56
Myer, Smit, Roux et
al. (2008)
South
Africa
n = 456 HIV+ AUDIT, CES-D,
LEC, MINI
19 14 65 6
Olley et al. (2003) South
Africa
n = 149 HIV+ Brief COPE, LES,
MINI, SDS,
56 34.9 18.1 21.5 14.8
Shisana et al. (2005) South
Africa
HIV+
HIV-
5 items from CIDI 41.6
29.6
Thom (2008) South
Africa
n = 300 HIV+ Structured DSM-IV 30 21
Voss et al. (2007) Southern
Africa
n = 538 HIV+ SSC-HIVrev 40
Adewuya et al.
(2007)
Nigeria n = 88 HIV+
n = 87 HIV-
MINI 59.1
19.5*
11.4
3.4*
9.1
3.4
8
2.3
12.5
1.1*
6.8
2.3
9.1
4.6
4.5
4.5
3.4
2.3
8
4.5
3.4
2.3
5.7
0*
Carson et al. (1998) Kenya n = 78 HIV+ CIS 12 13 23.9 10.9
n = 151 HIV- 8 12
Kaharazua et al.
(2006)
Uganda n =1 017 HIV+ CES-D (no somatic
items)
47
Maj, Janssen,
Starace et al. (1994)
DRC and,
Kenya
n = 258 HIV+
n = 150 HIV-
BPRS, CIDI,
MADRS
5.3
0.7
0
3.4
0
6.9
3.3
0
1.2
1.5
0
Martinez et al.
(2008)
Uganda n = 421 HIV+ AUDIT, HSCL 18.8 15.4
Petrushkin et al.
(2005)
Uganda n = 48 HIV+ MINI 82.6 54.3 8.7 19.6 32.6 4.3 0 17.4 17.4
Poupard et al. (2007) Senegal n = 200 HIV+ CES-D 18
Sebit et al. (2003) Zimbabwe n = 115 HIV+
n = 79 HIV-
AUDIT, BPRS, KPS,
MADRS
71.3
44.3*
23.5
10.1
14.8
12.6
24.6
16.5
15.6
10.1
*Indicates a significant difference between HIV-positive participants and controls
†Including agoraphobia
‡Non-affective psychosis
Table 1: Summary of studies of the prevalence of mental illness or mental illness symptoms in PLHIV (OCD = obsessive–compulsive disorder; PTSD = posttraumatic stress disorder; see
Appendix 1 for abbreviations of diagnostic/screening measures)
African Journal of AIDS Research 2011, 10(2): 101–122 105
abuse was the Alcohol Use Disorders Identification Test
(AUDIT), which was used in four studies. The CAGE
questionnaire and the Alcohol, Smoking and Substance
Involvement Screening Test (ASSIST) were used in one
study each. A significant number of studies investigating
alcohol and substance abuse were excluded because
formal measurement tools were not used.
According to this set of studies, problem drinkers are more
likely to be men, to have more sexual partners, to have had
transactional sex, and to have a more frequent history of
sexually transmitted infections (STIs) (Simbayi, Kalichman,
Jooste, Mathirti, Cain & Cherry, 2004; Kalichman, Simbayi,
Jooste & Cain, 2007). Although Simbayi et al. (2004) and
Kalichman, Simbayi, Jooste, Cain & Cherry (2006) showed
no difference in rate of unprotected vaginal intercourse
among problem drinkers as compared with non-problem
drinkers, Wong, Thompson, Huang, Park, DiGangi & De
Leon (2007) showed that problem drinking increases the
likelihood of drinking prior to sexual intercourse. Drinking
prior to sexual intercourse, particularly among men,
predicted unprotected sexual intercourse. Kalichman et al.
(2006) found that alcohol-induced sex expectations and
sensation-seeking were related to HIV risk, with alcohol
use in the context of sex partially mediating the relationship
between sensation-seeking and HIV risk.
Only one study investigated the effect of depression
and posttraumatic stress disorder (PTSD) on HIV-risk
behaviour. In the adjusted analysis, PTSD was associated
with increased HIV-risk behaviour, whereas depression
was associated with increased condom use (Smit, Myer,
Middelkoop, Seedat, Wood, Bekker & Stein, 2006). No
research was found which shows an effective intervention
related to HIV-risk behaviour and mental illness. Kalichman,
Simbayi, Vermaak, Cain, Jooste & Peltzer (2007) compared
a 60-minute behavioural-skills-building and HIV-risk-
reduction counselling session with a 20-minute didactic
HIV-educational/control intervention. Although they found
evidence of increased condom use and less drinking prior
to sex in the intervention group at three months, this differ-
ence was not apparent at the six month follow-up.
HIV in psychiatric patients
The problem of HIV infections among psychiatric patients
was investigated in 15 studies. HIV prevalence among
psychiatric in-patients ranged from 9% (Van Wyk, Von
Brandis-Martini, Pretorius & Webber, 2004; Jonsson,
Jeenah & Moosa, 2008; Parker & Milligan, 2008) to
23% (Acuda & Sebit, 1996; Singh, Vasant, Nair, Karim &
Vardas, 2002; Mashaphu & Mkize, 2007), with one of the
earliest studies reporting a prevalence of just 1% (Zingela,
Esterhuizen, Kruger & Webber, 2002). All but one of these
studies was performed in South Africa. These results should
be interpreted with caution as none of the studies used
community controls to compare HIV-prevalence levels, and
because the HIV-testing procedures varied greatly across
the studies.
The HIV-testing rate for psychiatric in-patients was reported
in the retrospective chart review by Janse van Rensburg &
Bracken (2007), wherein only 17.4% of the patients were
tested for HIV. This finding is similar to an informal survey
of psychiatrists which found that only two of 13 public-sector
psychiatrists interviewed in the Western Cape Province
(South Africa) routinely tested clients for HIV (Joska, Carey,
Lewis, Magni, Wilson & Stein, 2008). This highlights the
absence of routine HIV testing in psychiatric institutions,
despite not only high HIV prevalence in communities, but also
the evidence that HIV infection may be directly or indirectly
associated with psychiatric symptoms.
Only one study (Karim, 2006) investigated psychiatric
consultations in general hospitals. The main reasons for
referral in that retrospective chart review were behavioural
disturbances (58%) and psychotic features in the form of
hallucinations (48%) and delusions (47%); the most common
diagnosis was delirium (50%), followed by dementia due to
HIV (17%), and psychotic disorder due to HIV (17%) (Karim,
2006). No diagnoses of anxiety or depression were made.
Rather than indicating an absence of mood disorders, the
absence of referrals may indicate reluctance by health
professionals to refer patients for minor disorders.
HIV/AIDS knowledge was found to be similar among
psychiatric in-patients who were found to be HIV-positive
and those who were HIV-negative (Van Wyk et al., 2004).
Saunders (2006) found no differences in average age at
sexual debut, average number of partners, or frequency
of condom use between HIV-positive and HIV-negative
patients presenting with psychotic symptoms. Koen, Uys,
Niehaus & Emsley (2007) showed that poorer knowledge of
HIV-risk behaviour was associated with a higher number of
negative symptoms in schizophrenia.
Mental health of PLHIV
The majority of the 34 papers included in this set focused
on HIV-positive populations attending HIV/AIDS clinics or
support organisations and analysed the presence of mental
illness in relation to a number of variables. Four studies
compared the prevalence of mental illness with a control
population. The research was cross-sectional, apart from
the two papers reporting cohort studies (i.e. Olley, Seedat
& Stein, 2006; Stangl, Wamai, Mermin, Awor & Bunnell,
2007). Four papers on this topic investigated only women
(i.e. Lindner, 2006; Olley, 2006a; Olley, Abrahams & Stein,
2006; Brandt, 2007).
Using a variety of different measuring instruments,
the research showed that the prevalence of mental
illness in PLHIV ranged from about 5% in the Democratic
Republic of Congo (Maj, Janssen, Starace, Zaudig, Satz,
Sughondhabirom et al., 1994) to approximately 83% in
Uganda (Petrushkin, Boardman & Ovuga, 2005) (Appendix
1). Despite this diversity, in general, PLHIV were more
likely to screen positively for depression than HIV-negative
controls (Lindner, 2006; Brandt, 2007). There is some
evidence suggesting that the prevalence of PTSD and
schizophrenia is higher in PLHIV (Adewuya, Afolabi, Ola,
Ogundele, Ajibare & Oladipo, 2007; Brandt, 2007) while
there are mixed results regarding the prevalence of anxiety
in PLHIV (Carson, Sandler, Owino, Matete & Johnstone,
1998; Adewuya et al., 2007; Brandt, 2007).
Some studies found that the presence of any mental
illness, particularly depression, was associated with more
advanced stages of illness. Freeman, Nkomo, Kafaar &
Breuer, Myer, Struthers and Joska106
Kelly (2008) and Adewuya et al. (2007) both found that the
presence of any mental illness was associated with more
advanced stages of HIV illness. In addition, Bganya (1999)
and Freeman et al. (2008) found a relationship between
depression and a greater stage of illness. Kaharuza,
Bunnell, Moss, Purcell, Bikaako Kajura, Wamai et al.
(2006) found that participants with CD4 cell counts <100
were significantly more depressed than those with CD4
counts >500. However, Moosa, Jeenah & Vorster (2005)
and Reece, Shacham, Monahan, Yebei, Ong’or, Omollo &
Ojwang (2007) found no relationship between CD4 count
and depression. Similarly, Brandt (2007) found no relation-
ship between illness stage and depression, but found that
symptomatic HIV-positive participants, but not asymptomatic
HIV-positive participants, had significantly higher levels of
anxiety compared to HIV-negative controls. Poor social
support and the presence of life stressors and stigma were
found to increase the likelihood of depression or depressive
symptoms (Bganya, 1999; Olley, Seedat, Nei & Stein, 2004;
Lindner, 2006; Adewuya et al., 2007; Brandt, 2007; Simbayi,
Kalichman, Strebel, Cloete, Henda & Mqeketo, 2007).
Screening positive for anxiety was found to be associ-
ated with avoidant coping behaviour and substance abuse
(Brandt, 2007), while PTSD was found to be associated
with being female (Olley, Gxamza, Seedat, Theron, Taljaard,
Reid et al., 2003), disabled (Olley, 2006a Olley, Zeier,
Seedat & Stein, 2005) or having a lower household income
(Myer, Smit, Le Roux, Parker, Stein & Seedat, 2008). Being
male (Els, Boshoff, Scott, Strydom, Joubert & Van der
Ryst, 1999; Olley et al., 2003; Freeman, Nkomo, Kafaar &
Kelly, 2007; Myer, Smit, Le Roux et al., 2008) and being
unemployed (Freeman et al., 2007) predicted a positive
screen for alcohol or substance abuse.
While there is no clear evidence to show the effect
of antiretroviral therapy (ART) on mental illness, an
uncontrolled cohort study investigating quality of life
reported an improvement in mental-health summary scores
(Stangl et al., 2007). However, the majority of studies found
that there was no difference in measures of mental health
between PLHIV taking and those not taking ART (Simbayi et
al., 2007; Freeman et al., 2008; Martinez, Andia, Emenyonu,
Hahn, Hauff, Pepper & Bangsberg, 2008; Myer, Smit, Le
Roux et al., 2008). These studies were all cross-sectional
— therefore more rigorous evidence provided by prospec-
tive cohort studies investigating mental disorder before and
after commencement of ART would be useful in determining
an effect.
