HIV infection and mental health: suicidal behaviour--systematic review

Prevalence and Correlates of Suicidal Behaviors among College Students in Northeastern China: a Cross-Sectional Study

The present study aimed to investigate the prevalence and correlates of suicidal behaviors among college students in Jilin Province, China. A cross-sectional survey was conducted in 2016, using a self-reported questionnaire. Convenience sampling method was used to select college students as participants. The analysis was based on a sample of 730 college students. We use multivariate logistic model to determine the risk factors of suicidal behaviors.The prevalence of suicidal ideation, suicidal plan, suicidal attempts were respectively 13.2%, 3.3% and 3.4%. After controlling for the potential confounding factors, history of family psychiatric illness, depression and quality of life were significantly associated with suicidal ideation. Besides, suicidal plan was predicted significantly by not living together with university roommates and depression. In terms of suicidal attempts, not living together with university roommates and history of family psychiatric illness were its risk factors. Comprehensive interventions regarding aims at risk factors may be critical as effective strategies to protect college students from suicide.

Monomorphic ventricular tachycardia due to protease inhibitor intoxication by atazanavir

Atazanavir is a protease inhibitor approved for use in combination with other antiretroviral drugs for the treatment of human immunodeficiency virus infection. Atazanavir and other protease inhibitors can sometimes induce corrected QT prolongation and ventricular arrhythmia. A 40-year-old man with no comorbidities, except human immunodeficiency virus 1 infection, presented with palpitations 3 days after an overdose of 150 caps of atazanavir, with suicidal intent. His initial electrocardiogram showed monomorphic ventricular tachycardia, and hyperbilirubinemia was observed in his initial blood test. Immediately after magnesium sulfate infusion, his ventricular tachycardia was converted into junctional bradycardia with prolonged corrected QT. After 3 days of close observation in the intensive care unit, the corrected QT prolongation and hyperbilirubinemia were normalized.

Trained lay health workers reduce common mental disorder symptoms of adults with suicidal ideation in Zimbabwe: a cohort study

Background

Suicidal ideation may lead to deliberate self-harm which increases the risk of death by suicide. Globally, the main cause of deliberate self-harm is depression. The aim of this study was to explore prevalence of, and risk factors for, suicidal ideation among men and women with common mental disorder (CMD) symptoms attending public clinics in Zimbabwe, and to determine whether problem solving therapy delivered by lay health workers can reduce common mental disorder symptoms among people with suicidal ideation, using secondary analysis of a randomised controlled trial.

Methods

At trial enrolment, the Shona Symptom Questionnaire (SSQ) was used to screen for CMD symptoms. In the intervention arm, participants received six problem-solving therapy sessions conducted by trained and supervised lay health workers, while those in the control arm received enhanced usual care. We used multivariate logistic regression to identify risk factors for suicidal ideation at enrolment, and cluster-level logistic regression to compare SSQ scores at endline (6 months follow-up) between trial arms, stratified by suicidal ideation at enrolment.

Results

There were 573 participants who screened positive for CMD symptoms and 75 (13.1%) reported suicidal ideation at baseline. At baseline, after adjusting for confounders, suicidal ideation was independently associated with being aged over 24, lack of household income (household income yes/no; adjusted odds ratio 0.52 (95% CI 0.29, 0.95); p = 0.03) and with having recently skipped a meal due to lack of food (adjusted odds ratio 3.06 (95% CI 1.81, 5.18); p < 0.001). Participants who reported suicidal ideation at enrolment experienced similar benefit to CMD symptoms from the Friendship Bench intervention (adjusted mean difference − 5.38, 95% CI −7.85, − 2.90; p < 0.001) compared to those who had common mental disorder symptoms but no suicidal ideation (adjusted mean difference − 4.86, 95% CI −5.68, − 4.04; p < 0.001).

Conclusions

Problem-solving therapy delivered by trained and supervised lay health workers reduced common mental disorder symptoms among participants with suicidal thoughts who attended primary care facilities in Zimbabwe.

Trial registration

pactr.org ldentifier: PACTR201410000876178

The Moderating Effect of Smoking Status on the Relation between Anxiety Sensitivity, Sexual Compulsivity, and Suicidality among People with HIV/AIDS

PURPOSE

The present study examined the moderating effect of cigarette smoking status on the relation between anxiety sensitivity (fear of the expected negative consequences of anxiety and bodily sensations) and hazardous alcohol consumption, sexual compulsivity, and suicidality.

METHOD

A series of multiple hierarchical regressions were used to test the proposed hypothesis among a sample of 94 persons living with HIV/AIDS in the USA (64.5 % male, M _age = 48.3, SD = 7.5). Fifty-seven percent of the participants (n = 54) reported past-month smoking.

RESULTS

The results indicated that those who reported smoking and had higher anxiety sensitivity demonstrated the highest rates of hazardous alcohol use, sexual compulsivity, and suicidality. Simple slope analyses indicated that anxiety sensitivity was associated with higher rates of hazardous alcohol use, sexual compulsivity, and suicidality among individuals who reported past-month smoking, but not among individuals who did not smoke.

CONCLUSION

The present results suggest that smoking status moderates the relation between anxiety sensitivity and hazardous alcohol use, sexual compulsivity, and suicidality among persons living with HIV/AIDS. These data add to a growing literature, suggesting that smoking has a negative impact among persons living with HIV/AIDS, which extends beyond physical health problems to a variety of clinically significant behavioral health sequelae.

Interventions and approaches to integrating HIV and mental health services: a systematic review

BACKGROUND

The frequency in which HIV and AIDS and mental health problems co-exist, and the complex bi-directional relationship between them, highlights the need for effective care models combining services for HIV and mental health. Here, we present a systematic review that synthesizes the literature on interventions and approaches integrating these services.

METHODS

This review was part of a larger systematic review on integration of services for HIV and non-communicable diseases. Eligible studies included those that described or evaluated an intervention or approach aimed at integrating HIV and mental health care. We searched multiple databases from inception until October 2015, independently screened articles identified for inclusion, conducted data extraction, and assessed evaluative papers for risk of bias.

RESULTS

Forty-five articles were eligible for this review. We identified three models of integration at the meso and micro levels: single-facility integration, multi-facility integration, and integrated care coordinated by a non-physician case manager. Single-site integration enhances multidisciplinary coordination and reduces access barriers for patients. However, the practicality and cost-effectiveness of providing a full continuum of specialized care on-site for patients with complex needs is arguable. Integration based on a collaborative network of specialized agencies may serve those with multiple co-morbidities but fragmented and poorly coordinated care can pose barriers. Integrated care coordinated by a single case manager can enable continuity of care for patients but requires appropriate training and support for case managers. Involving patients as key actors in facilitating integration within their own treatment plan is a promising approach.

CONCLUSION

This review identified much diversity in integration models combining HIV and mental health services, which are shown to have potential in yielding positive patient and service delivery outcomes when implemented within appropriate contexts. Our review revealed a lack of research in low- and middle- income countries, and was limited to most studies being descriptive. Overall, studies that seek to evaluate and compare integration models in terms of long-term outcomes and cost-effectiveness are needed, particularly at the health system level and in regions with high HIV and AIDS burden.

