Journal Review
Whetten K, Reif S, Whetten R, et al. Trauma, Mental Health, Distrust, and Stigma Among HIV-Positive Persons: Implications for Effective Care Psychosomatic Medicine 70:531-538 (2008)
The critical need to address mental health issues has been recognized globally and in the United States, however, significant deficiencies in access to mental health care remain for the general population and for people living with HIV/AIDS, the authors of this review article warn.
Individuals living with HIV often have complicated histories, including negative experiences such as traumatic events, mental illness, and stigma. As the medical community in the United States adapts to managing HIV as a chronic disease, understanding factors such as these negative experiences that may be associated with poorer adherence to treatment regimens, greater HIV risk behavior, and lower patient quality of life becomes critical to HIV care and prevention. In less wealthy nations, these issues are also critical for addressing quality of life as well as medication adherence in the areas where antiretroviral therapies are being made available. This article presents a review of the literature regarding the following psychosocial factors as they relate to HIV/AIDS in the US and globally: traumatic events; mental illness, including depression, anxiety, and posttraumatic stress disorder; lack of trust in the healthcare system and government; and experiences of stigma among individuals with HIV disease. These factors have been found to be prevalent among individuals with HIV/AIDS, regardless of gender or race/ethnicity. Traumatic events, mental illness, distrust, and stigma have also been linked with poorer adherence to medication regimens and HIV risk behavior.
"This review of published literature high rates of trauma, depression, anxiety, stigma, and distrust were identified among HIV-infected individuals regardless of race, gender, or sexual orientation," the authors conclude. "These findings indicate that significant attention to these issues in the context of HIV treatment and prevention is warranted. The need for a focus on these factors and a modification of treatment practices to adequately address them is particularly compelling because of their relationships with HIV-related behaviors including medication adherence and HIV risk behaviors. These psychosocial factors have also been associated with poorer disease outcomes."
One consideration for addressing trauma would be the development of standardized trauma protocols for infectious disease providers that assume most patients have experienced some form of trauma and would benefit from clinician sensitivity to potential trauma triggers. For example, important tenets to working with patients who have been sexually abused include seeing the patient clothed before the examination, encouraging questions and explaining all parts of the physical examination and any needed procedures, and allowing patients to opt out of any or all parts of a physical examination. In addition, acknowledging the high prevalence of trauma helps the patient feel more comfortable when asking about trauma history. Explaining that the same questions are asked of all patients is an important step in creating a safe environment for the patient.
Healthcare funding mechanisms, such as Medicaid and Ryan White funds, may need to be broadened to provide comprehensive mental health coverage for persons with HIV. Such policy changes could result in financial savings due to improved health outcomes and decreased emergency room visits and hospitalizations. To support this contention, the authors cite a study that found providing mental health services for the HIV-infected with psychiatric disorders resulted in decreased treatment costs and improved health outcomes.1 Innovative approaches to address issues of stigma and distrust in the medical community and government are also needed to improve HIV care and prevention.
In particular, further research is needed to elucidate the extent of unmet needs for mental health care as well as individual and policy level interventions that may effectively address mental illness, trauma history, stigma, mistrust, and the challenges unique to women with HIV. "Failure to understand and address the psychosocial factors that may influence medication adherence and risk behavior among HIV-infected individuals may have ramifications for quality of life as well as morbidity and transmission of HIV," the authors note.
Reference
- Whetten K, Reif S, Ostermann J, et al. Improving health outcomes among individuals with HIV, mental illness, and substance use disorders in the Southeast. AIDS Care 2006;18(Supply 1):18–26.
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