Indian J Med Res 121, April 2005, pp 451-467
451
Psychological and psychiatric issues associated
with HIV infection have received considerable
attention in the last decade owing to the emotional
impact of the disease and its effect on an individual’s
personal, sexual, occupational and social life. Apart
from the more obvious impact of HIV on mental health,
there are several ways in which HIV infection and
psychiatric disorders are linked.
(i) HIV infection owing to its malignant course and
the associated stigma often results in emotional
reactions of a serious nature among those infected.
(ii) The HIV has direct effects on the brain that may
lead to neurocognitive disturbances, psychosis or
behavioural changes. (iii)  Opportunistic neurological
and systemic infections and their treatment may lead
to neuropsychiatric problems. (iv) Some of the drugs
used in HAART (highly active antiretroviral therapy)
are known to be associated with psychiatric side
effects. (v) Persons with severe mental illness are
known to be vulnerable to HIV infection and there
are special management concerns in this population.
(vi) Substance abuse and HIV are linked in direct
ways (intravenous drug use: IVDU) and in indirect
ways by their influence on sexual behaviour. (vii)
Treatment adherence and course of illness have been
found to be influenced by emotional factors and
substance use.
The above description indicates the complexities
of the link between psychiatric syndromes and HIV
infection. In a given individual, more than one of these
factors might be involved thus leading to complex
clinical manifestations and requiring a multipronged
Key words AIDS - depression - HIV - mental illness - substance use
HIV & psychiatric disorders
Prabha S.Chandra, Geetha Desai* & Sanjeev Ranjan
Department of Psychiatry, National Institute of Mental Health & Neurosciences, Bangalore &
*Manipal Institute of Higher Education, Manipal, Karnataka, India
Accepted January 28, 2005
HIV infection and psychiatric disorders have a complex relationship. Being HIV infected could
result in psychiatric disorders as a psychological consequence of the infection or because of the
effect of the HIV virus on the brain.  Disorders may be as varied as depression, post-traumatic
stress disorders, AIDS phobias, grief and the whole gamut of cognitive disorders. In addition,
several psychiatric conditions may predispose individuals to acquiring HIV infection as a
consequence of their influence on behaviour. There is also strong evidence of the relationship of
substance use disorders and severe mental illnesses with HIV infection. HIV related psychiatric
disorders also offer a challenge to clinicians in issues of differential diagnosis and management.
Majority of the work in India has focused on substance use and HIV, and to a lesser extent on the
psychiatric effects of HIV infection. Given the magnitude of the problem in the country and the
multiple physical and psychological stressors that persons with HIV face in India, more research
is needed.
452 INDIAN J MED RES, APRIL  2005
approach in assessment and management of the
problem.
This review attempts at delineating each of these
links between HIV and psychiatric disorders; and also
reviews the available Indian literature and discusses
it in the context of research from other parts of the
world.
Psychiatric disorders as a reaction to HIV
infection
AIDS phobia: Phobias and fears related to HIV and
AIDS have been reported early in the history of HIV
infection1.  There have been reports from the late
eighties describing the problems of the “worried well”-
i.e., people with an overwhelming fear of having
contracted AIDS. The initial reports were
predominantly from homosexual men and users of IVD
who were particularly at risk for HIV infection 1,2.
Subsequently, there have been reports of a spectrum
of disorders such as anxiety disorders, panic,
hypochondriacal beliefs and obsessive-compulsive
disorders related to HIV infection1-3. These could be
primary disorders or manifested as psychopathology
in depression and/or psychotic disorders. Cases of
AIDS related phobia among heterosexuals with risky
sexual behaviour have been reported from India2. In
addition to distinct AIDS related fears, somatization
disorders have been reported among men with risky
behaviour who tested negative for HIV 3  but continue
to have concerns about the infection.  AIDS related
fears and phobias have been associated with an
anxious temperament, are more among those with
health anxiety, and are often associated with
misinformation and inadequate knowledge, particularly
in countries like India.