Association between serotonin transporter gene polymorphisms and increased suicidal risk among HIV positive patients in Uganda

BACKGROUND

Persons living with HIV/AIDS (PLWHA) are at an increased risk of suicide. Increased suicidal risk is a predictor of future attempted and completed suicides and has been associated with poor quality of life and poor adherence with antiretroviral therapy. Clinical risk factors have low predictive value for suicide, hence the interest in potential neurobiological correlates and specific heritable markers of suicide vulnerability. The serotonin transporter gene has previously been implicated in the aetiology of increased suicidal risk in non-HIV infected study populations and its variations may provide a platform for identifying genetic risk for suicidality among PLWHA. The present cross-sectional study aimed at identifying two common genetic variants of the serotonin transporter gene and their association with increased suicidal risk among human immunodeficiency virus (HIV)-positive adults in Uganda.

RESULTS

The prevalence of increased suicidal risk (defined as moderate to high risk suicidality on the suicidality module of the Mini Neuropsychiatric Interview (M.I.N.I) was 3.3% (95% CI, 2.0-5.3). The 5-HTTLPR was found to be associated with increased suicidal risk before Bonferroni correction (p-value = 0.0174). A protective effect on increased suicidal risk was found for the 5-HTTLPR/rs25531 S A allele (p-value = 0.0046)- which directs reduced expression of the serotonin transporter gene (5-HTT).

CONCLUSION

The S A allele at the 5-HTTLPR/rs25531 locus is associated with increased suicidal risk among Ugandan PLWHA. Further studies are needed to validate this finding in Ugandan and other sub-Saharan samples.

HIV infection and its psychiatric manifestations: A clinical overview

Highly active antiretroviral therapy (HAART) has led to a reduction in HIV-related morbidity and mortality, and the life expectancy of HIV-positive individuals has improved significantly. It is therefore becoming more likely that clinicians will encounter patients with psychiatric manifestations of the disease. This review summarises the evidence on prevalence, manifestations and treatment of psychiatric conditions in HIV-positive adults. The most prevalent psychiatric illness in this population is depression (35.6%), followed by substance misuse, anxiety, psychosis, adjustment disorder and bipolar affective disorder. Neurocognitive impairment is also common, ranging in severity from asymptomatic (the most frequent) to dementia (the least frequent). Effective treatment of both HIV and psychiatric manifestations is essential to maximising life expectancy and quality of life.

Learning Objectives

• Comprehend the prevalence, manifestations and treatment of psychiatric conditions in HIV-positive individuals

• Learn about the HIV-associated neurocognitive disorders

• Develop an understanding of the relationship between HIV infection and psychiatric symptoms

Psychiatric Symptoms in Patients Receiving Dolutegravir

INTRODUCTION

Psychiatric symptoms (PSs) are reported to occur frequently in people living with HIV and may be associated with specific antiretrovirals. We analyzed PSs observed with dolutegravir (DTG) and other frequently prescribed anchor drugs.

METHODS

Selected PSs (insomnia, anxiety, depression, and suicidality) occurring in HIV-positive patients during DTG treatment across 5 randomized clinical trials (3 double-blind), in the Observational Pharmaco-Epidemiology Research & Analysis (OPERA) cohort, and among cases spontaneously reported to ViiV Healthcare were analyzed.

RESULTS

In clinical trials, PSs were reported at low and similar rates in patients receiving DTG or comparators [atazanavir, darunavir, efavirenz, or raltegravir (RAL)]. Insomnia was most commonly reported. The highest rates were observed in SINGLE (DTG 17%, efavirenz 12%), with consistently lower rates in the other trials (DTG: 3%-8% versus comparator: 3%-7%). More efavirenz-treated patients withdrew because of PSs than patients treated with other anchor drugs. In OPERA, history of PSs at baseline was lowest in efavirenz-treated patients compared with patients treated with DTG, RAL, or darunavir. Despite baseline differences, prevalence and incidence during treatment were similar across the 4 anchor drugs. Withdrawal rates for PSs were lowest for DTG (0%-0.6%) and highest for RAL (0%-2.5%). Spontaneously reported events were similar in nature to clinical trial data.

CONCLUSIONS

Analysis of 3 different data sources shows that, similar to other frequently prescribed anchor drugs to treat HIV infection, PSs are also reported in DTG-treated patients. These events are reported with low frequency and rarely necessitate DTG discontinuation.

Suicidal behaviors among newly diagnosed people living with HIV in Changsha, China

Newly-diagnosed people living with HIV (NPLWH) are at high risk of suicide. We aimed to evaluate the prevalence of suicidal behaviors among NPLWH, and explore the relationships between HIV-related stress, depression, anxiety, and social support and suicidal ideation after diagnosed with HIV infection. A cross-sectional study was conducted using a standard set of questionnaires during 1 March 2013 and 30 September 2014 in the HIV/AIDS Voluntary Counseling and Testing Clinic of the Changsha Center for Disease Control and Prevention. Among 557 NPLWH, 27.5% (n = 153) had lifetime suicidal ideation, and 25.0% (n = 139) had suicidal ideation after HIV diagnosis. The results of multiple regression analyses indicated that suicidal ideation after HIV diagnosis was associated with HIV-related clinical symptoms (OR = 2.50), HIV-related stress (OR = 3.64), the co-morbidity of positive depressive and anxiety symptoms (OR = 3.30), and social support (OR = 0.52). Overall, the prevalence of suicidal behaviors is high among NPLWH in Changsha emphasizing the need of suicidality monitoring and tracking, depression and anxiety screening, with an additional focus on stress management and social support enhancement in this vulnerable group.

Depression, suicidality, and alcohol use disorder among people living with HIV/AIDS in Nigeria

BACKGROUND

People Living with HIV/AIDS (PLHIV) face various day-to-day and long-term personal, interpersonal, social, physical and psychological challenges as a result of, and in addition to the health conditions they are susceptible to due to their HIV status. There is a dearth of large-scale research to provide robust prevalence estimates of mental health problems among PLHIV, especially in Nigeria. This study aimed to ascertain the prevalence and factors associated with major depressive episodes, suicidality, and alcohol use disorder among people living with HIV/AIDS in Nigeria.

METHODS

A survey of 1187 participants aged 18 years and above was conducted within three HIV treatment centres in Abuja, Nigeria. Depression, suicidality, and alcohol use disorder modules of the WHO World Mental Health Composite International Diagnostic Interview questionnaire were used for this study. A socio-demographic questionnaire was also used to collect other health and demographic data. Descriptive statistics (frequency distribution, percentage, mean, median, mode, and standard deviation) and regression analyses were conducted to explore associations between mental health problems and demographic and other health-related factors.

RESULTS

Twelve-month prevalence rates were 28.2% for major depressive episodes, 2.9% for suicidal ideation, 2.3% for suicide attempts, 7.8% for harmful alcohol use, 7.0% for alcohol abuse, and 2.2% for alcohol dependence. Major depressive episodes were significantly associated with having planned suicide and marital status. Suicidal ideation was significantly associated with major depressive episodes, marital status, and religion. Females were less likely to be diagnosed with alcohol disorders.

CONCLUSIONS

Some people living with HIV/AIDS also tend to suffer from depression, suicidality, and alcohol use disorders. These findings highlight the need for the integration of mental health services into HIV/AIDS care in Nigeria.