Neurocognitive changes in PLHIV
Among adult PLHIV, the prevalence of cognitive deficits
ranged from 4% in the Democratic Republic of Congo (Maj,
Satz, Janssen, Zaudig, Starace, D’Elia et al., 1994) to 99%
in Nigeria (Odiase, Ogunrin & Ogunniyi, 2006). Cognitive
deficits were higher in symptomatic HIV-positive participants
than in asymptomatic HIV-positive participants as compared
to HIV-negative controls (Odiase et al., 2006).
In one study, using the Community Screening Interview for
Dementia (CSI-D), rates of impairment of 99% and 32.6%,
in symptomatic and asymptomatic HIV-positive patients
respectively, were reported (Odiase et al., 2006). There was
no significant difference in neurocognitive deficits between
asymptomatic HIV-positive participants and HIV-negative
controls. Howlett, Nkya, Mmuni & Missalek (1989) also
found a high prevalence of cognitive disorders (54%)
among clinical AIDS patients. Using the International HIV
Dementia Scale, Wong, Robertson, Nakasujja, Skolasky,
Musisi, Katabira et al. (2007) found that 31% of HIV-positive
participants had mild dementia, 47% had a minor cognitive
disorder, and only 22% had no impairment.
The evidence for a relationship between CD4 cell
count and global neurocognitive change is mixed. Wong,
Robertson, Nakasujja et al. (2007) found a 100 cell/l
decrement in CD4 cell count increased the odds of
having HIV dementia by 1.69 (95% confidence interval =
1.04–2.33). However, Salawu, Bwala, Wakil, Bani, Bukbuk &
Kida (2008) reported no significant correlation between CD4
cell count and CSI-D status in HIV-positive participants.
Research among children, performed predominantly
in the pre-HAART era, indicates that HIV infection affects
both motor and cognitive development. HIV-positive infants
have been shown to have poorer gross motor skills, slower
gross motor growth rate, and poorer cognitive development
compared to HIV-negative infants born of HIV-negative
mothers (controls) or HIV-negative infants born of
HIV-positive mothers (sero-reverters) (Msellati, Lepage,
Hitimana, Van Goethem, Van de Perre & Dabis, 1993;
Drotar, Olness, Wiznitzer, Schatschneider, Marum, Guay et
al., 1999; Ballieu, 2005). Already by age 12 months, 30%
of HIV-positive infants had developed motor abnormalities,
compared with 11% of sero-reverters and 5% of controls
(Drotar, Olness, Wiznitzer, Guay, Marum, Svilar et al., 1997).
And Ballieu (2005) showed evidence of language delay in
HIV-positive infants.
Two studies investigated older survivors of previous birth
cohorts. Because these studies were undertaken prior to
the introduction of antiretroviral (ARV) drugs, the propor-
tion of HIV-positive infants surviving beyond age 2 years
was low. A study of children over age 2 (Boivin, Green,
Davies, Giordani, Mokili & Cutting, 1995) used previous
birth cohorts of HIV-positive children to identify possible
participants. However, only 4 of 26 from one birth cohort
(15.3%) and 7 of 26 (27%) from a second birth cohort of
children were alive and well enough to undertake further
neurocognitive testing. That study showed that HIV-positive
children had lower motor and global processing scores than
sero-reverters and controls (Boivin et al., 1995). However,
a follow-up study investigating the 19% who had survived
the original birth cohort found no difference with regard
to cognitive or neurologic measures (Bagenda, Nassali,
Kalyesbula, Sherman, Drotar, Boivin & Olness, 2006).
Impact of HIV/AIDS on the mental health of related
individuals
Orphans
The studies in this set provided strong evidence that
children orphaned by AIDS (i.e. children who have lost one
or both parents to HIV-related illness) experience depres-
sion, with an estimated prevalence of 17% as compared to
10% prevalence of depression among non-AIDS-orphaned
children and 9% among non-orphans (Cluver, Gardner &
African Journal of AIDS Research 2011, 10(2): 101–122 107
Operario, 2007). Cluver, Gardner & Operario (2008) found
that HIV stigma is a full mediator between HIV-related
orphanhood and depression. Similarly, there was a high
prevalence of PTSD among children orphaned by AIDS,
with 73% meeting the criteria for PTSD, and stigma was
also found to be a full mediator between HIV-related
orphanhood and PTSD (Cluver et al., 2008). A relation-
ship between generalised anxiety and orphanhood is not
as evident. Cluver et al. (2007) found 10% prevalence of
clinically significant anxiety among children orphaned by
AIDS, which was similar to the 8% prevalence among both
non-AIDS-orphaned children and non-orphans. However,
both Atwine, Cantor-Graae & Bajunirwe (2005) and Onuhua,
Manukata, Serumanga-Zake, Nyonyintono & Bogere (2008)
found higher levels of anxiety in AIDS-orphaned children as
compared to non-orphans; however, those two studies did
not differentiate between PTSD and anxiety.
Discussion
This review of the research highlights the relationship
between HIV and mental disorders in sub-Saharan Africa.
This is demonstrated across studies of HIV-risk behaviour,
the prevalence of mental disorders (including neurocog-
nitive disorders), and the impact of mental disorders on
quality of life. The findings are similar to those reported
in studies conducted in high-income countries but have
implications for practice in a region where HIV prevalence
is high, sexual HIV transmission is mainly heterosexual, and
resources for mental health are scarce. Resource limitations
are seen in the fact that the reviewed studies differ widely
in their methodologies and variety of scope, as well as the
unmet research needs in this field. In many cases, the small
number of available studies affects the generalisability of
the findings. Carefully developed studies which will allow
the findings to be more widely generalised and integrated
into routine HIV care should be considered.
There has been a considerable increase in research
regarding HIV and mental illness since 2003. This encour-
aging finding may be due to the increased availability of
ART in sub-Saharan Africa and the subsequent increase in
average life expectancy. Therefore, the focus of research
has shifted to include factors affecting treatment adherence
and quality of life such as relates to mental illness. In
addition, the funding of research on this topic became
possible due to an increase in donor-funding programmes:
much research was funded by international funding
agencies and with significant involvement from overseas
collaborators. This review shows that although there is a
trend towards more research investigating HIV in relation
to mental illness, and vice versa, there remains a paucity of
such research from sub-Saharan Africa.
The main areas and findings of the research
Studies of risk behaviour in the context of mental illness
in sub-Saharan Africa have generally been confined to
the use and abuse of alcohol. In summary, the studies
reviewed reported that people who exhibit alcohol-abuse
patterns are more likely to drink before sex, and that this
is more likely to be unprotected sex. Only seven studies
on this topic were included in this review as other studies
did not use a formal screening or diagnostic tool for alcohol
or substance abuse. In comparison, in 2007, a systematic
review of research on alcohol use and HIV-risk behaviour
in sub-Saharan Africa (Kalichman, Simbayi, Kaufman, Cain
& Jooste, 2007) included any study that measured alcohol
use and found 33 studies that fit the inclusion criteria; that
review found that alcohol, specifically drinking before sex,
was related to decreased condom use, increased likelihood
of having concurrent partners, and a higher prevalence of
STIs. Further studies confirming this and exploring these
behaviours in relation to other kinds of substance use, such
as methamphetamine, should be considered.
In addition, no studies in sub-Saharan Africa investigated
severe mental illness and HIV-risk behaviour. However, this
topic has been studied extensively in the United States. In a
systematic review and meta-analysis of 52 studies (predom-
inantly from the United States), HIV-risk behaviour (such as
infrequent or no condom use, multiple partners, injection
drug use and needle-sharing) was high among people with
severe mental illness (Meade & Sikkema, 2005). Similar
local cohort studies exploring risk behaviour in the context
of severe mental illness and its effects on HIV acquisition
and subsequent disease progression are needed. Additional
research on interventions that target this vulnerable popula-
tion who might not otherwise seek care is particularly
important.
International data suggest that HIV prevalence is much
higher among people with severe mental illness (Carey,
Weinhardt & Carey, 1995; Cournos & McKinnon, 1997).
This is difficult to determine from the available South African
studies due to their lack of control subjects. A large South
African national HIV-prevalence survey in 2005 estimated
an HIV prevalence of 16.2% in adults aged 15–49 years
and 5.7% in adults older than age 50 (Shisana, Rehle,
Simbayi, Parker, Zuma, Bhana et al., 2005). However, HIV
prevalence varied across regions and population groups.
All the studies (except for one) reported an HIV prevalence
of at least 9%, which suggests that HIV prevalence
among people with severe mental illness at least approxi-
mates that of the general population — but with evidence
that prevalence may be significantly higher (29.1% in one
province in South Africa: Singh et al., 2002). Despite this
and the relatively high community-levels of HIV prevalence
in the region, only 17% of patients with mental illness in a
South African hospital received HIV testing (Janse van
Rensburg & Bracken, 2007).
The reported prevalence of mental disorders in
HIV-positive populations in sub-Saharan Africa differed
widely (from 5–83%) in part due to the range of assess-
ment tools used as well as to the populations being studied.
Depression occurred more frequently in PLHIV (Lindner,
2006; Brandt, 2007), but there were mixed findings
regarding anxiety and PTSD. This is partly due to the lack
of control groups in the studies. Common mental disorders
such as depression tend to increase in PLWHIV with late
stage disease, while the use of HAART was shown in one
study to improve general mental health (Adewuya et al.,
2007; Stangl et al., 2007; Freeman et al., 2008). Prospective
research is required to determine the effect of the HIV
Breuer, Myer, Struthers and Joska108
diagnosis, disease progression, HAART and HIV stigma on
mental illness.
Neurocognitive problems in both adults and children
with HIV were reported as highly prevalent. Studies among
adults were mostly cross-sectional, and reported prevalence
levels of neurocognitive disorders in adults in late stages
of HIV disease ranged from 31% to 99%, depending on
the tool used and the clinical status of the patient group.
Studies (mostly ones performed in the pre-HAART era)
confirm that HIV in children is associated with develop-
mental delays across domains in addition to a high mortality
rate. Greater understanding of the role of ART in the modifi-
cation of the effects of HIV infection on mental illness as
well as neurocognitive changes in adults and children would
be valuable.
Research on the mental health effects of HIV among
children orphaned by AIDS found high levels of depression
and PTSD in the group, mainly caused by stigma. Further
research on the effect of possible interventions to alleviate
stigma and concomitant mental illness are necessary.
Insufficient research has been conducted on the effect that
living with HIV has on the mental health of other individuals,
particularly caregivers, as well as the effect of the context of
a large-scale HIV epidemic in communities.