Bereavement and grief: The severity of HIV and
AIDS, the loss of health, a decrease in functioning,
the deterioration of body integrity, and the anticipatory
loss of life may also result in bereavement.
Homosexual men with AIDS who have witnessed
multiple deaths during their illness experience
recurrent episodes of bereavement4. The bereaved
person typically considers symptoms of sadness,
insomnia, poor appetite, and weight loss as being
normal reactions to their loss. Though these symptoms
share common characteristics with major depression,
these do differ in the presence and intensity of survivor
guilt, loss of warmth in relationships, emergence of
hostility, and the preoccupation with images of the
deceased. If bereavement persists for longer than two
months and is accompanied by increasing functional
impairment, morbid preoccupation with
worthlessness, and marked psychomotor retardation,
the diagnosis of major depressive episode can be
established. If bereavement remains unresolved with
persistent yearning, over identification with the
deceased, and an inability to express sadness or rage,
then grief resolution therapy should be offered. In
India, bereavement in the context of AIDS has not
been systematically studied. However, it has been
reported that because the deaths due to HIV infection
are shrouded in stigma and secrecy, and incomplete
funeral and death rituals, it acts as a risk factor for
unresolved family grief5,6. In addition in Africa and
India, HIV infection in a family is associated with
multiple losses as more than one person is usually
infected and anticipatory grief at the possible loss of
more than one person is often a feature 7,8. More
research in this area is needed to guide health workers
in managing this problem in a culturally sensitive
manner.
Anxiety disorders: Anxiety disorders may manifest
throughout the course of HIV infection, with a general
trend for increased prevalence of these disorders as
the illness progresses. Researchers have reported a
prevalence range of 29 to 38 per cent10 depending
upon the stage of illness. A study demonstrated
elevated level of panic disorders in HIV positive men
with unresolved grief compared to those with resolved
grief11. Using Hospital Anxiety and Depression Scale,
a study conducted on a group of 51 seropositive
persons at a tertiary care centre in south India 12,
found 36 per cent of the patients to score above the
cut-off level for diagnosis of anxiety disorders. The
majority fulfilled the diagnostic criteria of generalized
anxiety disorder. Pain, concurrent alcohol abuse/
dependence, poor family support and presence of
AIDS in the spouse accounted for 57 per cent of the
total variance in the level of anxiety. In comparison
with the western studies, the number of individuals
diagnosed as having anxiety disorders in this study
was higher. It is notable that the sample in this study
453
differed from that in the western studies in terms of
recruiting greater number of individuals symptomatic
(55% of the total sample) for HIV infection. Thus
physical suffering could account for the higher rate
of anxiety disorders. In addition, cultural factors like
stigma, relative lack of appropriate treatment facilities,
poor access to the health care, and low educational
level could have significantly contributed. Since the
individuals were assessed for anxiety soon after
revelation of HIV status (within 2-3 months), it could
also account for the higher incidence of anxiety
disorders in this study.
Post-traumatic stress disorders and multiple loss
syndromes have been described in some persons who
have experienced AIDS related multiple losses. HIV
positive women have a higher prevalence of post-
traumatic stress disorder symptoms13. Evaluation of
anxiety in HIV infected individuals should take into
account the variety of medical conditions, which can
present with anxiety symptoms. Many of the
medications used in treatment of HIV/AIDS have
been reported to cause anxiety as a possible side
effect. Psychoactive substances, both prescribed and
recreational, should also be considered in evaluation
of anxiety.
Depression in HIV infection: Depression is the
commonest psychiatric syndrome reported in studies
among HIV infected individuals. Major depression in
HIV-positive population is elevated about two fold
above those in healthy community sample. Rates of
depression have ranged from 5 to 25 per cent or even
higher10-12. The study conducted at the specialty HIV
clinic at a tertiary care centre of south India12 reported
that 40 per cent of the seropositive individuals studied
suffered from syndromal depression. Majority (90%)
of the patients who had depressive symptoms also
had prominent anxiety symptoms and fulfilled the ICD-
10 criteria for generalized anxiety disorder. Among
the depressed patients, 20 per cent expressed death
wishes, 12 per cent reported occasional suicidal
ideations, and 6 per cent reported persistent suicidal
ideations whereas 8 per cent had made attempts to
commit suicide. Notably all those, who had attempted
suicide, had a past history of psychiatric illness. All
the suicide attempts were made during the first week
after revelation of the seropositive status.