Suicidal Ideation is Associated with Limited Engagement in HIV Care

PHQ-9 data from persons living with HIV (PLWH, n = 4099) being screened for depression in three clinics in the southeastern USA were used to determine the prevalence of suicidal ideation (SI). SI was reported by 352 (8.6 %); associated with <3 years since HIV diagnosis (1.69; 95 %CI 1.35, 2.13), and HIV RNA >50 copies/ml (1.70, 95 %CI 1.35, 2.14). Data from PLWH enrolled in a depression treatment study were used to determine the association between moderate-to-high risk SI (severity) and SI frequency reported on PHQ-9 screening. Over forty percent of persons reporting that SI occurred on "more than half the days" (by the PHQ-9) were assessed as having a moderate-to-high risk for suicide completion during the Mini International Neuropsychiatric Interview. SI, including moderate-to-high risk SI, remains a significant comorbid problem for PLWH who are not fully stabilized in care (as indicated by detectable HIV RNA or HIV diagnosis for less than 3 years).

Suicidal Behavior Among People Living with HIV (PLHIV) in Medical Care in Estonia and Factors Associated with Receiving Psychological Treatment

People living with HIV (PLHIV) have higher rates of suicidal behavior than the general population. This study assessed suicidal behavior (ideation and/or attempts, ever and in the past 12 months) among PLHIV receiving outpatient HIV medical care in Estonia and associations between suicidal behavior and psychological treatment. The cross-sectional study collected data from January to November 2013 using a self-report questionnaire. Eight hundred PLHIV participated, 39 % (n = 306) of whom had been suicidal. Lifetime prevalence was 36 % for suicidal ideation and 20 % for attempts. Younger age, incarceration, having ever abused alcohol and also injected drugs, having lived with HIV for more than 10 years, and being depressed were associated with lifetime suicidal behavior. Suicidal behavior within the past 12 months was reported by 20 % (n = 156) of respondents. Of these, 27 % received psychological treatment (counseling and/or psychotherapy), 20 % had taken antidepressants, and 49 % sedatives. Individuals perceiving a need for treatment were significantly more likely to receive psychological treatment when experiencing suicidal behavior (OR 25.65, 95 % CI 2.92-225.47). In conclusion, suicidal behavior is frequent among PLHIV but psychological treatment is not often received. One of the barriers to treatment is patients' lack of perceived need for help.

Suicidal Ideation, Resilience, and Healthcare Implications for Newly Diagnosed HIV-Positive Men Who Have Sex with Men in China: A Qualitative Study

Globally, suicidal ideation and behavior have been widely reported among people living with human immunodeficiency virus (HIV). Knowledge gaps exist regarding the longer life and resilience-related experiences of people living with HIV (PLWH). Specifically, there is a dearth of data about the interaction of perceived risk and resilient factors resulting in a wide spectrum of intentional suicidal ideation outcomes in a Chinese cultural context. This qualitative research drew from a larger ethnographic study of newly diagnosed HIV-positive men who have sex with men (MSM) in Mainland China. Interviews were conducted with 31 MSM within 6 months of diagnosis of HIV infection. Initial suicidal ideation was commonly reported with participants subsequently feeling more resilient to these thoughts through gaining a greater understanding of their prognosis and treatment. Post-HIV diagnosis, some participants reported forming new relationships and receiving increased support from their partners, friends, peers, families, and community-based organizations. At follow-up, these participants generally reported suicidal ideation had declined. However, participants who continued to express suicidal ideation perceived extended pressure from their families' expectations for them to engage in heterosexual marriages and parenthood. Furthermore, these men reported ongoing hardships in their daily life, unemployment, lack of social support, and isolation. Among this Mainland Chinese cohort of HIV-positive MSM, suicidal ideation may be a transient phenomenon experienced initially following HIV diagnosis that resolves with increased and specific familial, social, and service-based support. It is crucial to identify the causes of stress and social suffering associated with HIV diagnosis in order to reduce suicidal ideation. In China, action is needed to develop routine mental health screening and to increase services that support PLWH. Important services mechanism to accomplish this are promoting resilience through intentional activities as well as continued public health campaigns to reduce stigma toward HIV-positive MSM.

Prevalence and Associated Factors of Suicidal Ideation and Attempt among People Living with HIV/AIDS at Zewditu Memorial Hospital, Addis Ababa, Ethiopia: A Cross-Sectional Study

Background. Human Immune Deficiency Virus (HIV/AIDS) continues to be an underrecognized risk for suicidal ideation, suicidal attempt, and completion of suicide. Suicidal ideation and attempt in HIV/AIDS is not only a predictor of future attempted suicide and completed suicide. Methods. An institution based cross-sectional study was conducted among HIV-positive patients attending HIV care at Zewditu Memorial Hospital. Systematic random sampling technique was used to recruit 423 participants from April to May 2014. Composite International Diagnostic Interview was used to collect data. Multivariable logistic regression was computed to assess factors associated with suicidal ideation and attempt. Result. Suicidal ideation and suicidal attempt were found to be 22.5% and 13.9%, respectively. WHO clinical stage of HIV, not being on HAART, depression, family history of suicidal attempt, and perceived stigma were associated with suicidal ideation. WHO clinical stage, being female, not being on HAART, use of substance, and depression were associated with suicidal attempt. Conclusion. Early diagnosis and treatment of opportunistic infections, depression, and early initiation of ART need to be encouraged in HIV-positive adults. Furthermore, counseling on substance use and its consequences and early identification of HIV-positive people with family history of suicidal ideation have to be considered.

Enhancing Public Health HIV Interventions: A Qualitative Meta-Synthesis and Systematic Review of Studies to Improve Linkage to Care, Adherence, and Retention

Although HIV services are expanding, few have reached the scale necessary to support universal viral suppression of individuals living with HIV. The purpose of this systematic review was to summarize the qualitative evidence evaluating public health HIV interventions to enhance linkage to care, antiretroviral drug (ARV) adherence, and retention in care. We searched 19 databases without language restrictions. The review collated data from three separate qualitative evidence reviews addressing each of the three outcomes along the care continuum. 21,738 citations were identified and 24 studies were included in the evidence review. Among low and middle-income countries in Africa, men living with HIV had decreased engagement in interventions compared to women and this lack of engagement among men also influenced the willingness of their partners to engage in services. Four structural issues (poverty, unstable housing, food insecurity, lack of transportation) mediated the feasibility and acceptability of public health HIV interventions. Individuals living with HIV identified unmet mental health needs that interfered with their ability to access HIV services. Persistent social and cultural factors contribute to disparities in HIV outcomes across the continuum of care, shaping the context of service delivery among important subpopulations.

Stigma and suicide among gay and bisexual men living with HIV

HIV positive gay and bisexual men (GBM) continue to struggle with the pervasiveness of HIV stigma, but little is known about the health effects of stigma. In this article, suicidal ideation and attempts are measured among GBM living with HIV, evaluating the extent to which these experiences are associated with stigma and suicide. Drawing from an online national survey of Canadian GBM completed by 7995 respondents, a sub-set of data provided by respondents self-reporting HIV-positive status was used for the current study. The associations between suicidal ideation (SI) and attempts (SA) and four measures of HIV stigma were measured: social exclusion, sexual rejection, verbal abuse and physical abuse. A total of 673 HIV-positive men completed the survey (8% of total sample). Among this group, 22% (n = 150) reported SI and 5% (n = 33) SA in the last 12 months. After adjusting for sociodemographic factors, SI and SA were associated with each of the four measures of HIV stigma: being excluded socially for being HIV positive (SI adjusted odds ratio, AOR 2.0 95% CI 1.4-3.1; SA AOR 3.8 95% CI 1.9-7.9), rejected as a sexual partner (SI AOR 1.6 95% CI 1.1-2.4; SA AOR 2.6 95% CI 1.1-6.0), verbally abused (SI AOR 2.9 95% CI 1.9-4.5; SA AOR 2.4 95% CI 1.1-5.1), and physically abused (SI AOR 4.5 95% CI 1.8-11.7; SA AOR 6.4 95% CI 2.0-20.1). Furthermore, experiencing multiple forms of stigma was associated with significantly increased risk of SI and SA. The authors conclude that HIV positive GBM experience significant levels of stigma that are associated with heightened risk for suicide. The findings affirm the need for targeted interventions to prevent suicide amid public health efforts to de-stigmatize HIV and mental illness.