The methodological quality of the research and the
effects on its interpretation
A number of methodological challenges to research into
mental illness and HIV in sub-Saharan Africa were brought
to light by the review. First, certain sampling issues have
led to participant groups that may be unrepresentative of
the broader population of affected individuals. Second,
many studies did not use control groups or else the control
groups were poorly recruited. Third, few studies have
made use of prospective cohort designs, limiting the ability
of the research to link HIV and mental illness. Finally,
poorly or non-validated measuring instruments as well as
self-designed measuring instruments limit the integrity of the
research.
Several studies drew on samples that may not be wholly
representative of individuals with HIV or AIDS, and/or
those with mental disorders, a common concern in psychi-
atric epidemiology (Bromet, Susser, Heiman & Gorman,
2006). For example, in studies of HIV prevalence in psychi-
atric patients, up to 20% of the subjects approached
declined to be tested for HIV (Zingela et al., 2002; Van Wyk
et al., 2004). In this case, the ethical responsibility of the
researchers conflicts with the quality of the research by
resulting in a less representative sample of patients. In two
studies investigating the effect of mental illness on HIV-risk
behaviour (Smit et al., 2006; Kalichman, Simbayi, Vermaak
et al., 2007), only approximately half of the subjects who
were approached agreed to participate. Often the studies
did not describe the number of patients asked to partici-
pate and the proportion opting for non-participation (e.g.
Botha, 1996; Bganya, 1999; Els et al., 1999). In other
studies, it was difficult to determine the appropriateness of
the sampling frame because the referral criteria for inclusion
were not described (e.g. Carson et al., 1998; Moosa et al.,
2005; Voss, Nonhlanhla, Seboni, Makoae, Moleko, Human
et al., 2007). In some instances, choice of the study popula-
tion means that the findings should be interpreted with
caution. For example, Carson et al. (1998) and Clifford,
Mitike, Mekonnen, Zhang, Zenebe, Melaku et al. (2007)
both measured HIV-related neurological impairment among
factory workers. Because this working population would
include a healthier group of PLHIV the results cannot be
generalised to the general population of PLHIV.
Many studies did not use control groups when determining
the prevalence of mental illness among PLHIV (e.g. Carson
et al., 1998; Bganya, 1999; Els et al., 1999; Olley et al.,
2003; Moosa et al., 2005; Petrushkin et al., 2005; Kaharuza
et al., 2006; Freeman et al., 2007; Simbayi et al., 2007;
Martinez et al., 2008; Myer, Smit, Le Roux et al., 2008;
Thom, 2008). Therefore, although the prevalence of mental
illness appears to be high among PLHIV, the studies cannot
confirm that this prevalence is different from that in the
general population. Not all studies that used control groups
recruited appropriately. For example, Hughes, Jelsma,
Maclean, Darder & Tinise (2004) used community controls
but did not take a medical history or check participants’ HIV
status. They also only recruited participants during specific
times of day when many of the working population may
have been absent. In some cases where control groups
were used, the researchers used different inclusion and
exclusion criteria between the groups, leading to difficulties
in interpretation. For example, when measuring for mental
illness, Sebit, Tombe, Siziya, Balus, Nkomo & Maramba
(2003) excluded people with neurological disorders and
head trauma from the HIV-positive group but not from the
HIV-negative group.
The majority of the studies (82%) relied on a cross-
sectional design, with just over 10% using cohort studies.
Although cross-sectional designs are useful to determine
prevalence and generate questions around causality, they
should not be used in isolation. Where cohort designs were
used, >50% loss to follow up occurred in some studies (e.g.
Sebit, Chandiwana, Latif, Gomo, Acuda, Makoni & Vushe,
2002; Olley, Seedat & Stein, 2006; Kalichman, Simbayi,
Vermaak et al., 2007). Well-designed prospective cohort
studies are necessary to deal with the complexity of the
relationship between HIV and mental illness. This is particu-
larly important in ascertaining patterns of mental-disorder
onset in comparison with HIV acquisition, diagnosis and
disease progression.
The use of diverse measurement tools is another
important issue in the available literature. The measure-
ment tools varied from diagnostic tools, such as the
Structured Clinical Interview for DSM-IV (SCID) and the
Mini International Neuropsychiatric Interview (MINI), to
screening tools such as the Center for Epidemiologic
Studies Depression Scale (CES-D) and self-developed
questionnaires. More than nine different measurement
tools were used to measure depression alone; as each of
these studies had a different sensitivity for detecting mental
illness, comparison across the studies is difficult. Similarly,
neurocognitive changes in adults were measured with
various combinations of neuropsychological test batteries
and screening tools. The standardisation of measurement
tools across research studies is essential as it allows greater
African Journal of AIDS Research 2011, 10(2): 101–122 109
comparability of the findings. In addition, diagnostic tools
should be used where possible in preference to screening
tools, unless they have been validated in the research
setting.
Well-executed local validation studies are necessary as
there may be cultural differences in interpretation, particu-
larly following translation (Swartz, 1998). Although many of
the studies reviewed used internationally validated measure-
ment instruments, only seven studies validated their instru-
ments locally with the study population (i.e. O’Keefe &
Wood, 1996; Kaaya, Fawzi, Mbwambo, Lee, Msamanga &
Fawzi, 2002; Sacktor, Wong, Nakasujja, Skolasky, Selnes,
Musisi et al., 2005; Kaharuza et al., 2006; Ganasen,
Fincham, Smit, Seedat & Stein, 2008; Myer, Smit, Le Roux
et al., 2008; Shacham, Reece, Monahan, Yebei, Omollo,
Owino Ong’or & Ojwang, 2008). This limits the generalis-
ability and applicability of the findings. In one instance this
local validation was obviously flawed as it used another
screening test, the Mini-Mental State Examination (MMSE)
rather than a diagnostic tool to validate the HIV Dementia
Scale (Ganasen et al., 2008).
This review also had some methodological limitations.
First, one strength of the review is that it offers an inclusive
summary of all the quantitative research on HIV and mental
disorder in sub-Saharan Africa. However, as a consequence
of the breadth of the search criteria, the included studies are
heterogeneous. Because of this heterogeneity, a detailed
synthesis of the main findings only, rather than the entire
body of work, is presented. Similarly, due to the heteroge-
neity of the studies, a meta-analysis was not warranted.
Second, although the literature search and data extraction
was thorough and based on an a-priori protocol, it was only
performed by one author (EB). Nevertheless, any questions
regarding the inclusion or exclusion of a study in the review
or the methodological flaws of the studies were discussed
with the second author (LM), an analytic epidemiologist.
The needs for research in HIV and mental health
This review has shown the comparative paucity of research
on mental illness and HIV in southern Africa. Although the
number of articles on the topic is increasing, there remains
a need for local operational research to determine how
to manage the mental-health consequences of the HIV
epidemic. The review has revealed regional evidence that
mental illness is higher among PLHIV.
Two major gaps in the research were identified. The first
is the need for well-designed prospective studies looking
at mental illness in the general population in relation to
subsequent HIV acquisition, diagnosis and disease progres-
sion in the sub-Saharan African setting. Studies from
high-income countries suggest that PLHIV with mental
illness are more likely to start on HAART later (Fairfield,
Libman, Davis & Eisenberg, 1999), be less adherent
(Ammassari, Trotta, Murri, Castelli, Narciso, Noto et al.,
2002), show adverse immunological outcomes (Ironson,
Balbin, Stuetzle, Fletcher, O’Cleirigh, Laurenceau et al.,
2005) and have higher morbidity and mortality (Ickovics,
Hamburger, Vlahov, Schoenbaum, Schuman, Boland &
Moore, 2001) than PLHIV without mental illness. Conversely,
PLHIV with treated mental disorders have better adherence
(Yun, Maravi, Kobayashi, Barton & Davidson, 2005) and
improved quality of life (Elliott, Russo & Roy-Byrne, 2002)
than those remaining untreated.
Second, there have been relatively few studies of mental
health treatment in HIV-positive populations, apart from a
few reports of the effectiveness of non-pharmacological
treatments in depression among PLHIV. More good-quality
studies on treatment options for HIV-related mental illness
in resource-poor settings are needed. Moreover, research
in resource-limited settings is required on interventions
such as group psychotherapies, lay health-worker-adminis-
tered interventions and stepped-care models. There are
some published studies which support these modali-
ties (e.g. Bolton, Bass, Neugebauer, Verdeli, Clougherty,
Wickramaratne et al., 2003; Rojas, Fritsch, Solis, Jadresic,
Castillo, Gonzalez et al., 2007). In these resource-limited
settings research is needed into evidence-based interven-
tions for PLHIV as well as their children and caregivers.
It is worth noting that a growing body of qualitative
research informs this field. This is particularly important in
considering the aetiology of mental illness and the complex
psychosocial risk factors that impact on PLHIV. Qualitative
research has been used to investigate people’s experi-
ences, particularly among adolescents, of many issues
around HIV and AIDS, including HIV-risk behaviour, sexual
violence, meaning-making, treatment adherence, stigma,
orphanhood and bereavement (e.g. Morojele, Kachieng’a,
Mokoko, Nkoko, Parry, Nkowane et al., 2006; Murray,
Haworth, Semrau, Singh, Aldrovandi, Sinkala et al., 2006;
Plattner & Meiring, 2006; Thomas, 2006; Wood, Chase &
Aggleton, 2006; Cluver & Gardner, 2007; Nam, Fielding,
Avalos, Dickinson, Gaolathe & Geissler, 2008). Further
research may utilise well-designed qualitative studies to
explore novel areas and to inform directions for quantitative
investigations.
Impacts of the current body of research on policy, and
how future studies can refine this
Most importantly, the existing body of research should
be translated into changes in practice — particularly, that
mental health providers consider initiating HIV testing
among their patients as well as providing education about
HIV-risk behaviour. Policies should be developed with
consideration for alternative approaches to increasing
HIV-testing practices, such as the introduction of opt-out
HIV testing, which is not used in all sub-Saharan African
countries.
Conversely, HIV/AIDS clinicians should be made aware
of the increased prevalence of mental illness among
HIV-positive patients. Ideally, opportunities for mental-health
screening and referral to appropriate psychiatric services
need to be made available at HIV clinics. Similarly, organisa-
tions that provide support and care to orphans and carers of
HIV-positive people should be made aware of mental-illness
issues and appropriate treatment and support opportunities,
where available.
Currently, resources in sub-Saharan Africa are inadequate
to deal with the burden of mental illness (cf. Okasha, 2002).
The WHO African Region has only 1 200 psychiatrists and
12 000 psychiatric nurses for a population of 620 million,
Breuer, Myer, Struthers and Joska110
while the European population has 86 000 psychiatrists and
280 000 psychiatric nurses for a population of 840 million
(Saxena, Thornicroft, Knapp & Whiteford, 2010). Even in
South Africa, which is considered well-resourced compared
to the rest of sub-Saharan Africa, there is only 11.95 staff
per 100 000 population working in public mental health
facilities, with only 0.28 psychiatrists per 100 000 popula-
tion; this compares to the 23.8 staff per 100 000 population
and 0.5 psychiatrists per 100 000 population for full mental
health coverage, as calculated by Lund, Kleintjes, Kakuma,
Flisher & MHaPP Research Programme Consortium (2010).
Therefore, options for treatment in primary healthcare are
essential to overcome the double burden of HIV and mental
illness.
