This literature review aims at exploring the Global burden of HIV and its relationship with mental health, Identifying mental and psychological health issues experienced by the HIV positive patients. The review also aims at analyzing the effects of these mental health issues in disease progression and overall impact of these issues on their quality of life. Furthermore, the review will also explore some of the Global and regional initiatives for provision of mental health facilities to this vulnerable population. Finally the review concludes with the critical appraisal and gaps with my research question and approach.
Methodology/ Search strategy
A systematic and comprehensive literature search was conducted to review and analyze the existing literature on the subject under study. A general to specific approach and skimming of the title and abstracts was followed to segregate relevant articles. Several nursing and non-nursing data bases were searched. The search strategy is summarized in Figure. I. Initially the search was started from the Google scholar internet based database to get hold of the general perspective of the research problem. The Google scholar search revealed more than 100,000 results which were refined through key words. The search was built on with the key words in nursing databases like CINAHL plus (cumulative index to nursing and allied health literature), Medline and PubMed, Figure. I. For the purpose of searching more relevant studies on the research problem, ancestry approach was followed; citations from already searched articles from the databases were used to track other studies on the similar topic. Manual search was also performed in AKUH periodicals like, Current opinion in HIV and AIDS, HIV medicine and Journal of HIV/AIDS & Social Services. This literature review paper is based on synthesis of 8 studies and 2 literature reviews extracted from different sources, combination of Western and Asian context, and a combination of qualitative and quantitative studies. Abstracts, conference proceedings and commentaries were excluded. However, WHO, UNAIDS and World Bank reports on HIV were included. No studies were found from Pakistani context in regard to mental health issues among HIV patients.
Background and significance of the Research problem
Global Burden of HIV
Human Immunodeficiency Virus (HIV) remains a real threat to the health and socioeconomic wellbeing of many of the nations of the world. According to the World Health Organization (2011) global summary of the AIDS epidemic, the total number of people living with HIV is 34.0 million out of which 30.7 million are adults, 16.7 million are women and 3.3 million accounts for children < 15 years of age. There is a considerable variation in trends globally. Kilmarx (2009) indicates a decrease in HIV prevalence in Burma, Cambodia, and Thailand, whereas increasing rapidly in Pakistan, Vietnam, and some provinces of Indonesia. Moreover, there is an increasing progress of new infections in the very populous countries of Bangladesh and China. Ma, Zhang, He et al (2007) lists the major factors contributing towards HIV globally and in most Asian countries which are, injection drug use, sex work, male-male sex, and overlap in these behaviors.
Relationship between HIV and mental health
HIV is one of the most complicated social challenges faced by contemporary societies due to its strong ties with sexual and societal stigmatized behavior. Asante (2012) states that once diagnosed with HIV, it may lead to lower self- esteem, ineffective coping and social isolation and poor psychological wellbeing. The WHO (2008) report on HIV AIDS and mental health remark mental health and HIV/AIDS as closely interlinked. Mental health problems including substance abuse are associated with increased risk of HIV infection and AIDS and interfere with their treatment. While on the other hand, some mental disorders occur as a direct result of HIV infection.
It is important to understand that mental health issues in HIV positive patients may be associated with negative experiences and poor adherence to treatment regimens, leading to greater HIV risk behavior, and lower quality of life which is a critical factor in HIV care and prevention. WHO (2008) also affirms the vulnerability of mental disorders that may interfere with the ability to acquire or use information about HIV and practice safe behaviors. Collins, Hollman, Freeman, and Patel (2006) reveal that depression results in worst outcomes for people living with HIV and those with anxiety, mood and substance abuse disorders demonstrate a less or slow response towards anti-retroviral therapy as compared to those without any mental illness.
Critical Analysis of the Literature
Based on the critical analysis of the research articles, following themes were identified which are discussed in detail below. The studies were a combination of qualitative and quantitative, mostly cross-sectional studies with mixed methods. A variety of tools were used in these studies to study different aspects e.g. demographic data, behaviors and mental health issues.