Prevalence and psychosocial correlates of suicidal ideation among pregnant women living with HIV in Mpumalanga Province, South Africa

Pregnant women living with HIV (WLHIV) in South Africa (SA) report higher rates of suicidal ideation than those who are HIV uninfected, and antenatal suicidal ideation has been previously associated with adverse maternal and neonatal outcomes. Few studies have attempted to identify correlates and psychosocial predictors of suicidal ideation in this population. In this study, we sought to estimate the prevalence of and identify risk factors for suicidal ideation among pregnant WLHIV in rural SA (N = 673). Thirty-nine percent of women endorsed suicidal ideation (95% CI: 35.2% to 42.3%) and in multivariable logistic regression analysis, suicidal ideation was associated with intimate partner violence and stigma, which interacted to multiplicatively increase the odds of suicidal thoughts. Given the high rates of reported suicidal ideation identified in this sample, and the potential harm to mothers and neonates, suicide risk assessment and management protocols for pregnant WLHIV should be considered for inclusion in the standard of care in rural SA.

Suicidal ideation among MSM in three West African countries: Associations with stigma and social capital

BACKGROUND

Suicidal ideation is understudied among men who have sex with men (MSM) across Sub-Saharan Africa.

AIMS

This study aimed to explore social capital and sexual behavior stigma associated with suicidal ideation among MSM in the West African nations of The Gambia, Burkina Faso and Togo.

METHODS

Participants were recruited using respondent-driven sampling and snowball sampling across multiple cities (n = 1555) from July 2011 to August 2013. During a single study visit, participants completed a survey. Logistic regression models were used to assess bivariate and multivariable associations with suicidal ideation.

RESULTS

The prevalence of lifetime suicidal ideation was 13% overall and ranged 6%-17% across study sites. After adjusting for potential confounders, MSM who reported stigma as a result of having sex with men were more likely to report suicidal ideation. Physical and sexual violence was strongly associated with suicidal ideation, including being physically harmed (adjusted odds ratio (aOR) = 2.94, 95% confidence interval (CI) = 1.91, 4.52), tortured (aOR = 3.86, 95% CI = 2.17, 6.86) and raped (aOR = 3.07, 95% CI = 2.05, 4.60). In contrast, increasing social participation with the broader community was associated with decreased report of suicidal ideation (aOR = 0.91, 95% CI = 0.85, 0.99).

CONCLUSION

Sexual behavior stigma should be addressed to improve mental health among MSM in Western Sub-Saharan Africa.

Experience of sexual self-esteem among men living with HIV

Much of the focus on sexual health for people living with HIV has been on promoting safe sex behaviours. However, also important for sexual health is a positive sexual self-esteem. This article reports on an interpretative phenomenological analysis of interviews with seven men about the impact that having HIV has had on their sense of sexual self. Five overarching themes were identified: the 'destruction' of a sexual self; feeling sexually hazardous; sexual inhibition; reclaiming a sexual self and finding a place through sero-sorting. With HIV now being a chronic illness, interventions are required to support people to lead sexually satisfying lives.

The Mental Health of People Living with HIV in China, 1998-2014: A Systematic Review

BACKGROUND

Understanding the mental health burdens faced by people living with HIV in China is instrumental in the development of successful targeted programs for psychological support and care.

METHODS

Using multiple Chinese and English literature databases, we conducted a systematic review of observational research (cross-sectional, case-control, or cohort) published between 1998 and 2014 on the mental health of people living with HIV in China.

RESULTS

We identified a total of 94 eligible articles. A broad range of instruments were used across studies. Depression was the most widely studied problem; the majority of studies reported prevalence greater than 60% across research settings, with indications of a higher prevalence among women than men. Rates of anxiety tended to be greater than 40%. Findings regarding the rates of suicidality, HIV-related neurocognitive disorders, and substance use were less and varied. Only one study investigated posttraumatic stress disorder and reported a prevalence of 46.2%. Conflicting results about health and treatment related factors of mental health were found across studies.

CONCLUSIONS

Despite limitations, this review confirmed that people living with HIV are vulnerable to mental health problems, and there is substantial need for mental health services among this population.

Mental health among men who have sex with men in Cambodia: Implications for integration of mental health services within HIV programmes

Background

Poor mental health contributes to poor HIV prevention, treatment and care outcomes. This paper documents factors associated with psychological distress among men who have sex with men (MSM) in Cambodia and discusses potential ways in which routine mental health management could be integrated into HIV services.

Methods

A cross-sectional study was conducted in 2014 among 394 MSM randomly selected from two provinces using a two-stage cluster sampling method. A structured questionnaire was used to assess psychological distress, sexual behaviors, substance use, adverse childhood experiences and family dysfunction. Multivariate logistic regression analysis was performed to explore factors associated with levels of psychological distress.

Results

In total, 10.7 % of the respondents reported having suicidal thoughts and 6.6 % reported having attempted to commit suicide in the past three months, while 38.8 % had a higher level of psychological distress (GHQ-12 > 3), which indicates poor mental health. Higher levels of psychological distress were independently associated with older age (AOR = 1.09, 95 % CI 1.03–1.14), alcohol use (AOR = 3.3, 95 % CI 1.36–7.83), illicit drug use (AOR = 3.53, 95 % CI 1.12–11.18), poor self-reported quality of life (AOR = 7.45, 95 % CI 1.79–3.04), and reduced condom use at last sex (AOR = 0.40, 95 % CI 0.21–0.73). MSM with higher levels of psychological distress were significantly more likely to report that a family member said hurtful things to them (AOR = 1.80, 95 % CI 1.10–2.97), a parent or guardian had been physically abused (AOR = 3.51, 95 % CI 1.86–6.62), and a family member had been mentally ill (AOR = 4.01, 95 % CI 2.06–7.81) when they were growing up.

Conclusions

In order to mitigate psychological distress among MSM in Cambodia, integration of mental health interventions within HIV programmes should be strengthened. To achieve optimal impact, these interventions should also address alcohol and other substance use, and low condom use among distressed MSM. In addition, training of clinical and non-clinical HIV service providers to screen for mental health symptoms, and subsequent provision of peer-based outreach and social support for MSM identified with psychological distress is required.

Adherence to HIV/AIDS antiretroviral therapy among drug users: A qualitative study in Iran

Background:

The introduction of antiretroviral therapy has caused a remarkable decrease in the occurrence of diseases and mortality among HIV-positive patients, while this success has not been achieved among injection addicts due to a low adherence to antiretroviral medicine. This study aims at clarifying the important factors affecting adherence to treatment in addicts suffering from HIV.