Given the potentially close relationship between
mental illness and HIV and the high prevalence of HIV in
sub-Saharan Africa, mental illness needs to be made a
funding priority. In 2005, only 62.2% of sub-Saharan African
countries had a budget specifically allocated to mental
health care. In addition, only 50% had a mental health
care policy. In 2005, mental health care legislation existed
in 79.5% of sub-Saharan African countries but was largely
outdated with only 30% of these countries have passed a
law involving mental health since 1990. This is particularly
concerning because a shift towards mental health treatment
that protects the human rights and dignity of people with
mental illness is quite recent. Therefore, it is imperative that
mental health legislation be updated (WHO, 2005).
This review reveals the early development of a body of
research that needs to evolve in complexity and quality.
With the high prevalence of HIV and increased access to
HAART, more PLHIV will be living longer. More than ever it
is important to understand the complexities of HIV-related
mental illness and treatment, especially in resource-poor
settings.
Acknowledgements — This review was funded by the United States
President’s Emergency Plan for AIDS Relief (PEPFAR), through
USAID under the terms of award no. 674-A-00-08-00009-00 to the
Anova Health Institute. The opinions expressed herein are those of
the authors and do not necessarily reflect the views of USAID or
PEPFAR.
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Breuer, Myer, Struthers and Joska116
Authors Study design (site) Measurement tools Main findings
Mental illness and HIV-risk behaviour
Kalichman et al. (2006) C-S; STI clinic (South Africa) AUDIT HIV-risk behaviour increases among problem drinkers.
Kalichman, Simbayi, Jooste et
al. (2007)
C-S; STI clinic (South Africa) AUDIT Drinking prior to sex increases likelihood of unprotected sex.
Kalichman, Simbayi, Vermaak
et al. (2007)
RCT; STI clinic (South Africa) AUDIT HIV-risk-reduction counselling reduces HIV-risk behaviour in the short-term.
Simbayi et al. (2004) C-S; STI clinic (South Africa) AUDIT Problem drinking increases HIV-risk behaviour.
Smit et al. (2006) C-S (South Africa) AUDIT, CES-D, LEC Depression, alcohol abuse, and PTSD is associated with forced sex,
transactional sex, and condom use.
Ward et al. (2005) C-S; clinic (South Africa) ASSIST High-risk substance abuse increases sexual risk behaviour in young adults.
Wong, Thompson, Huang et
al. (2007)
C-S (South Africa) AUDIT Problem drinkers are more likely to have unprotected sex due to drinking
prior to sex.
HIV in psychiatric populations
Acuda & Sebit (1996) C-S; psychiatric ward (Zimbabwe) Standard psychiatric admission HIV prevalence 23.8%.
Janse van Rensburg &
Bracken (2007)
[A]
Retrospective chart review; psychiatric
ward (South Africa)
Standard hospital psychiatric
diagnosis
22 of 113 psychiatric inpatients were tested for HIV.
Jonsson et al. (2008)
[A]
C-S; neuropsychiatric ward (South Africa) Standard psychiatric admission HIV prevalence 9.4%.
Joska et al. (2008)
[A]
Retrospective chart review; HIV/
neuropsychiatry ward (South Africa)
Standard hospital psychiatric
diagnosis
39.5% of HIV-positive psychiatric patients were admitted for psychosis and
25.5% for depression.
Karim (2006)
[A]
Retrospective chart review; general
hospital (South Africa)
Diagnosis by psychiatrist Main reasons for psychiatric referral of HIV-positive patients were
behavioural disturbances and psychotic features.
Mashapu & Mkize (2007) C-S; psychiatric ward (South Africa) DSM-IV criteria 23.8% of admissions with first-episode psychosis were HIV-positive.
Nakimuli Mpungu et al. (2006) C-S; psychiatric ward (Uganda) DSM-IV criteria, MMSE, YMRS Patients with HIV-related secondary mania were more likely to be female
and to have lower level of education, lower cognitive scores, and lower
socioeconomic status than HIV-negative patients with primary mania.
Parker & Milligan (2008)
[A]
Retrospective chart review; psychiatric
ward (South Africa)
Standard psychiatric admission HIV prevalence 9%.
Saunders (2006) C-S; psychiatric ward (South Africa) DSM-IV criteria, MINI, other
disorder-specific rating scales
sHIV+ psychotic patients were less likely to have had previous psychiatric
admission as compared to aHIV+ and HIV-negative patients.
Singh et al. (2002)
[A]
C-S; psychiatric ward (South Africa) DSM-IV criteria HIV prevalence 29.1%.
Van Wyk et al. (2004) C-S; psychiatric ward (South Africa) DSM-IV criteria HIV prevalence 9%.
Zingela et al. (2002)
[A]
C-S; psychiatric ward (South Africa) Standard psychiatric admission HIV prevalence 1.15%.
Koen et al. (2007) C-S; psychiatry clinic (South Africa) DIGS (version 2), AIDS-KT,
ARBAQ
Schizophrenia negative symptoms were associated with poor HIV/AIDS
knowledge.
Dawood et al. (2006) C-S; school (South Africa) Self-developed questionnaire HIV/AIDS knowledge was poorer than average among adolescents with mild
mental retardation.
Appendix 1: Summary of the studies included in the review of HIV/AIDS and mental health research in sub-Saharan Africa (n = 104 studies)
African Journal of AIDS Research 2011, 10(2): 101–122 117
Mental illness in PLHIV
Adewuya et al. (2008) C-S; HIV-support centre (Nigeria) MINI, WHOQOL-BREF Depression prevalence 28.7%; QoL associated with absence of depressive
disorders.
Adewuya et al. (2007) C-S; HIV-support centre (Nigeria) MINI PTSD, any affective disorder, anxiety disorder, or any psychotic disorder
were more common in HIV-positive versus HIV-negative clients.
Bganya (1999) C-S; HIV clinic (South Africa) BDI (if BDI score >17, then
DSM-IV)
Prevalence of major depression 38%; depression was associated with Stage
IV illness, taking cotramoxazole, and loss of support.
Botha (1996) C-S; HIV clinic (South Africa) IBQ, IES Mean score on IES for aHIV+ was 38.8 ±10.6.
Brandt (2007) C-S; clinic (South Africa) Brief COPE, CES-D,
MOSSS-rev
Significant difference in prevalence of depression between HIV-negative and
HIV-positive clients.
Carson et al. (1998) C-S; occupational health clinic (Kenya) WAIS-R, delayed word recall
and word recognition tests
No difference in psychiatric morbidity between HIV-positive and HIV-negative
clients.
Els et al. (1999) C-S; immunology clinics (South Africa) MINI, HAS, SAS (Zung) Prevalence levels: major depression 35%, dysthymic disorder 3%, bipolar
disorder and anxiety disorder 21%, PTSD 6%.
Freeman et al. (2007) C-S; HIV clinics (South Africa) WHO CIDI Prevalence levels: any mental illness 43.7%, major depression 11%, minor
depression 29.1%, alcohol abuse 12.9%, PTSD 3.9%.
Freeman et al. (2008) C-S; HIV clinics (South Africa) WHO CIDI Depression was associated with severe stage of HIV disease; alcohol abuse
was associated with being male and unemployed.
Kaharuza et al. (2006) C-S; home-based HIV care (Uganda) Modified CES-D Depression prevalence 47%; depression was associated with being female,
>50 years, and having no education as compared to having post-primary
education and a dependent income compared with own trade.
Lindner (2006) C-S (South Africa) Modified CES-D, Brief COPE,
HESSI, HIV Stigma Scale, IAS,
LSC-R, NSI checklist, PSI
Age, marital status, self-reported HIV status, and nutrition level predicted
depression.
Maj, Janssen, Starace et al.
(1994)
C-S; HIV clinic (DRC and Kenya) BPRS, CIDI, MADRS Higher prevalence of depression among sHIV+ versus HIV-negative clients.
Martinez et al. (2008) C-S; immunology clinic (Uganda) AUDIT, modified HCL Alcohol use was not associated with depressive symptoms.
Moosa et al. (2005) C-S; HIV clinic (South Africa) BDI Depression prevalence 56%; no significant association found between CD4
cell counts and depression.
Myer, Smit, Roux et al. (2008) C-S; HIV clinics (South Africa) AUDIT, CES-D, HTQ, MINI Prevalence levels: major depression 14%, PTSD 5%, alcohol abuse 1%.
Olley et al. (2003) C-S; HIV clinic (South Africa) Brief COPE, LES, MINI, SDS Prevalence levels: any mental illness 56%, major depression 34.9%,
dysthymic disorder 21.5%.
Olley et al. (2005) C-S; HIV clinic (South Africa) Brief COPE, LES, MINI, SDS PTSD prevalence 14.8%; PTSD was associated with being female and
having been sexually assaulted in the past year.
Olley (2006a) Cohort; HIV clinic (South Africa) Brief COPE, LES, MINI, SDS Major depression was associated with disability and impairment in the
domain of social life and degree of stressful life events in women.
Olley, Seedat & Stein (2006) Cohort; HIV clinic (South Africa) Brief COPE, LES, MINI, SDS Total disability scores at follow-up were associated with major depression at
follow-up; total disability at baseline associated with PTSD at follow-up.
Olley et al. (2004) C-S; HIV clinic (South Africa) Brief COPE, LES, MINI, SDS Major depression was associated with being female, a greater impact of life
events, and disability.
Olley, Abrahams & Stein
(2006)
C-S; HIV clinic (South Africa) Brief COPE, LES, MINI, SDS Lifetime prevalence of rape among women clients was 4.8%; significant
association found between experience of rape and drug dependence, alcohol
dependence, and major depression.
Petrushkin et al. (2005) C-S; HIV-support organisation (Uganda) MINI Prevalence of mental illness 82.6%.
Authors Study design (site) Measurement tools Main findings
Appendix 1: Continued
Breuer, Myer, Struthers and Joska118
Poupard et al. (2007) C-S; HIV clinic (Senegal) CES-D No difference in prevalence of depression between patients on protease-
inhibitor-based triple therapy and those on efavirenz-based triple therapy.
Reece et al. (2007) C-S; HIV-support network (Kenya) BSI Psychological distress was not associated with relationship status, level of
education, employment status or CD4 cell count.
Sebit et al. (2003) C-S (Zimbabwe) AUDIT, BPRS, KPS, MADRS,
MMSE
HIV-positive persons are more likely to have mental illness or depression
versus HIV-negative persons.
Shacham, Reece, Owino
On’gor et al. (2008)
C-S; HIV-support network (Kenya) PHQ Common symptoms in women: paranoid ideation, somatization, overall
distress; in men: somatic symptoms.
Shisana et al. (2005) C-S; national sample (South Africa) 5 items adapted from the
screening section of the CIDI;
anonymous HIV testing
HIV-positive people reported more depressive symptoms versus
HIV-negative people surveyed.
Simbayi et al. (2007) C-S; HIV clinic (South Africa) AIDS-Related Stigma Scale,
CES-D, 3 items from the SSQ
Depression was associated with age, gender, race, years since HIV
diagnosis, taking ART, social support, alcohol and drug-taking, and
internalised stigma.