A two-year follow up study14 has revealed that
10-25 per cent of seropositive women report
depression during the course of the illness. Adjustment
disorders with depressed mood are more commonly
seen than major depressive disorders. Women with
HIV-positive status exhibit higher rates of major
depressive disorder and more symptoms of anxiety
and depression than HIV-negative women14.
Barriers to diagnosing depression : There are
several barriers to the diagnosis of depression in HIV
infected individuals. Firstly, patients often do not
discuss their mood or emotions with health care
professionals for fear of being stigmatized further.
Secondly, health care professionals may view the
depression as a normal reaction to the infection rather
than treating it as a condition that needs assessment,
referral and treatment. Finally, difficulties in
diagnosing depression because of somatic symptoms
such as fatigue, loss of appetite, poor concentration
may complicate the differential diagnosis in physically
ill HIV-infected individuals. To overcome this, the
cardinal psychological symptoms of depression should
be sought to confirm diagnosis. These include sad
mood, distinct loss of interest or pleasure,
worthlessness, suicidality, sense of failure or
sinfulness. Health care professionals should
encourage expression of emotions in clinics and need
training in the assessment of psychiatric syndromes.
High prevalence rates of depression have been
reported in India among HIV seropositive individuals
ranging from 10 to 40 per cent12,15,16. The difference
in rates of depression among studies is often a
reflection of the population studied, the tools used and
the setting in which the study was conducted. Rates
may differ because of the group being studied (gay
men, IVDUs, women, bereaved), the setting
(community vs. hospice or hospital), stage of illness
(later stages of illness reporting higher rates of
depression), symptoms such as pain and fatigue and
time after disclosure. Studies have revealed
conflicting results regarding the influence of stage of
illness on anxiety and depression. However, the study
conducted at a tertiary care centre of south India
found no relation between stage of illness and
depression12. Depressive symptoms were related to
the severity of physical pain (33% reported severe
454 INDIAN J MED RES, APRIL  2005
pain), abuse or dependence on alcohol (47%), and
poor social support (43%). Importantly, 43 per cent
of the study population had HIV seropositive spouses
and 24 per cent had their spouses already diagnosed
with AIDS. This was another factor related to the
depressive symptoms. The results of this study
indicated a higher rate of depression in persons living
with HIV/AIDS (PLWHA). However, it should be
noted that contrary to studies from west, the sample
in this study consisted of a greater proportion of
physically symptomatic individuals12,16. In addition,
several cultural factors like stigma, low education
level, lack of and access to treatment facilities could
well underlie the higher prevalence of depression in
this sample.
Effect of depression on natural course of HIV
infection: While some evidence points to lack of an
association between depression and medical
outcome17, other studies12,16 have reported that
presence of depressive disorder could result in neglect
of physical health and poor compliance to treatment
regimen among individuals with HIV infection. Studies
have also demonstrated the association of
psychological distress and immune system function
in HIV spectrum disease. Psychological distress has
been associated with decreased number of helper
cells and B cells at low levels of viral burden18,19.
HIV status disclosure and depression: Disclosure
has several important connotations in HIV in India,
especially in the context of stigma and myths
surrounding the illness. Disclosure may impact mental
health in positive and negative ways. Discussion of
one’s HIV status with significant others may open
up the opportunities to receive support or may add to
stress by causing discrimination and withdrawal of
support. Concealing one’s status on the other hand,
may be equally stressful and may impact on mental
health. A study that examined the impact of disclosure
related variables on mental health investigated the
nature (voluntary or without consent), extent (number
of people to whom disclosure occurred) and the
outcome of disclosure among 68 subjects with HIV
infection20. Voluntary disclosure was reported by
65 per cent while 35 per cent reported that disclosure
to their family and friends was made without
consulting them. A strong need to disclose was
reported by 42 per cent of the sample while 40 per
cent reported a moderate need to disclose. The
remaining 18 per cent felt no need to disclose at all.