Materials and Methods:

In this qualitative research, data were gathered through in-depth interviews and field notes, and were interpreted through content analysis in the form of constant comparison. The participants were 16 drug addicts living with HIV/AIDS. Most of them had records of imprisonment and were receiving Highly Active Antiretroviral Therapy (HAART) drug treatments in the AIDS center of Imam Khomeini Hospital complex, affiliated to Tehran University of Medical Sciences. Sampling was started in a purposive method and was continued until data were saturated.

Results:

Four main categories including psychological reactions, contradictory beliefs, perceived support, and individual and environmental barriers were extracted from the data, each having some sub-categories.

Conclusions:

The obtained results indicated that adherence to the treatment of HIV is not constant and mono-dimensional, but is a function of different factors. Hence, an individual having feeble adherence in a specific time and under specific circumstances may show desirable adherence under a different circumstance. Thus, treatment of addicts living with HIV/AIDS requires physical, psychological, and social attention along with drug treatments.

Mechanisms Influencing Circadian Blood Pressure Patterns Among Individuals with HIV

HIV+ individuals have an increased risk for cardiovascular disease (CVD), but the mechanisms behind this association are poorly understood. While hypertension is a well-established CVD risk factor, clinic-based blood pressure (BP) assessment by itself cannot identify several important BP patterns, including white coat hypertension, masked hypertension, nighttime hypertension, and nighttime BP dipping. These BP patterns can be identified over a 24-h period by ambulatory BP monitoring (ABPM). In this review, we provide an overview of the potential value of conducting ABPM in HIV+ individuals. ABPM phenotypes associated with increased CVD risk include masked hypertension (i.e., elevated out-of-clinic BP despite non-elevated clinic BP), nighttime hypertension, and a non-dipping BP pattern (i.e., a drop in BP of <10 % from daytime to nighttime). These adverse ABPM phenotypes may be highly relevant in the setting of HIV infection, given that increased levels of inflammatory biomarkers, high psychosocial burden, high prevalence of sleep disturbance, and autonomic dysfunction have been commonly reported in HIV+ persons. Additionally, although antiretroviral therapy (ART) is associated with lower AIDS-related morbidity and CVD risk, the mitochondrial toxicity, oxidative stress, lipodystrophy, and insulin resistance associated with long-term ART use potentially lead to adverse ABPM phenotypes. Existing data on ABPM phenotypes in the setting of HIV are limited, but suggest an increased prevalence of a non-dipping BP pattern. In conclusion, identifying ABPM phenotypes may provide crucial information regarding the mechanisms underlying the excess CVD risk in HIV+ individuals.

No Evidence of an Association Between Efavirenz Exposure and Suicidality Among HIV Patients Initiating Antiretroviral Therapy in a Retrospective Cohort Study of Real World Data

Recently, published studies have reported conflicting results regarding the association between efavirenz exposure and the risk of suicidality among patients with human immunodeficiency virus. The objective of this analysis was to compare the rate of suicidality among patients initiating efavirenz-containing versus efavirenz-free antiretroviral (ARV) regimens.This retrospective cohort study used US administrative claims data for commercially and Medicaid-insured individuals for the years 2006 to 2013. ARV-naive patients aged ≥12 years initiating an efavirenz-containing or efavirenz-free ARV regimen with ≥6 months of continuous insurance enrollment prior to ARV initiation were selected. The primary outcome was suicidality, defined as the occurrence of any medical claim with a diagnosis code for suicidal ideation or an inpatient or emergency department medical claim for suicide attempt. Unadjusted incidence rates were calculated and propensity score-adjusted hazard ratios were estimated to account for differences in patient characteristics.There were 19,983 patients (efavirenz-containing, n = 11,187; efavirenz-free, n = 8796) in the commercial database and 5154 patients (efavirenz-containing, n = 2224; efavirenz-free, n = 2930) in the Medicaid database. Unadjusted incidence rates (95% confidence interval [CI]) of suicidality per 1000 person-years were: commercial, efavirenz-containing (3.3 [2.4-4.4]), efavirenz-free (4.0 [2.7-5.8]); Medicaid, efavirenz-containing (25.7 [18.8-34.4]), efavirenz-free (40.6 [31.9-50.9]). In propensity score-adjusted analyses, efavirenz use was not associated with suicidality: adjusted hazard ratio (95% CI) of suicidality compared with efavirenz-free regimen, commercial, 1.029 (0.636-1.665); Medicaid, 0.902 (0.617-1.319).This analysis found no conclusive evidence of an increased risk of suicidality among patients initiating an efavirenz-containing ARV regimen. However, channeling bias may exist even after adjusting for measured patient characteristics.

Suicidal Behavior and Associations with Quality of Life among HIV-Infected Patients in Ibadan, Nigeria

BACKGROUND

Suicidality has rarely been studied in HIV-infected patients in sub-Saharan Africa. This study explored suicidal behavior in a clinic sample of people living with HIV, in Nigeria.

METHODS

Consecutive patients were interviewed using the Composite International Diagnostic Interview (CIDI-10.0) and the World Health Organization Quality of Life (WHO-QOL-HIV-BREF). Associations of suicidal behavior were explored using logistic regression models.

RESULTS

In this sample of 828 patients (71% female, mean age 41.3 ± 10 years), prevalence of suicidal behaviors were 15.1%, 5.8%, and 3.9% for suicidal ideation, plans, and attempts, respectively. Women were more likely than men to report suicidal ideation (odds ratio 1.7; 95% confidence interval 1.05-2.64). Depression and/or anxiety disorder was associated with increased odds of all suicidal behaviors. Suicidal behavior was associated with significantly lower overall and domain scores on the WHO-QOL.

CONCLUSION

Suicidal behaviors were common and significantly associated with the presence of mental disorders and lower quality of life.

Listening to Our Patients: Learning About Suicide Risk and Protective Factors From Veterans With HIV/AIDS

PURPOSE

We sought to gather perspectives of veterans with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) regarding suicide risk factors, warning signs, and protective factors. We also aimed to modify an existing Veterans Health Administration tool, the Suicide Risk Assessment Guide Pocket Card, for HIV/AIDS provider use.

METHODS

Twenty male veterans participated in audio-recorded semistructured interviews that were transcribed and coded for themes.

FINDINGS

Veterans highlighted personally relevant psychosocial stressors (i.e., poverty, social isolation and loneliness, and physical health). Although the concept of warning signs did not seem salient to participants, they named indicators of elevated imminent risk for self-directed violence (i.e., "relapse," "not take'n medications," and "miss'n appointments") and few protective factors. No themes emerged regarding recommended pocket card changes.

CONCLUSIONS

This sample of veterans identified self-directed violence risks noted in the general population and others with HIV/AIDS, as well as proximal events associated with increased risk. Care providers are encouraged to explore the relevance of noted imminent and persistent indicators of increased risk with veterans seeking care.

Child and Adolescent Suicide Attempts, Suicidal Behavior, and Adverse Childhood Experiences in South Africa: A Prospective Study

PURPOSE

This is the first known prospective study of child suicidal behavior in sub-Saharan Africa. Aims were to determine whether (1) cumulative exposure to adverse childhood experiences (ACEs) predicts later suicidality and (2) heightened risks are mediated by mental health disorder and drug/alcohol misuse.

METHODS

Longitudinal repeated interviews were conducted 1 year apart (97% retention) with 3,515 adolescents aged 10-18 years in South Africa (56% female; <2.5% refusal). Random selection of census enumeration areas from urban/rural sites within two provinces and door-to-door sampling included all homes with a resident adolescent. Measures included past-month suicide attempts, planning, and ideation, mental health disorders, drug/alcohol use, and ACE, for example, parental death by AIDS or homicide, abuse, and exposure to community violence. Analyses included multivariate logistic regression and multiple mediation tests.