Stangl et al. (2007) Cohort; home-based care (Uganda) CES-D, MOS-HIV Psychosocial and mental summary scores significantly improved after 12
months on HAART.
Thom (2008)
[A]
C-S; HIV clinics (South Africa) SCID Prevalence levels: any mental illness 30%, depression/anxiety 21%.
Voss et al. (2007) C-S; HIV clinics (southern Africa) SSC-HIVrev Severity of depressive symptoms explained 4% of the variance in fatigue
severity.
Wingood et al. (2008) C-S; clinics (South Africa) CES-D, HIV Stigma Scale/
Public Attitude Subscale,
MOS-HIV
HIV-stigma was associated with depressive symptomatology and lower QoL.
Mental health of pregnant PLHIV
Antelman et al. (2007) Cohort; antenatal clinics (Tanzania) HSCL, Social Support Scale Depression is associated with increased risk of WHO Stage-III/IV diagnosis
and all-cause mortality.
Bernatsky et al. (2007) C-S; HIV clinic (Angola) GHQ-12 More HIV-positive versus HIV-negative women reported emotional distress.
Collin et al. (2006) Cohort; antenatal clinic
(Zambia)
SRQ-20 Physical morbidity was not associated with mental morbidity in either the
HIV-positive or HIV-negative clients.
Kwalombota (2002) C-S; general hospital (Zambia) Self-developed questionnaire 91% of HIV-positive pregnant women reported they had lost interest in life
and felt worthless.
Rochat et al. (2006) C-S; PMTCT clinics (South Africa) EPDS Depression prevalence 41%, with no difference found between HIV-positive
and HIV-negative clients.
Neurocognitive changes in adults with HIV
Carson et al. (1998) C-S; occupational health clinic (Kenya) CIS, neuropsychological test
battery
No difference between HIV-positive and HIV-negative clients in
neuropsychological tests.
Clifford et al. (2007) C-S; occupational health clinic (Ethiopia) IHDS, neuropsychiatric and
neuropsychological test battery
Prevalence of central or peripheral nervous system disorders same in
HIV-positive and HIV-negative clients.
Howlett et al. (1989) C-S; medical centre (northern Tanzania) Neuropsychological test battery,
acute neurological admissions
Prevalence of dementia in AIDS patients: 54%; HIV prevalence among acute
neurological admissions: 12%.
Maj, Satz, Janssen et al.
(1994)
C-S; HIV clinics (DRC and Kenya) Self-developed activities of daily
living scale, neuropsychological
test battery
Dementia prevalence: 4.4% in Kinshasa, 5.5% in Nairobi.
Odiase et al. (2006) C-S; HIV clinic (Nigeria) CSI-D Abnormal CDI scores: 99% of HIV-positive clients and 32.6% of aHIV+.
Authors Study design (site) Measurement tools Main findings
Appendix 1: Continued
African Journal of AIDS Research 2011, 10(2): 101–122
119
Odiase et al. (2007) C-S; HIV clinic (Nigeria) FePsy A CD4 cell count <500 cells/mm
3
was associated with decreased verbal and
non-verbal memory.
Ogunrin & Odiase (2006) C-S; HIV clinic (Nigeria) FePsy sHIV+ (versus aHIV+ and HIV-negative) clients had longer auditory and
visual reaction time and slower motor speed.
Ogunrin et al. (2007) C-S; HIV clinic (Nigeria) FePsy sHIV+ and aHIV+ (versus HIV-negative) clients took longer and were less
accurate in the binary-choice reaction test.
Sacktor et al. (2005) C-S; infectious diseases clinic (Uganda) IHDS, neurological test battery HIV-positive (versus HIV-negative) clients scored lower for: total IHDS, verbal
memory, constructional practice, psychomotor performance, and reaction
time.
Sacktor et al. (2006) C-S; infectious diseases clinic (Uganda) IHDS, KPS, neurological test
battery, WHO/UCLA audiovisual
language test
Proportion of mild cognitive impairment and mild dementia decreased after
six months on HAART.
Salawu et al. (2008) C-S; blood donor clinic (Nigeria) CSI-D HIV-positive (versus HIV-negative) persons scored worse on CSI-D.
Turnbull et al. (1991) C-S; haematology clinic (South Africa) Qualitative and quantitative
neuropsychological examination
One case of neurological impairment and three cases of pseudo-neurological
impairment found among 27 HIV-positive haemophiliacs.
Wong, Robertson, Naasujja
et al. (2007)
C-S; infectious diseases clinic (Uganda) IHDS, KPS, neurological test
battery, WHO/UCLA audiovisual
language test
Age and CD4 cell count were associated with a diagnosis of HIV dementia.
Neurocognitive changes in children with HIV
Bagenda et al. (2006) C-S; general hospital [children aged 6–12
years] (Uganda)
KABC, WRAT (3rd edition) No cognitive or neurologic differences found between C+M+, C-M+ and
C-M-.
Ballieu (2005) C-S; children’s clinic [children aged 18–30
months] (South Africa)
BSMMD (2nd edition) Mean developmental delay in months: motor 7.63, cognitive 9.65 (mean age
25.3 months)
Boivin et al. (1995) C-S; general hospital [children aged
18–30 months] (DRC)
DDST C+M+ (versus C-M+ and C-M-) scored significantly lower on all domains:
personal/social, language, fine-motor adaptive and gross motor.
ECSP, KABC C+M+ (versus C-M+ and C-M-) lower on all global processing scores of
KABC (55 infants aged ±8 months).
Drotar et al. (1997) Cohort; general hospital [infants aged 6
weeks to 24 months] (Uganda)
BSMMD (2nd edition), FTII,
HOME, neurodevelopmental
assessment, Sigman’s
measures of mother/child
interaction
C+M+ (versus C-M+ and C-M-) infants had greater deficiencies in motor and
neurologic status but not information-processing ability or scores for home
environment and infant’s interactions.
Drotar et al. (1999) Cohort; general hospital [infants aged 6
weeks to 24 months] (Uganda)
BSMMD (2nd edition), FTII,
HOME, neurodevelopmental
assessment, Sigman’s
measures of mother/child
interaction
Abnormal mental and motor scores at baseline affect rate of motor
development but not rate of mental development in C+M+ infants.
McGrath et al. (2006) Cohort; general hospital [infants aged 6 to
18 months] (Tanzania)
BSMMD (2nd edition) Risk of physical and mental delay is higher for HIV-positive infants diagnosed
<21 days.
Msellati et al. (1993) Cohort; general hospital [infants aged 6 to
24 months] (Rwanda)
DDST, The Development of
the Infant and Young Child
(Illingworth)
C+M+ (versus C-M+ and C-M-) infants had significantly higher abnormal
global neurodevelopment scores.
Authors Study design (site) Measurement tools Main findings
Appendix 1: Continued
Breuer, Myer, Struthers and Joska120
Peterson et al. (2001) C-S; general hospital [infants] (Uganda) BSMMD (2nd edition), Sigman’s
measures of mother/child
interaction, Global Dimensions
Rating Scale, Attachment Q-Set
C+M+ (versus C-M+ and C-M-) infants had less secure attachments and less
positive affect.
Potterton (2006) RCT; children’s clinic [infants] (South
Africa)
BSMMD (2nd edition), PST-SF Individual home-based intervention improves cognitive and motor
development in HIV-positive children.
Mental health-related quality of life in PLHIV
Crowther et al. (2008) RCT; HIV/AIDS clinics (Rwanda) MINI, WHOQOL-BREF Six months of exercise training improved QoL in HIV-positive persons
receiving HAART-related lipodystrophy versus usual care.
Hughes et al. (2004) C-S; HIV clinic (South Africa) EQ-5D (Xhosa version) No significant difference in degree of depression or anxiety between sHIV+
and controls.
Jelsma et al. (2005) Cohort; HIV clinic (South Africa) EQ-5D (Xhosa version) Patients reported fewer problems after 12 months on HAART versus at
baseline.
Louwagie et al. (2007) C-S; HIV clinics (South Africa) EQ-5D No difference in degree of depression/anxiety among those receiving, versus
waiting for, HAART.
Mast et al. (2004) C-S (Uganda) MOS-HIV (Luganda) HIV-positive (versus HIV-negative) persons had significantly lower physical
and mental summary scores.
O’Keefe & Wood (1996) C-S; HIV clinic (South Africa) MOS SF-36 HIV-positive clients had lower QoL scores on all subscales.
Stangl et al. (2007) Cohort; home-based care (Uganda) MOS-HIV, CES-D Psychosocial and mental summary scores significantly improved after 12
months on HAART.
Wouters et al. (2007) C-S; HIV clinics (South Africa) EQ-5D, 3-item participant
well-being scale
Length of time on ART was associated with an increase in physical QoL.
Validity and reliability of measurement tools for mental illness in PLHIV
Ganasen et al. (2008) C-S; HIV clinics (South Africa) HDS compared to MMSE ROC 0.90.
O’Keefe & Wood (1996) C-S; HIV clinic (South Africa) MOS SF-36 compared to
nurse-led interviews
Median kappa for test/retest reliability: Afrikaans 0.60, Xhosa 0.53.
Myer, Smit, Le Roux et al.
(2008)
C-S; HIV clinics (South Africa) AUDIT, CES-D compared to
MINI, HTQ
AUDIT, HTQ, CES-D versus MINI, ROC: AUDIT 0.96, HTQ 0.74, CES-D
0.76.
Kaaya et al. (2002) C-S; antenatal clinic (Tanzania) HSCL-25 compared to MOS
SF-36, SCID
HSCL-25 versus SF-36, ROC analysis: specificity 80%, sensitivity 89%.
Kaharuza et al. (2006) C-S; home-based HIV care (Uganda) Modified CES-D Modified CES-D: Cronbach’s α = 0.90.
Mast et al. (2004) C-S (Uganda) MOS-HIV (Luganda) MOS-HIV: Cronbach’s α >70 for five of eight domains, with a range of 0.51 to
0.84.
Sacktor et al. (2005) C-S; infectious diseases clinic (Uganda) IHDS compared to clinical
assessment and neurological
test battery
IHDS, ROC analysis: specificity 55%, sensitivity 80%.
Shacham, Reece, Owino
On’gor et al. (2008)
C-S; HIV-support network (Kenya) BSI compared to PHQ BSI versus PHQ, reliability: Cronbach’s α = 0.95; validity: Pearson correlation
between scales = 0.6.
Treatment for mental illness in PLHIV
Field (2008) Control trial; HIV-support group (South
Africa)
BDI-II, MHLC scale Doll-making led to higher mean difference in depression scores as compared
to viewing comedy films.
Authors Study design (site) Measurement tools Main findings
Appendix 1: Continued
African Journal of AIDS Research 2011, 10(2): 101–122
121
Sebit et al. (2002) Cohort; C-S (Zimbabwe) BPRS, MADRS, SCID HIV-positive people taking conventional medical therapy (but not HAART)
were 1.32-times more likely to have a psychiatric diagnosis versus those
taking traditional medicinal herbs.
Olley (2006b) Control trial; voluntary HIV-testing centre
(Nigeria)
BDI, CCEI, Brief COPE Psychological education reduces psychological symptoms in HIV-positive
persons.