The outcome of disclosure was reported to be
predominantly positive by 54 per cent whereas the
remaining 46 per cent reported a mixture of positive
and negative outcomes. Results indicated that it was
not the nature or extent of disclosure but the motivation
to disclose and the outcome of disclosure that had an
impact on mental health and quality of life variables20.
Positive outcomes and wanting to disclose one’s HIV
status were associated with better mental health and
better quality of life. It is not clear whether this is
related to cause or effect. Persons with better mental
health may have better social support and hence may
be more motivated to reveal their status or the other
way round. Further studies need to address these issues
and also look at gender and geographical (rural/urban)
differences in the relationship between illness disclosure
and mental health.
Gender and depression in HIV infection: Several
studies have assessed the role of gender in psychiatric
morbidity, particularly depression and anxiety. Majority
of studies in India have reported higher rates of
depression and anxiety among women compared to
men21-23. Women with HIV infection in India face
higher caregiver burden, more stigma and poor health
care, which probably contribute to the higher
prevalence of depression.
Psychiatric problems in children with HIV
infection: Despite the growing numbers of children
with HIV infection in India, there are no studies
addressing the impact of HIV infection on the mental
health of children either affected or infected with HIV.
A recent prospective cohort study designed to examine
long-term outcome among HIV infected children and
HIV uninfected infants born to HIV infected parents
reported an incidence of 6.17 psychiatric cases per
1000 person-years. This was significantly higher than
the incidence of 1.70 cases per 1000 person-years in
the general paediatric population24. The majority of
patients were admitted because of   depression or
behavioural disorders while 47 per cent underwent
multiple psychiatric hospitalizations. The median age
at the first psychiatric hospitalization was 11 yr
(range: 4-17 yr) when all patients had been perinatally
455
infected. It was also seen that the  knowledge of HIV
seropositivity status and having experienced   a
significant life event were both significantly
associated  with an increased risk of psychiatric
hospitalization.  Studies are needed in the Indian
context as more and more children are being infected
and affected by HIV.
Psychosis in HIV infection
The presence of psychotic symptoms in patients
with HIV contributes to difficulties in medical care
and residential placement and may have other serious
consequences. Psychotic symptoms can appear as a
part of delirium, dementia or any other organic brain
syndrome. New onset psychotic symptoms are not
uncommon in HIV infection. One of the earliest
studies reviewed cases of new onset psychosis in
HIV infected patients and reported that patients with
psychotic symptoms and abnormal computed
tomography (CT) and electro encephalography (EEG)
findings at the time of presentation with psychosis
tended to have relatively rapid deterioration in
cognitive and medical status25. A subsequent study26
reviewed records of 20 HIV infected individuals with
psychosis without delirium, current substance abuse
or previous psychotic episodes. Subjects with
psychosis had higher rates of stimulant abuse and at
follow up higher mortality rate. They also showed
greater neuropsychological impairment.
Mania typically occurs as part of bipolar affective
disorder, but it may occur secondary to a variety of
medical and pharmacological antecedents in HIV
infection. The prevalence of mania is reported to be
significantly increased in patients with AIDS
compared to the general population27-29. Patients with
secondary mania did not differ in clinical
characteristics and response to treatment compared
to mania associated with bipolar affective disorder.
However, neuroradiological abnormalities and
cognitive dysfunction have been commonly reported.
Hence it is important to differentiate secondary or
organic mania from a pre existing or concurrent manic
syndrome. A few cases of AIDS related mania and
psychosis have been reported from India 30,31, but
systematic studies on the clinical manifestation and
course of illness are lacking.
Cognitive dysfunction related to HIV infection
Cognitive disorders and subtle cognitive impairment
are seen throughout the spectrum of HIV infection.