RESULTS

Past-month suicidality rates were 3.2% of adolescents attempting, 5.8% planning, and 7.2% reporting ideation. After controlling for baseline suicidality and sociodemographics, a strong, graded relationship was shown between cumulative ACE and all suicide behaviors 1 year later. Baseline mental health, but not drug/alcohol misuse, mediated relationships between ACE and subsequent suicidality. Suicide attempts rose from 1.9% among adolescents with no ACE to 6.3% among adolescents with >5 ACEs (cumulative odds ratio [OR], 2.46; confidence interval [CI], 1.00-6.05); for suicide planning, from 2.4% to 12.5% (cumulative OR, 4.40; CI, 2.08-9.29); and for suicide ideation, from 4.2% to 15.6% (cumulative OR, 2.99; CI, 1.68-5.53).

CONCLUSIONS

Preventing and mitigating childhood adversities have the potential to reduce suicidality. Among adolescents already exposed to adversities, effective mental health services may buffer against future suicidality.

Suicide mortality among people accessing highly active antiretroviral therapy for HIV/AIDS in British Columbia: a retrospective analysis

BACKGROUND

Suicide rates have been reported at elevated levels among people living with HIV/AIDS. We sought to characterize longitudinal suicide rates among people living with HIV/AIDS who are accessing free highly active antiretroviral treatment (HAART) in British Columbia and evaluate the sociodemographic, clinical and behavioural factors associated with suicide in this population.

METHODS

Retrospective analysis of all patients in the HAART Observational Medical Evaluation and Research (HOMER) cohort who were 19 years of age and older who started treatment between August 1996 and June 2012. The primary outcome variable was death due to suicide. Data on deaths were obtained monthly through a linkage with the British Columbia Ministry of Health Vital Statistics Agency. Logistic regression and Cox proportional hazards models were used to identify factors independently associated with suicide mortality.

RESULTS

A total of 993 deaths among 5229 patients accessing treatment were recorded, of which 82 (8.2%) were caused by suicide. Death from suicide peaked at 961 deaths per 100 000 person-years in 1998 and declined to 2.81 deaths per 100 000 person-years in 2010. Cox regression analysis showed that a history of injection drug use (adjusted hazard ratio [AHR] = 3.95, 95% confidence interval [CI] 1.99-7.86) or having no experience with an AIDS-defining illness (AHR = 4.45, 95% CI 1.62-12.25) were factors independently associated with suicide. This model showed a 51% reduction (AHR = 0.49, 95% CI 0.45-0.54) in the suicide rate per calendar year.

INTERPRETATION

Deaths from suicide declined substantially over time, and factors other than progression of HIV disease, such as injection drug use, may be important targets for intervention to reduce suicide risk.

Social support as a protective factor for depression among women caring for children in HIV-endemic South Africa

Social support has been shown to be a protective resource for mental health among chronically ill adults and caregiver populations. However, to date no known studies have quantitatively explored the relationship between social support and depression among women caring for children in HIV-endemic Southern Africa, although they represent a high risk population for mental health conditions. Using data from a household survey with 2,199 adult female caregivers of children, living in two resource-deprived high HIV-prevalence South African communities, we conducted hierarchical logistic regression analysis with interaction terms to assess whether social support had a main effect or stress-buffering effect on depression. Findings provide evidence of stress-buffering of non-HIV-related chronic illness, but not HIV-related illness. Results reinforce the importance of social support for the mental health of chronically ill caregivers, and suggest that factors related to the specific nature of HIV/AIDS may be hindering the potential stress-buffering effects of social support among people living with the disease. Implications for future research and interventions are discussed.

Undertreatment of human immunodeficiency virus in psychiatric inpatients: a cross-sectional study of seroprevalence and associated factors

BACKGROUND

The aims of this study were to evaluate the prevalence of HIV and its associated demographic and clinical factors among psychiatric inpatients of a general hospital.

METHODS

This was a single-center, observational, cross-sectional study that included patients consecutively admitted to our unit aged 16 years or older and with no relevant cognitive problems. The patients were evaluated using a semistructured interview and an appropriate test for HIV infection.

RESULTS

Of the 637 patients who were screened, 546 (86%) who consented to participate were included in the analyses. Twenty-five (4.6%, 95% confidence interval [CI] 3.0-6.8) patients were HIV-positive. The prevalence was higher among patients with substance misuse (17.4%, 95% CI 9.7-28.8). All except one of the 25 patients knew of their seropositive condition prior to participation in the study. Only 14 (56%) of the 25 seropositive patients had previously received pharmacological treatment for their infection. According to the multiple logistic regression analysis, the likelihood of HIV infection was lower in patients with higher levels of education and higher among patients who were single, had history of intravenous drug use, and had an HIV-positive partner, particularly if they did not use condoms. Among the patients with HIV infection, 18 (72%) had a history of suicide attempts compared with 181 (34.7%) of the patients without HIV infection (relative risk 2.1, 95% CI 1.6-2.7; P<0.001).

CONCLUSION

HIV infection is highly prevalent in patients admitted to a psychiatric unit, especially those with a diagnosis of substance misuse. Seropositive patients show very poor treatment adherence. The risk of suicide seems to be very high in this population. Implementing interventions to reduce the suicide risk and improve adherence to antiretroviral therapy and psychotropic medications seems crucial.

Elevated Risk of Suicidal Ideation in HIV-Positive Persons

Globally, suicide and HIV/AIDS remain two of the greatest healthcare issues, particularly in low- and middle-income countries. Several studies have observed a relationship between suicidal behaviour and HIV/AIDS. Materials and Methods. The main objective of this research was to determine the prevalence of elevated risk of suicidal ideation in HIV-positive persons immediately following voluntary HIV counselling and testing (VCT). The study sample consisted of adult volunteers attending the VCT clinic at a university-affiliated, general state hospital. Participants completed a sociodemographic questionnaire, Beck's Hopeless Scale, and Beck's Depression Inventory. Results. A significantly elevated risk of suicidal ideation was found in 83.1% of the patients who tested seropositive. Despite a wide age range in the cohort studied, the majority of patients with suicidal ideation were males in the younger age group (age < 30 years), consistent with the age-related spread of the disease and an increase in suicidal behaviour in younger people. Relevant associated variables are discussed. Conclusion. The results serve as important markers that could alert healthcare professionals to underlying suicide risks in HIV-positive patients. It is recommended that screening for elevated risk of suicidal ideation and prevention of suicidal behaviour should form a routine aspect of comprehensive patient care at VCT clinics.

Evidence of impact: health, psychological and social effects of adult HIV on children

There is a growing evidence base on the immediate and short-term effects of adult HIV on children. We provide an overview of this literature, highlighting the multiple risks and resultant negative consequences stemming from adult HIV infection on the children they care for on an individual and family basis. We trace these consequences from their origin in the health and wellbeing of adults on whom children depend, through multiple pathways to negative impacts for children. As effective treatment reduces vertical transmission, the needs of affected children will predominate. Pathways include exposure to HIV in utero, poor caregiver mental or physical health, the impact of illness, stigma and increased poverty. We summarize the evidence of negative consequences, including those affecting health, cognitive development, education, child mental health, exposure to abuse and adolescent risk behaviour, including sexual risk behaviour, which has obvious implications for HIV-prevention efforts. We also highlight the evidence of positive outcomes, despite adversity, considering the importance of recognizing and supporting the development of resilience. This study is the first in a series of three commissioned by President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID), the summary provided here was used to inform a second study which seeks to identify insights from the broader child development field which will help us predict what long-term negative consequences children affected by HIV and AIDS are likely to experience. The third study discusses the design of a model to estimate these consequences. Although comprehensive, the review is often hampered by poor-quality research, inadequate design, small sample sizes and single studies in some areas.