[See also Potterton (2006); Crowther et al. (2008)]
Mental illness in those affected by HIV or AIDS — Orphans
Cluver et al. (2007) C-S (South Africa) CBCL, CDI, Child PTSD
Checklist, CMAS, SDQ
AIDS-related orphanhood was associated with depression but not anxiety.
Cluver & Gardner (2006) C-S (South Africa) IES, SDQ Orphanhood was not associated with total conduct or emotional problems or
hyperactivity.
Cluver et al. (2008) C-S (South Africa) CBCL, CDI, Child PTSD
Checklist, CMAS, Peer
Victimization Scale, SDQ,
Stigma Scale
Stigma is a full mediator between AIDS-related orphanhood and depression,
PTSD, delinquency and conduct problems.
Onuhua et al. (2008) C-S; NGOs and schools (South Africa and
Uganda)
BSSS, CES-D for children,
DAS-DQ, GHQ, modified MRI,
PBI, Rosenberg Self-Esteem
Scale, Schwarzer & Schulz’s
Received Social Support Scale,
self-developed child abuse
AIDS-related orphans with mentors (versus those without) had better mental
health.
Atwine et al. (2005) C-S (Uganda) BYI Orphanhood is associated with depression, anxiety and anger.
Sengendo & Nambi (1997) C-S; World Vision (Uganda) CDI Orphanhood is associated with depression.
Makame et al. (2002) C-S (Tanzania) Semi-structured interview,
Internalizing Problems Scale,
WRAT
Orphanhood is associated with increased internalisation of problems.
Bhargava (2005) C-S (Ethiopia) MMPI-2 Lower adjustment if: female, mother has died of HIV, have unsympathetic
foster family.
De Witt & Lessing (2005) C-S (South Africa) Self-developed questionnaire Educators agree that children orphaned by AIDS need psychological support
services.
Mental illness in those affected by HIV or AIDS — Caregivers
Bauman (2006) C-S; community organisations
(Zimbabwe)
Mothers: CBQ, PSI;
Children: CDI, IPPA, adapted
Parentification Scale, modified
Emotional Parentification Scale
Prevalence of depression among child caregivers: 63%.
Singh et al. (2006) C-S; Highway and Estcourt Hospices
(South Africa)
PRIME-MD PHQ, Brief Burden
Interview
Burden of care is associated with depression.
Mental illness in those affected by HIV or AIDS — Community
Myer, Seedat, Stein et al.
(2008)
C-S; national sample (South Africa) WHO CIDI Knowing someone who died of HIV increased likelihood of mental illness.
Authors Study design (site) Measurement tools Main findings
Appendix 1: Continued
Breuer, Myer, Struthers and Joska122
Appendix 1: Continued
Abbreviations
[A] = abstract only
aHIV+ = asymptomatic persons with HIV
AIDS-KT = AIDS-Risk Behavior Knowledge Test
ARBAQ = AIDS-Risk Behavior Assessment Questionnaire
ASSIST = Alcohol, Smoking and Substance Involvement
Screening Test
AUDIT = Alcohol Use Disorders Identification Test
BDI = Beck Depression Inventory
BDI-II = Beck Depression Inventory (2nd edition)
BPRS = Brief Psychiatric Rating Scale
Brief COPE = abbreviated version of the COPE inventory
BSI = Brief Symptom Inventory
BSMMD = Bayley Scales of Mental and Motor Development
BYI = Beck Youth Inventories
CBCL = Child Behaviour Checklist
CBQ = Conflict Behaviour Questionnaire
CCEI = Crown Crisp Experiential Index
CDI = Child Depression Inventory
CES-D = Center for Epidemiologic Studies Depression Scale
CIDI = Composite International Diagnostic Interview
CIS = Clinical Interview Schedule
C+M+, C-M+ and C-M- = indicates child (C) or mother (M)
HIV-positive or HIV-negative
CMAS = Children’s Manifest Anxiety Scale
C-S = community sample
CSI-D = Community Screening Instrument for Dementia
DAS-DQ = Detroit Area Study Discrimination Questionnaire
DDST = Denver Developmental Screening Test
DIGS = Diagnostic Interview for Genetic Studies
DSM-IV = Diagnostic and Statistical Manual of Mental
Disorders (4th edition)
ECSP = Early Childhood Screening Profile
EPDS = Edinburgh Postnatal Depression Scale
EQ-5DTM = EuroQol Group’s standardised instrument for
use as measure of health outcome
FePsy = ‘The Iron Psyche’ for automated neuropsychological
testing
FTII = Fagan Test of Infant Intelligence
GHQ-12 = the 12-item General Health Questionnaire
HAS = Hamilton Anxiety Scale
HDS = HIV Dementia Scale
HESSI = Household Economic and Social Status Index
HOME = Home Observation for Measurement of the
Environment
HSCL = Hopkins Symptom Checklist
HTQ = Harvard Trauma Questionnaire
IAS = IPAT [Institute for Personality and Ability Testing]
Anxiety Scale
IBQ = Illness Behaviour Questionnaire
IES = Impact of Events Scale
IHDS = International HIV Dementia Scale
IPPA = Inventory of Parent and Peer Attachment
KABC = Kaufmann Assessment Battery for Children
KPS = Karnofsky Performance Scale
LEC = Life Events Checklist
LES = Life Events Scale
LSC-R Life Stressor Checklist (Revised)
MADRS = Montgomery-Åsberg Depression Rating Scale
MHLC = Multidimensional Health Locus of Control scale
MINI = Mini-International Neuropsychiatric Interview
MOS-HIV = Medical Outcomes Study HIV Health Survey
MOS SF-36 = Medical Outcomes Study Short Form 36-item
health survey
MMPI-2 = Minnesota Multiphasic Personality Inventory
(version 2)
MMSE = Mini-Mental State Examination
MOSSS-rev = Medical Outcomes Social Support Survey
(revised)
MRI = Ragin’s Mentor Role Instrument
NSI = Nutrition Screening Initiative
PBI = Parental Bonding Instrument
PHQ = Patient Health Questionnaire
PRIME-MD PHQ = Primary Care Evaluation of Mental
Disorders Patient Health Questionnaire
PSI = Physical Symptoms Inventory
PST-SF = Parenting Stress Index Short Form
QoL = quality of life
RCT = Randomised Clinical Trials
ROC = ‘receiver operating characteristic’ curve
SAS = Self-rating Anxiety Scale
SCID = Structured Clinical Interview for DSM-IV
SDQ = Strengths and Difficulties Questionnaire
SDS = Sheehan Disability Scale
sHIV+ = symptomatic persons with HIV
SRQ-20 = Self-Reporting Questionnaire 20 items
SSQ = Social Support Questionnaire
SSC-HIVrev = Sign and Symptom Checklist for HIV
(Revised)
STAI = Spielberger’s State/Trait Anxiety Inventory
WAIS-R = Wechsler Adult Intelligence Scale (Revised)
WHO CIDI = World Health Organization’s Composite
International Diagnostic Interview
WHOQOL-BREF = abbreviated version of the World Health
Organization Quality of Life Assessment Instrument
WRAT = Wide-Range Achievement Test
YMRS = Young Mania Rating Scale
... Given that both pregnancy and living with HIV have been found to be independently associated with poor mental health among adolescents [23,33,34], experiencing the syndemic of both adolescent pregnancy and living with HIV may compound poor mental health experience. Such experiences may also have a bidirectional relationship with poor mental health [23,33,34]. ...
... Given that both pregnancy and living with HIV have been found to be independently associated with poor mental health among adolescents [23,33,34], experiencing the syndemic of both adolescent pregnancy and living with HIV may compound poor mental health experience. Such experiences may also have a bidirectional relationship with poor mental health [23,33,34]. Poor mental health has previously been found to be prevalent among adult populations living with HIV within pregnancy and the postpartum period [35]-however, explorations of mental health among adolescent populations are yet to be undertaken. ...
Article
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The mental health of adolescents (10–19 years) remains an overlooked global health issue, particularly within the context of syndemic conditions such as HIV and pregnancy. Rates of pregnancy and HIV among adolescents within South Africa are some of the highest in the world. Experiencing pregnancy and living with HIV during adolescence have both been found to be associated with poor mental health within separate explorations. Yet, examinations of mental health among adolescents living with HIV who have experienced pregnancy/parenthood remain absent from the literature. As such, there exists no evidence-based policy or programming relating to mental health for this group. These analyses aim to identify the prevalence of probable common mental disorder among adolescent mothers and, among adolescents experiencing the syndemic of motherhood and HIV. Analyses utilise data from interviews undertaken with 723 female adolescents drawn from a prospective longitudinal cohort study of adolescents living with HIV (n = 1059) and a comparison group of adolescents without HIV (n = 467) undertaken within the Eastern Cape Province, South Africa. Detailed study questionnaires included validated and study specific measures relating to HIV, adolescent motherhood, and mental health. Four self-reported measures of mental health (depressive, anxiety, posttraumatic stress, and suicidality symptomology) were used to explore the concept of likely common mental disorder and mental health comorbidities (experiencing two or more common mental disorders concurrently). Chi-square tests (Fisher’s exact test, where appropriate) and Kruskal Wallis tests were used to assess differences in sample characteristics (inclusive of mental health status) according to HIV status and motherhood status. Logistic regression models were used to explore the cross-sectional associations between combined motherhood and HIV status and, likely common mental disorder/mental health comorbidities. 70.5% of participants were living with HIV and 15.2% were mothers. 8.4% were mothers living with HIV. A tenth (10.9%) of the sample were classified as reporting a probable common mental disorder and 2.8% as experiencing likely mental health comorbidities. Three core findings emerge: (1) poor mental health was elevated among adolescent mothers compared to never pregnant adolescents (measures of likely common mental disorder, mental health comorbidities, depressive, anxiety and suicidality symptoms), (2) prevalence of probable common mental disorder was highest among mothers living with HIV (23.0%) compared to other groups (Range:8.5–12.8%; Χ ² = 12.54, p = 0.006) and, (3) prevalence of probable mental health comorbidities was higher among mothers, regardless of HIV status (HIV & motherhood = 8.2%, No HIV & motherhood = 8.2%, Χ ² = 14.5, p = 0.002). Results identify higher mental health burden among adolescent mothers compared to never-pregnant adolescents, an increased prevalence of mental health burden among adolescent mothers living with HIV compared to other groups, and an elevated prevalence of mental health comorbidities among adolescent mothers irrespective of HIV status. These findings address a critical evidence gap, highlighting the commonality of mental health burden within the context of adolescent motherhood and HIV within South Africa as well as the urgent need for support and further research to ensure effective evidence-based programming is made available for this group. Existing antenatal, postnatal, and HIV care may provide an opportunity for mental health screening, monitoring, and referral.
... 4 While research from high-income countries has demonstrated that there is a bi-directional relationship between HIV/AIDS and mental illness, there may be differences in the way this relationship is expressed in SSA. 5 There is much needed cross-cultural insight into the relationship between HIV/AIDS and psychosis. Culture may influence the patients' perception and experience of psychosis as well as the clinical presentation. ...