Prevalence of Mental Health issues among HIV positive individuals
World Health Organization (2008) report on HIV AIDS and mental health report higher rates of depression in HIV-positive people compared with control groups both in low- and high income countries. Studies in India have consistently reported a high prevalence of mental health problems among HIV positive patients as compared to the general population (Das & Leibowitz, 2011). Similar study in United States also reveals 22-32% prevalence of depression in HIV infected individuals which is 2-3 time higher than prevalence of depression in general community (Bing, et al., 2001). The findings from these studies are significant and thought provoking in terms of prevalence of mental health issues among HIV population as compared to controls. These findings suggest the need for addressing mental health issues pertinent to HIV population.
Stigma and Discrimination
A significant number of researchers reported that social stigma and discrimination of HIV infected individuals, (Das & Leibowitz, 2011; Li, Lee, Thammawijaya, Jiraphongsa, & Rotheram-Borus, 2009) fear and helplessness (Whetten, Reif, Whetten, & Murphy-McMillan, 2008), cause greater mental and psychological turmoil which ultimately leads to mental health problems. The stigma attached with being HIV positive creates a sense of worthlessness and the individuals develop an attitude of transmitting the virus as revenge. Shin, et al., (2011) performed a qualitative analysis to identify the factors that contribute to poor emotional health and its impact among Peruvian HIV-infected individuals. Focus group discussions with patients and providers were conducted. Analysis revealed a thoughtful insight into the profound impact of stigma, depression, isolation, and lack of social support among these patients. Moreover it was found that living with HIV, contributed significantly to mental health problems experienced by HIV-positive individuals. The study also reported incidences of experiencing hopelessness, stigma, and socio-economic marginalization of many of these patients once diagnosed with HIV. These results were consistent with another study by Jin, Zhao, Zhang, Feng, and Wu (2010) to investigate the psychological status and the psychosocial experiences of HIV-positive people. The outcomes of this study suggest that HIV-positive people in eastern China also suffered from psychological distress and experience a negative psychosocial environment once stigmatized as HIV positive. These studies reveal that HIV positive individuals experience significant stigma and discrimination which has a profound impact on their psychological and mental health and its association with their overall quality of life.
Depression, Mood /Anxiety disorders and substance abuse
In one of the study by Bing, et al., (2001) to measure the prevalence of mental disorders and drug use among HIV positive individuals in United States, half of the population screened positive for either one or more psychiatric disorders ( mood disorders, dysthymia, generalised anxiety disorders and major depression). Moreover, approximately half of the population reported use of illicit drug out of which 12% were drug dependent. Similar study in Denmark by Rodkjaer, Laursen, Balle, and Sodemann, (2010) found to have a 38% prevalence of depression among the HIV positive participants. The commonly reported mental health issues in various other studies were found to be mood/ anxiety diagnosis (39%) substance abuse (21%) clinically relevant depression (76%) and post-traumatic stress disorder (11%) (Pence, Miller, Whetten, Eron & Gaynes, 2006), depression 62.3% and anxiety 82.3% respectively (Morrison, et al., 2011). Studies in India also support the high prevalence of depressive disorders, anxiety, adjustment disorders, suicidal intents and attempts and alcohol dependence among HIV positive individuals (Collins, Hollman, freeman & Patel, 2006). Whetten, Reif, Whetten, and Murphy-McMillan (2008) attributed mental illness including depression, anxiety, and posttraumatic stress disorder (PTSD) related to HIV, as associated with poor health outcomes including adherence to medication regimens and HIV risk behavior, such as unprotected sex and needle sharing. The overall impact suggests the increased magnitude of mental health disorders including depression, substance abuse, general anxiety disorders, suicidal ideation, suicidal attempts and substance abuse among HIV positive patients.