Mental health of carers of children affected by HIV attending community-based programmes in South Africa and Malawi

There is strong evidence that both adults and children infected with and affected by HIV have high levels of mental health burden. Yet there have been few studies investigating carer mental health outcomes in the context of HIV in Malawi and South Africa. The objective of this study was to assess the mental health of carers of children affected by HIV as a part of the Child Community Care study, which aims to generate evidence on the effectiveness of community-based organisation (CBO) services to improve child outcomes. In a cross-sectional study, we interviewed 952 carers of children (aged 4-13 years) attending 28 randomly selected CBOs funded by 11 major donors in South Africa and Malawi. Psychological morbidity was measured using the Shona Symptom Questionnaire and suicidal ideation was measured using an item from the Patient Health Questionnaire. Carers were asked about care-seeking for emotional problems. Overall, 28% of carers scored above the clinical cut-off for current psychological morbidity and 12.2% reported suicidal ideation. We used logistic regression models to test factors associated with poor outcomes. Household unemployment, living with a sick family member and perceived lack of support from the community were associated with both psychological morbidity and suicidal ideation in carers. Reported child food insecurity was also associated with psychological morbidity. In addition, carers living in South Africa were more likely to present with psychological morbidity and suicidal ideation than carers in Malawi. Rates of help-seeking for mental health problems were low. Carers of children affected by HIV are at risk for mental health problems as a result of HIV, socio-economic, care-giving and community factors. We call for increased recognition of the potential role of CBOs in providing mental health care and support for families as a means to improve equity in mental health care. Specifically, we highlight the need for increased training and supervision of staff at CBOs for children affected by HIV, and the inclusion of CBOs in broader efforts to improve population mental health outcomes.

A systematic review examining whether interventions are effective in reducing cognitive delay in children infected and affected with HIV

Cognitive delay has been recorded in children infected and affected by HIV. This finding is well established, yet few countries report provision of special educational interventions for this group of children. The general rehabilitation literature describes an array of effective interventions for children with learning difficulties. These have rarely been adapted for children affected by HIV, despite their growing numbers. A systematic review was conducted to examine effective interventions for cognitive delay in children (under 18 years) infected with HIV and/or exposed to HIV (HIV-negative child born to an HIV-positive mother). A keyword search of electronic databases with reference follow-up generated 1745 hits. These abstracts were screened for relevance, resulting in 17 papers available for shortlisting. Studies were then included if they were randomised control trials, were longitudinal, pre/post or cohort studies and presented empirical data on an intervention for children infected by HIV or exposed to HIV and had at least one cognitive measure. Carer interventions were included if they had at least one child cognitive measure. Of the 17 papers, 4 met the inclusion criteria based on design and quality. Interventions included cognitive rehearsal, home-based stimulation and parental support. All four interventions showed at least one significant child improvement at follow-up. Despite such improvements, many children still scored within the disability range at follow-up. These results show that the effective interventions are available and should be scaled up to meet the needs of children. Complex interventions are not sufficiently studied. This review suggests an ongoing need to build evidence-based interventions, but calls on evidence-based programmes to be initiated for HIV-positive and HIV-affected children.

Determinants of suicide and accidental or violent death in the Australian HIV Observational Database

Background

Rates of suicide and accidental or violent death remain high in HIV-positive populations despite significantly improved prognosis since the introduction of cART.

Methods

We conducted a nested case-control study of suicide and accidental or violent death in the Australian HIV Observational Database (AHOD) between January 1999 and March 2012. For each case, 2 controls were matched by clinic, age, sex, mode of exposure and HIV-positive date to adjust for potential confounding by these covariates. Risk of suicide and accidental or violent death was estimated using conditional logistic regression.

Results

We included 27 cases (17 suicide and 10 violent/accidental death) and 54 controls. All cases were men who have sex with men (MSM) or MSM/ injecting drug use (IDU) mode of exposure. Increased risk was associated with unemployment (Odds Ratio (OR) 5.86, 95% CI: 1.69–20.37), living alone (OR 3.26, 95% CI: 1.06–10.07), suicidal ideation (OR 6.55, 95% CI: 1.70–25.21), and >2 psychiatric/cognitive risk factors (OR 4.99, 95% CI: 1.17–30.65). CD4 cell count of >500 cells/µL (OR 0.25, 95% CI: 0.07–0.87) and HIV-positive date ≥1990 (1990–1999 (OR 0.31, 95% CI: 0.11–0.89), post-2000 (OR 0.08, 95% CI: 0.01–0.84)) were associated with decreased risk. CD4 cell count ≥500 cells/µL remained a significant predictor of reduced risk (OR 0.15, 95% CI: 0.03–0.70) in a multivariate model adjusted for employment status, accommodation status and HIV-positive date.

Conclusions

After adjustment for psychosocial factors, the immunological status of HIV-positive patients contributed to the risk of suicide and accidental or violent death. The number of psychiatric/cognitive diagnoses contributed to the level of risk but many psychosocial factors were not individually significant. These findings indicate a complex interplay of factors associated with risk of suicide and accidental or violent death.

HIV infection and depression

Major depression is highly prevalent among HIV-positive patients (HIVpp). The prevalence of depression ranges between 18% and 81%, depending on the population studied and the methodology of the study. The etiology of depression in HIVpp is likely determined by: (i) biological factors (alterations in the white matter structure, hypothalamic-pituitary-thyroid dysfunction, Tat-protein-induced depressive behavior); (ii) psychosocial factors (HIV stigma, occupational disability, body image changes, isolation and debilitation); (iii) history or comorbidity of psychiatric illness; and (iv) the perinatal period in HIVpp women. Symptomatology of depression differs between HIVpp and HIV-negative patients (HIVnp). Depression may also alter the function of lymphocytes in HIVpp and decrease natural killer cell activity, contributing to the increased mortality in these patients. Selective serotonin re-uptake inhibitors are considered the first-line treatment. Treatment of depression can improve quality of life and lead to a better prognosis of HIV infection.

Effectiveness of Psycho-Educational Intervention in HIV Patients' Treatment

Adherence to Highly Active Antiretroviral Therapy (HAART) is the main prognostic factor associated with HIV disease progression and death. The aim was to evaluate the effectiveness of a psycho-educational program to promote adherence to HAART in HIV patients. A longitudinal study (n = 102) over 9 months in an Infectious Diseases Hospital was carried out. Adherence to HAART was measured with standardized scales and values of viral load. Two groups were defined: adherents and non-adherents. In the latter, a psycho-educational program was implemented and 6 months later measured adherence to HAART. Knowledge about the infection, CD4 T lymphocytes and HIV-ribonucleic acid values were measured before and after this program. The sample was predominantly male (70%), heterosexual (78%), with a mean age of 49 (SD = 12.7) years, and 48% of participants were not adhering to HAART. After the program, non-adherence decreased to 21.6%. Knowledge about the infection increased from 79 to 97%. A significant increase in CD4 T lymphocytes (mean 540-580) and a decrease in viral load (mean 5411-3052) were observed, the latter of statistical significance. This program seems to be feasible and efficient, improving adherence to HAART.