... Cognitive impairment is well established in both psychotic disorders and HIV infection, being exacerbated in psychotic patients with HIV. 13 Being HIV positive is traditionally associated with a sub-cortical cognitive impairment, the prevalence of cognitive deficits being reported to range from 4% to 99% in a systematic review of HIV research in SSA. 5 De Ronchi et al 7 described cognitive screen deficits in a sample of 22 patients with FEP living with HIV in Italy. Participants had impaired attention and concentration on the Mini Mental State Examination (MMSE) but no other differences on cognitive impairment. ...
Article
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Introduction: South Africa (SA) has a high HIV prevalence and limited mental healthcare resources. Neuropsychiatric complications such as psychosis onset in people living with HIV (PLWHIV) remains poorly understood. The study aims to compare the socio-demographic, clinical, substance use, cognitive and trauma profile of PLWHIV presenting with first episode psychosis (FEP) to those with the condition but without HIV. Methods and analysis: This study will compare presentation, course, and outcome of a cohort of PLWHIV and FEP with a control group recruited over a 3-year period. We will prospectively test the hypothesis that the 2 groups are socio-demographically, clinically and cognitively distinct at illness presentation, with higher trauma burden and poorer outcomes in those with the dual burden of HIV and FEP. FEP participants, confirmed by a structured neuropsychiatric interview, will have their socio-demographic, psychosis, mood, motor, trauma and substance use variables assessed. A neuropsychological battery will be completed to assess cognition, while quality of life, psychotic symptoms and HIV markers will be measured at 3, 6 and 12 months. Ethics and dissemination: The study protocol has been reviewed and ethics approval obtained from the Biomedical Research Ethics Committee (BC 571/18) of the University of KwaZulu-Natal. The results from this investigation will be actively disseminated through peer-reviewed journal publications and conference presentations.
... Contrary to studies that have examined HIV stigma and mental health [34,35,[55][56][57], stigma was not associated with any of the outcomes in the current study. Indeed, it has been suggested that shame is a more proximal predictor of mental health challenges than stigma [37]. ...
Article
Full-text available
This study examined the relationship between HIV-related shame, stigma and the mental health of adolescents (10–14 years) living with HIV in Uganda. Cross sectional data from a 2-year pilot study for adolescents living with HIV (N = 89) were analyzed. Multiple linear regression analyses were conducted to determine the relation between HIV-related shame, as measured by the Shame Questionnaire, stigma, and adolescents’ mental health functioning, including depressive symptoms, hopelessness, PTSD symptoms, loneliness and self-concept. The average age was 12.2 years, and 56% of participants were female. HIV-related shame was associated with higher levels of depressive symptoms (p < 0.05), hopelessness (p < 0.001), PTSD symptoms (p < 0.001), loneliness (p < 0.01), and low levels of self-concept (p < 0.01). HIV stigma was not associated with any of the outcomes. Findings support the need for the development of strategies to help adolescents overcome the shame of living with HIV and mitigate the effects of shame on adolescents’ mental health and treatment outcomes.
... Stigma can be internalized as a result of perceived negative public attitudes. It translates into feelings that the self is reprehensible, damaged and defective; and is associated with depression and post-traumatic stress disorders (PTSD) [12,13], feelings of loneliness and social isolation [14,15], poor treatment and adherence to medication [10,16], poor HIV-related physical health [17], and increased sexual risk-taking behavior [18]. Moreover, internalized stigma increases the risk of loss to treatment follow up [19]. ...
Article
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Background Sub-Saharan Africa (SSA) is heavily burdened by HIV, with 85% of the global new infections among adolescents happening in the region. With advances in medication and national policies promoting antiretroviral therapy (ART), children < 15 years living with HIV (CLWH) continue to grow with a chronic, highly stigmatized disease. Unfortunately, the stigma they experience results in much lower quality of life, including poor mental health and treatment outcomes. Family members also experience stigma and shame by virtue of their association with an HIV-infected family member. Yet, stigma-reduction interventions targeting CLWH and their families are very limited. The goal of this study is to address HIV-associated stigma among CLWH and their caregivers in Uganda. Methods This three-arm cluster randomized control trial, known as Suubi4Stigma, will evaluate the feasibility, acceptability, and preliminary impact of two evidence-based interventions: (1) group cognitive behavioral therapy (G-CBT) focused on cognitive restructuring and strengthening coping skills at the individual level and (2) a multiple family group (MFG) intervention that strengthens family relationships to address stigma among CLWH (N = 90, 10–14 years) and their families (dyads) in Uganda. Nine clinics will be randomized to one of three study arms (n = 3 clinics, 30 child-caregiver dyads each): (1) usual care; (2) G-CBT + usual care; and (3) MFG + usual care. Both treatment and control conditions will be delivered over a 3-month period. Data will be collected at baseline (pre-intervention) and at 3 months and 6 months post-intervention initiation. Conclusion The primary aim of the proposed project is to address the urgent need for theoretically and empirically informed interventions that seek to reduce HIV-associated stigma and its negative impact on adolescent health and psychosocial well-being. As several countries in SSA grapple with care and support for CLWH, this study will lay the foundation for a larger intervention study investigating how HIV-associated stigma can be reduced to foster healthy child development—especially for CLWH as they transition through adolescence. Trial registration ClinicalTrials.gov: NCT04528732; Registered August 27, 2020
... Depression is two to three times higher among people living with HIV than in the general population (Ciesla and Roberts 2001;Chibanda et al. 2016a;Breuer et al. 2011). High rates of depression may be linked with correlates of HIV such as social stigma, economic adversity, and the prospect of a long-term physical illness, which is fatal if untreated. ...
Chapter
Full-text available
Antiretroviral therapy has transformed HIV into a manageable disease, preventing the progression of HIV to AIDS and improving quality of life for people living with HIV. Increasing the number of people who test for HIV, initiating people living with HIV on anti- retroviral therapy, and supporting them to adhere to their regimen have become central goals to the global strategy to end AIDS by 2030. Although we have seen extraordinary achievements, we are not on track to achieve these goals. People living with HIV face considerable emotional and social challenges which are known to adversely impact on their capacity to engage fully with HIV care and to maintain adherence to HIV medication. Among formally diagnosed mental disorders in people living with HIV, depression has received the most attention. However, in many settings where HIV is endemic, there is no single word for depression and emotional responses may be seen as “weakness” and something to be hidden (Aggarwal et al., Int J Soc Psychiatr 62 (2):198–200, 2016). Sub-Saharan Africa carries the highest burden of HIV and has limited numbers of trained mental health care professionals. This chapter describes the global challenges to reducing new infections and HIV related deaths and illustrates innovative ways in which depression can be treated alongside HIV to allow people living with HIV to benefit from antiretroviral therapy and maintain healthy survival. Examples of innovations from sub- Saharan Africa provide evidence to support the urgent need for integrating mental health care into primary HIV services.
... The dual impact of such phenomena may compound experiences of mental disorder. Mental health may have a bidirectional relationship with the experience of adolescent pregnancy and HIV [26,29,30]. For example, worse mental health may lead to increased risk behaviour (i.e. ...
Article
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Adolescent (10–19 years) mental health remains an overlooked global health issue. Rates of adolescent pregnancy within sub-Saharan Africa are some of the highest in the world and occur at the epicentre of the global HIV epidemic. Both experiencing adolescent pregnancy and living with HIV have been found to be associated with adverse mental health outcomes, when investigated separately. Poor mental health may have implications for both parent and child. The literature regarding mental health within groups experiencing both HIV and adolescent pregnancy is yet to be summarised. This systematic review sought to identify (1) the prevalence/occurrence of common mental disorder amongst adolescents who are living with HIV and have experienced pregnancy, (inclusive of adolescent fathers) in sub-Saharan Africa (2) risk and protective factors for common mental disorder among this group, and (3) interventions (prevention/treatment) for common mental disorder among this group. A systematic search of electronic databases using pre-defined search terms, supplemented by hand-searching, was undertaken in September 2020. One author and an independent researcher completed a title and abstract screening of results from the search. A full-text search of all seemingly relevant manuscripts (both quantitative and qualitative) was undertaken and data extracted using pre-determined criteria. A narrative synthesis of included studies is provided. Quality and risk of bias within included studies was assessed using the Newcastle-Ottawa scale. A systematic keyword search of databases and follow-up hand searching identified 2287 unique records. Of these, thirty-eight full-text quantitative records and seven full-text qualitative records were assessed for eligibility. No qualitative records met the eligibility criteria for inclusion within the review. One quantitative record was identified for inclusion. This study reported on depressive symptomology amongst 14 pregnant adolescents living with HIV in Kenya, identifying a prevalence of 92.9%. This included study did not meet the high methodological quality of this review. No studies were identified reporting on risk and protective factors for common mental disorder, and no studies were found identifying any specific interventions for common mental disorder for this group, either for prevention or for treatment. The limited data identified within this review provides no good quality evidence relating to the prevalence of common mental disorder among adolescents living with HIV who have experienced pregnancy in sub-Saharan Africa. No data was available relating to risk and protective factors or interventions for psychological distress amongst this group. This systematic review identifies a need for rigorous evidence regarding the mental health of pregnant and parenting adolescents living with HIV, and calls for granular interrogation of existing data to further our understanding of the needs of this group. The absence of research on this topic (both quantitative and qualitative) is a critical evidence gap, limiting evidence-based policy and programming responses, as well as regional development opportunities.
... Musindo et al. (2018) found a positive relationship between neurocognitive performance and psychosocial factors, specifically, school performance and peer relationships among children. While research on the psychosocial issues facing children with HIV in Kenya is limited, a systematic review of HIV and mental health research in sub-Saharan Africa suggests high prevalence of mental illness among PLWHA (Breuer et al., 2011). While this review was not limited to children, it sheds some light on the psychosocial issues facing children with HIV. ...
Article
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Kenya has the twelfth largest HIV/AIDS epidemic in the world. In 2016, there was an estimated 1.6 million people living with HIV in Kenya. Youth ages 15–24 accounted for over half (51%) of the HIV incidence reported in 2015, a significant increase from 2013 where youth accounted for 29% of all new cases. The purpose of this paper is to review HIV prevalence and incidence among youth and other key populations in Kenya and to discuss the cultural attitudes and practices that impact the HIV epidemic including relevant laws, policies, and initiatives with a focus on the role of school psychologists in neuropsychological interventions for children and adolescents living with HIV. A broad range of biomedical, behavioral, and structural approaches for addressing the HIV-related needs among youth in Kenya are discussed as is the importance of addressing the psychosocial needs of youth living with HIV by acknowledging the relationship between physical health, mental health, and academic outcomes. The critical role of school psychologists and other school professionals in implementing these strategies is highlighted.