Social support and internalized shame:
Another theme which was found in few studies was internalized shame and social support. Li, Lee, Thammawijaya, Jiraphongsa, and Rotheram-Borus, (2009) carried out a research in Thailand to examine relationship among HIV related stigma, internalized shame and social support and its impact on quality of life of life of HIV positive individuals. The results revealed a significant negative association among social support, internalized shame (p= 0.001) and stigma (p= <0.05). Moreover significant correlation was found between depression and internalized shame (p< 0.001). Similar study was sought in Ghana by Asante (2012) to investigate the association between psychological wellbeing of HIV positives and social support. Results revealed a negative association of depression, stress and anxiety with social support. This indicates that social support is inversely proportional to stigma, depression and internalized shame and some modifications in the social environment may lead to successful psychological adaptation towards HIV.
Mental health services for HIV patients; Global and regional perspectives
The critical need to address mental health issues among HIV population is recognized globally. However, Reif, Whetten & Raper (2006) believes that significant paucity in access to mental health persists for this susceptible population. The WHO (2008) report on HIV/ AIDS and mental health proposed a series of modules and training material for integration of mental health interventions into antiretroviral therapy programs. However, the application and effectiveness of these modules have yet to be studied. Apart from WHO initiatives, Baingana, Thomas and Comblain (2005) affirms that The World Bank is currently "the largest long-term investor in the prevention and mitigation of HIV/AIDS in developing countries" (p.2). Despite having identified mental health issues as "an important emerging health problem for developing market economies" (p.2), it has yet not significantly addressed the role of mental health in the HIV/AIDS pandemic. On the other hand, Khan and Hyder (2001) in their article mention that private academic centers in Pakistan have played their role in conducting studies related to HIV prevalence and knowledge awareness and also providing appropriate medical facilities and counseling the HIV patients and families but these facilities are limited and general public has less access to them. The nature of counseling however, is not explicitly defined by the authors.
The analysis from the literature exhibits insufficient data in Pakistani cultural context regarding mental health challenges of people living with HIV, which could be used to provide the necessary services to meet the growing needs of HIV positive population. Hence, substantial relevant data needs be collected in order to suggest specific mental health services for these individuals exclusively.
Critical appraisal and Gaps
After an in-depth critical review on the literature, it was found that up till now there has been a dearth of research on the prevalence of HIV and its associated factors. However, limited researches have been done on the selected problem of mental health issues among this population globally. Global Initiative on Psychiatry GIP (2008) clearly regards the implications of untreated mental morbidity as both mental health and human rights issue. It further emphasizes that the strong link between mental health and HIV is a fact but very little attention has been paid to this association.
There seems a lack of evidence regarding mental health issues in developing countries like Pakistan. The reasons for this could be inadequate data, social stigma attached to HIV in the country and under reported HIV cases (Khan & Hyder, 2001).The evidences above ascertain the significance of the question under study. Moreover, no evidence of such study which could explore the mental health issues of HIV positive individuals in Pakistan was found during the literature search.
Restatement of Research Question
As part of my thesis, my research question after this review would be: "What mental health issues are prevalent among HIV positive patients in Pakistan, and what is the impact of these mental health issues in their perception, over disease progression and quality of life?"
This could be a mixed methodology, i.e. a combination of qualitative and quantitative approach. Appropriate tools would be selected for assessing specific parts of the research question after validation. Focus group discussions and interviews may be used where relevant to get the responses.
Conclusion
The analysis of the literature reveals that mental health problems are widespread among the known HIV-positive patient population. These problems include but are not limited to stigma, and social isolation, anxiety, major depression, substance abuse, post traumatic stress disorders, social isolation and many more. The findings indicate that significant attention to these issues in context of HIV treatment and prevention must be warranted (Whetten, Reif, Whetten, & Murphy-McMillan, 2008). The high prevalence of these disorders suggests the need for more mental health care facilities for HIV-positive patients especially in less developed and developing countries like Pakistan. There is inadequate counseling and psychiatric services available for this population especially in low income countries. The mental health intervention must not be undermined for these HIV positive individuals. Healthcare agencies must understand the psychosocial and socio cultural context of HIV, ensure treatment adherence and prevention and work at their best to alleviate mental health problems among HIV positive patients. This vulnerable population calls for a suitable position in the society and ensured optimum quality of life.