Caring for women living with HIV: gaps in the evidence

Introduction

In the management of HIV, women and men generally undergo the same treatment pathway, with gender differences being given limited consideration. This is in spite of accumulating evidence that there are a number of potential differences between women and men which may affect response to treatment, pharmacokinetics, toxicities and coping. There are also notable psychological, behavioural, social and structural factors that may have a unique impact on women living with HIV (WLWH). Despite our increasing knowledge of HIV and advances in treatment, there are significant gaps in the data relating specifically to women. One of the factors contributing to this situation is the under-representation of women in all aspects of HIV clinical research. Furthermore, there are clinical issues unique to women, including gynaecologic and breast diseases, menopause-related factors, contraception and other topics related to women's and sexual health.

Methods

Using scoping review methodology, articles from the literature from 1980 to 2012 were identified using appropriate MeSH headings reflecting the clinical status of WLWH, particularly in the areas of clinical management, sexual health, emotional wellbeing and treatment access. Titles and abstracts were scanned to determine whether they were relevant to non-reproductive health in WLWH, and papers meeting inclusion criteria were reviewed.

Results

This review summarizes our current knowledge of the clinical status of WLWH, particularly in the areas of clinical management, sexual health, emotional wellbeing and treatment access. It suggests that there are a number of gender differences in disease and treatment outcomes, and distinct women-specific issues, such as menopause and co-morbidities, that pose significant challenges to the care of WLWH.

Conclusions

Based on a review of this evidence, outstanding questions and areas where further studies are required to determine gender differences in the efficacy and safety of treatment and other clinical and psychological issues specifically affecting WLWH have been identified. Well-controlled and adequately powered clinical studies are essential to help provide answers to these questions and to contribute to activities aimed at improving the health and wellbeing of WLWH.

Community-based HIV/AIDS interventions to promote psychosocial well-being among people living with HIV/AIDS: a literature review

Background: This review explores the current community-based psychosocial interventions among people living with HIV/AIDS (PLWHA) across the globe. Methods: Evaluation studies were retrieved and reviewed regarding study location, characteristics of participants, study design, intervention strategies, outcome indicators, and intervention findings. Results: The 28 studies spanned a broad range of intervention strategies, including coping skills, treatment and cure, cultural activities, community involvement, knowledge education, voluntary counseling and testing, peer-group support, three-layered service provision, child-directed group intervention, adult mentoring, and support group interventions. Regardless of study designs, all studies reported positive intervention effects, ranging from a reduction in HIV/AIDS stigma, loneliness, marginalization, distress, depression, anger, and anxiety to an increase in self-esteem, self-efficacy, coping skills, and quality of life. Conclusion: Although the existing studies have limitation with regard to program coverage, intensity, scope, and methodological challenges, they underscore the importance of developing community-based interventions to promote psychosocial well-being among PLWHA. Future studies need to employ more rigorous methodology and integrate contextual and institutional factors when implementing effective interventions.

Suicide risk and sexual orientation: a critical review

Many studies have reported higher rates of suicide attempts among sexual minority individuals compared with their heterosexual counterparts. For suicides, however, it has been argued that there is no sexual orientation risk difference, based on the results of psychological autopsy studies. The purpose of this article was to clarify the reasons for the seemingly discrepant findings for suicide attempts and suicides. First, we reviewed studies that investigated if the increased suicide attempt risk of sexual minorities resulted from biased self-reports or less rigorous assessments of suicide attempts. Second, we reanalyzed the only two available case-control autopsy studies and challenge their original "no difference" conclusion by pointing out problems with the interpretation of significance tests and by applying Bayesian statistics and meta-analytical procedures. Third, we reviewed register based and clinical studies on the association of suicides and sexual orientation. We conclude that studies of both suicide attempts and suicides do, in fact, point to an increased suicide risk among sexual minorities, thus solving the discrepancy. We also discuss methodological challenges inherent in research on sexual minorities and potential ethical issues. The arguments in this article are necessary to judge the weight of the evidence and how the evidence might be translated into practice.

Frequency and correlates of anxiety and mood disorders among TB- and HIV-infected Zambians

We determined the frequency and correlates of current common mental disorders (CMDs) in a consecutive series of 649 adult patients with human immunodeficiency virus (HIV), tuberculosis (TB) or both receiving treatment at 16 primary health care centres across Zambia. Data on socio-demographic variables, clinical disease features, anxiety and mood disorders were collected. The frequency of any anxiety disorder (AD) was 30.8% and major depressive disorder (MDD) 11.3%. Although differences by disease group did not reach statistical significance, rates of suicidality (34.8%) and panic disorder (4.1%) were highest for the TB-HIV group (n = 269), while rates of generalised AD (13.3%), obsessive compulsive disorder (7.6%), posttraumatic stress disorder (7.4%) and any AD (37.8%) were highest for the HIV group (n = 149). Female gender (p = 0.004) predicted any current AD as well as current suicidality (p = 0.009), while lower education status (p < 0.001) predicted current MDD. World Health Organisation (WHO) clinical staging and antiretroviral treatment status were not significantly associated with MDD or anxiety in the HIV and co-infected groups. This study indicates the importance of early identification of CMDs in TB, HIV and co-infected patients, especially women and uneducated patients, newly initiated on treatment in primary care settings.

Factors contributing to dropping out from and returning to HIV treatment in an inner city primary care HIV clinic in the United States

Although advances in pharmacotherapy have enabled people living with HIV/AIDS to live longer, fuller lives, some leave medical care, resulting in sub-optimal treatment and increased health risk to themselves and others. Forty-one patients who dropped out of an urban, publically funded primary care HIV clinic were contacted and encouraged by outreach staff to return. Participants were interviewed within two weeks of returning, and themes associated with dropping out and returning were elicited and content analyzed. Dropping out was associated with drug/alcohol use, unstable housing/homelessness, psychiatric disorders, incarceration, problems with HIV medications, inability to accept the diagnosis, relocation, stigma, problems with the clinic, and forgetfulness. Returning was associated with health concerns, substance abuse treatment/recovery, stable housing, incarceration/release, positive feelings about the clinic, spirituality, and assistance from family/relocation. Because a large number of patients reported substance abuse, depression, and past suicide attempts. Clinic staff should assess substance use, depression, and suicidal ideation at each primary care visit and encourage patients to obtain substance abuse treatment and mental health care. Future interventions could include providing SBIRT and/or onsite mental health and substance abuse treatment, all of which may boost retention.

Suicidal behavior in war veterans

Military veterans represent a unique, heterogeneous population with suicide prevalence rates, risk factors and preventative management needs that differ from those of the rest of community. Veterans worldwide receive high proportions of their healthcare from community providers, and sensitivity to these distinct needs is required for optimized care. An overview of the recent prevalence-study literature, with a focus upon statistical design, is presented in order to provide a critical orientation within this field with high levels of popular media attention. Attention to psychiatric comorbidity, subthreshold symptomology, select signature disorders of contemporary conflicts (namely, post-traumatic stress disorder and traumatic brain injury), and veteran life narratives before, within and beyond military service will guide our review of risk factor assessment and management strategies. This critical review of the literature provides an overview of this active field of neuropsychiatric research with a select focus upon these topics of special interest.