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Background: The cascade of human immunodeficiency virus (HIV) care in patients with psychiatric disorders is poorly understood. Aim: This study determined the prevalence of HIV and described its cascade of care among patients with psychiatric disorders in the Eastern Cape province, South Africa. The study also examined the correlates of HIV comorbidity with psychiatric disorders in the cohort. Methods: In this cross-sectional study, a total of 368 individuals attending the Psychiatric Outpatients’ Department of Cecilia Makiwane Hospital in Eastern Cape were interviewed with a structured questionnaire. Relevant items on demographics and clinical information were extracted from the medical records. Virologic suppression was defined as viral load 1000 RNA copies/mL. Results: The HIV prevalence after the intervention was 18.8% and a significant proportion of participants already knew their status (n = 320; 87.0%). Linkage to care and antiretroviral therapy initiation occurred in 61 participants, of those diagnosed with HIV (88.4%), with 84.1% being eligible for viral load monitoring (n = 58) and 53.4% having achieved virologic suppression. Being female (AOR = 5.48; 95% CI 2.61–11.51) and black (adjusted odds ratio [AOR] = 3.85; 95% confidence interval [CI] 1.06–14.03) were independent predictors of HIV comorbidity in individuals living with psychiatric disorders. Conclusion: This study found a moderately high prevalence (close to 19%) of HIV in individuals with psychiatric disorders, with a significant correlation with being female and being black people. This study also found a significant gap in the linkage to antiretroviral therapy (ART) initiation and a low rate of virologic suppression of 53.4%. Clinicians, therefore, should monitor and provide interventions for patients with concomitant HIV infection along this cascade of care.
Article
Background People living with HIV/AIDS (PLWHA) are at increased risk of stigma and mental illness, and this appears to be a particular issue in South Africa, which is home to 19% of the world's HIV-positive population. This paper aims to systematically review the literature investigating the relationship between HIV-stigma and depressive symptoms amongst PLWHA in South Africa. Methods A keyword search of four bibliographic databases (CINAHL, Ovid MEDLINE, PsycINFO, and Web of Science) and two grey literature websites was conducted. The quality of eligible studies was assessed using established criteria. Results Fourteen quantitative studies were included in the review. PLWHA in South Africa experience high levels of HIV-stigma and depressive symptoms. All forms of stigma were found to be associated with depressive symptoms amongst PLWHA. Prospective findings were mixed, with one study finding that stigma did not predict depressive symptoms over 36 months, and another that depressive symptoms predicted stigma 12 months later, suggesting a potentially bidirectional relationship. Females and young adults may be particularly vulnerable to HIV-stigma and its negative psychological effects. Some support was found for the moderating role of social support in the relationship between stigma and depressive symptoms across different sub-populations. Limitations Few studies conducted prospective analyses or tested mediation/moderation. Conclusions Despite limitations, this study highlights the importance of understanding the mechanisms underlying HIV-stigma across different sub-populations in South Africa. This may lead to more effective and context-specific interventions to combat adverse mental health outcomes.
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Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
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p> Objective. Published studies on the prevalence of depressive symptoms using rating scales and the relationship between depression and immune status offer inconsistent results. Depressive symptoms are common and impact on functioning, quality of life, and health status, highlighting the importance of diagnosis and treatment of patients with HIV infection. The aim of the study was to determine the occurrence of depression among HIV-positive patients using the Beck's Depression Inventory (BDI) and to determine a relationship, if any, between depressive symptoms and CD4 count. Method. Forty-one patients aged 18 years or more were recruited from the HIV outpatient clinic. All the subjects completed the 21-item BDI and their CD4 counts were determined. Patients who had a score of 10 or more on the BDI were considered positive for a depressive disorder. Results. More than half (56%) of the study sample had a BDI of ≥ 10 indicating significant symptoms of depression. There was no significant difference in the CD4 counts between the depressed and non-depressed groups (p > 0.05), and no correlation between CD4 counts and BDI scores in the total study sample (r = 0.27, p > 0.05). The affective components of the BDI contributed significantly to the overall BDI score compared with the somatic component (p < 0.05). Conclusion. The evidence from the study supports the BDI as a suitable measure for identifying those patients who meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for minor or major depression. The HIV epidemic is the most serious health challenge in South Africa and it is imperative that HIV-infected patients who complain of fatigue or insomnia be screened routinely for major depression, followed by a structured interview to confirm the diagnosis.</p
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p> Background. In order to gauge the impact of the HIV epidemic on psychotic disorders, the magnitude and causal direction of the association between HIV infection and psychosis need to be examined closely. Objective. To determine the HIV seropositivity rate among adult patients presenting with first-episode psychosis (FEP) to Town Hill Hospital in Pietermaritzburg, KwaZulu-Natal. Design. A cross-sectional, point-prevalence study was done over a 6-month period. Results. Of the 63 FEP patients in the study, 48 tested HIV- negative and 15 tested positive, giving a seroprevalence rate of 23.8%. Conclusion. The prevalence of HIV seropositivity is high among patients with FEP.</p
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Human immunodeficiency virus-1 (HIV-1) causes mild to severe cognitive impairment and dementia. The transactivator viral protein, Tat, is implicated in neuronal death responsible for neurological deficits. Several clades of HIV-1 are unequally distributed globally, of which HIV-1 B and C together account for the majority of the viral infections. HIV-1-related neurological deficits appear to be most common in clade B, but not clade C prevalent areas. Whether clade-specific differences translate to varied neuropathogenesis is not known, and this uncertainty warrants an immediate investigation into neurotoxicity on human neurons of Tat derived from different viral clades We used human fetal central nervous system progenitor cell-derived astrocytes and neurons to investigate effects of B- and C-Tat on neuronal cell death, chemokine secretion, oxidative stress, and mitochondrial membrane depolarization by direct and indirect damage to human neurons. We used isogenic variants of Tat to gain insights into the role of the dicysteine motif (C30C31) for neurotoxic potential of Tat Our results suggest clade-specific functional differences in Tat-induced apoptosis in primary human neurons. This study demonstrates that C-Tat is relatively less neurotoxic compared with B-Tat, probably as a result of alteration in the dicysteine motif within the neurotoxic region of B-Tat This study provides important insights into differential neurotoxic properties of B- and C-Tat, and offers a basis for distinct differences in degree of HIV-1-associated neurological deficits observed in patients in India. Additional studies with patient samples are necessary to validate these findings.
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Objective: The authors hypothesized that in the majority of HIV-positive patients presenting with mania, the mania is secondary to HIV infection and that its presentation and correlates differ from those of HIV-negative patients with primary mania. Method: A comparative cross-sectional study was conducted with HIV-negative and HIV-positive patients admitted to psychiatric wards with acute mania. The authors compared the patients' psychiatric, physical, and immunological (CD4 cell counts) and other laboratory parameters. Pairwise comparisons were done for the two groups on a number of variables. Results: Of 141 patients who presented with acute mania during a 6-month period and were eligible for the study, 61 met criteria for HIV-related secondary mania. Compared with HIV-negative patients with primary mania, they were older, more cognitively-impaired less educated, and more likely to be female. Patients in this group had more manic symptoms: they were more irritable, more aggressive, more talkative, and had higher rates of paranoid delusions, visual hallucinations, and auditory hallucinations. More of the HIV-positive secondary mania group had CD4 counts below 350 cells/mm³. Conclusions: Primary mania and HIV-related secondary mania are clinically and immunologically distinct. The relation between secondary mania and depressed CD4 counts suggests that in the setting of an HIV/AIDS epidemic in poor countries, secondary mania may be used as an indicator to initiate highly active antiretroviral therapy.
Article
Background. To the best of our knowledge no previous studies have been published on the rates of psychopathology in HIV-infected patients from a predominantly black, heterosexual Third-World population. Objective. To evaluate the levels of anxiety experienced by patients infected with HIV, the presence of specific anxiety and other psychiatric disorders, as well as to determine whether this is associated with disease stage and time after diagnosis. Methods. One hundred HIV-infected patients attending the immunology clinics at the Universitas and Pelonomi hospitals in Bloemfontein, South Africa, were screened for the presence of psychiatric disorders using the Mini International Neuropsychiatric Interview (MINI). More specifically, anxiety was evaluated using the Zung self-rating and Hamilton anxiety (HAM-A) scales. Disease stage of the patient was determined by clinical examination and CD4- T-cell count values. Results. According to the MINI, 35% of the patients had a major depressive disorder. A further 3% had dysthymic disorder, while bipolar disorder was diagnosed in 6%. As regards anxiety disorders, the following was found: panic disorder 37%, agoraphobia 9%, social phobia 15%;, specific phobias 10%, obsessive-compulsive disorder 3% and generalised anxiety disorder 21%. Post-traumatic stress disorder was diagnosed in 6%. Thirty-one of the patients scored above the cut-off on both the HAM-A and Zung scales. Conclusions. The results indicate that psychiatric comorbidity is common in HIV-infected patients. Anxiety and depressive disorders were found in a large number of patients, significantly more than the proportion expected in the general population. The identification and treatment of these co-morbid psychiatric syndromes in HIV-infected patients should be actively pursued, as treatment could lead to an improvement in quality of life.
Article
Objective — Educators' perceptions of the psychosocial needs of HIV/AIDS orphans are important in supporting these children. The objective of this research is to determine the view of educators regarding the psychosocial needs of HIV/AIDS affected children.Method — A questionnaire, based on a thorough literature study was administered to determine the views of teachers. A convenient sample of 120 teachers from different schools, who attended a workshop organised for the primary schools in a particular school district in Tswane was used.Results — Only about half of the educators indicated that their schools provided support for HIV/AIDS orphans. Lack of food and clothing were viewed as the most pressing physical needs of the orphans. The desire for security, acceptance, dealing with stress, managing fears and psychological support services were identified as important psychological needs. Lack of security was seen as the most important factor affecting the psychosocial behaviour of these learners. Depression, sadness and stigmatisation were viewed as primary influences on behaviour. Teaching position, gender and age significantly influenced educators' views of various aspects of the learners' needs and behaviours.Conclusion — These findings have important implications for the training of educators to support learners and caregivers of children affected by the disease.
Article
Since the beginning of the epidemic, people living with HIV and the social groups to which they belong have been stigmatized worldwide. This cross-sectional study, conducted between July and November 2003, investigated the association between HIV stigma and mental health status among black women living with HIV in the Western Cape province of South Africa. Eligible participants completed a questionnaire that assessed HIV stigma, sociodemographic, and mental health status measures. Participants were recruited from one of five primary health care clinics in the rural Western Cape. Recruiters screened 177 women to assess their eligibility. Of those screened, 68% (n = 120) were eligible because they were black South Africans, between the ages of 18 and 45, were living with HIV/AIDS, sought primary health care from one of the five study clinics, spoke Xhosa, and provided written informed consent. A priori hypotheses postulated that women reporting more HIV stigma would experience more consequences for mental health sequelae. The main outcome measures were mental health status variables, including depressive symptomatology, stress of HIV discrimination, quality of life, post-traumatic stress, suicidal ideation and fear of HIV disclosure. In linear regression models, more reports of HIV stigma were associated with significantly more depressive symptomatology (P = 0.03) and a lower quality of life (P = 0.00). The findings from this study indicate that HIV stigma is associated with adverse mental health sequelae among black Xhosa women living with HIV. Educational and legal efforts are required to reduce HIV stigma. Moreover, a public health infrastructure that integrates HIV/AIDS treatment and mental health services may be a promising strategy for reducing the adverse mental health consequences of HIV stigma.