Delirium occurs frequently among hospitalized HIV
infected patients with reported prevalence ranging
from 29-57 per cent32. The etiology of delirium is often
multifactorial in HIV infection and patients are
susceptible to the development of delirium in the
context of underlying HIV brain infection, common
use of polypharmacy and the frequency of multiple
medical complications. Evaluation and correction of
the underlying medical cause of delirium is of primary
importance. Prompt management of agitation due to
delirium is extremely important because of the distress
caused to the patient and family, potential for self
harm as well the potential for exposure of HIV to
others. Repeated mental status examinations, careful
review of medications, thorough physical and
neurological examinations, search for infections/
metabolic abnormalities, neuroradiologic examination,
CSF examination and EEG are essential in evaluation
of delirious patients.
Cognitive dysfunction in asymptomatic HIV
infection: Neuropsychological impairment among
asymptomatic HIV infected persons has been an
important area of study. Several studies in India
have reported neurocognitive disturbances in this
group33-36. Factors such as brain injury, malnutrition,
neurological infections, alcohol and depression are all
known to have a role in the causation of
neurocognitive problems. All the above studies found
significant deficits compared to controls, particularly
in the areas of fine motor speed and information
processing. One study that examined both central and
peripheral electrophysiological parameters, found
evidence of subtle abnormalities in clinical testing,
EEG and brain stem auditory evoked responses36.
AIDS dementia
The prevalence of HIV-1-associated dementia
(HAD) among otherwise  asymptomatic subjects in
United States and Europe has been estimated at 15 to
30 per cent37,38. In contrast, a study from India 38
CHANDRA et al: HIV & PSYCHIATRIC DISORDERS
456 INDIAN J MED RES, APRIL  2005
documented an unusually low incidence (about 1 to
2%) of HAD. It should be noted that the low levels  of
HAD in economically developing societies like India
are often  attributed to underdiagnosis, shorter life
expectancy, or other factors.  In an extensive follow
up of earlier studies, however, six cases of HAD were
found among 427 HIV-infected asymptomatic
individuals (1.4%), indicating that the low incidence
of HAD was not an artifact38.
To explain this lower incidence of HIV dementia,
one of the causes hypothesized has been a
compromised chemotactic function of C-Tat protein
that is responsible for the monocytic chemotactic
activity which has an important role in HIV dementias.
It was found that the CS natural variant was defective
for monocyte chemotactic activity without a loss in
the transactivation property39. While the CC mutant
was functionally competent for both the functions, in
contrast, the SC mutant was defective in both.
Therefore, the loss of the C-Tat chemotactic property
may underlie the reduced incidence of HAD.
Although not presenting conclusive evidence, this
study provided the first evidence for a potential
epidemiologic phenomenon associated with biological
differences in the subtypes of viruses39. The scenario
may change in India with the early detection of HIV,
prompt treatment of opportunistic infections, and
HAART therapy. Better documentation and
assessment of patients presenting with cognitive
dysfunctions is needed to chart the occurrence,
comorbidity and course of HIV dementias.
Psychiatric side effects of anti retroviral drugs
Antiretroviral drugs although over the years  have
provided hope, are associated with significant side
effects. Various reports have been published on the
psychiatric side effects, which range from anxiety to
psychosis. Multiple medications for other problems
in HIV may also add to the side effects of the
antiretrovirals.  Foster et al40 reported a case of
antiretroviral-induced psychosis, which remitted once
the drug was withdrawn. Other drugs that have been
reported to cause psychiatric side effects include
efavirenz and nevirapine41,42. With the onset of
HAART therapy in India, it is important to record
psychiatric side effects of antiretroviral drug
combinations. While negative effects of HAART have
got attention, benefits have also been recorded.
Psychological effects of HAART in terms of mood,
hope and life satisfaction studied among a cohort of
173 HIV-positive gay and  bisexual men followed up
for two years on HAART indicated a definite overall
psychological improvement43.
Psychotropic drugs in HIV infection
Patients with HIV infection commonly receive
multiple medications, which include antibiotics,
antifungal agents along with antiretroviral medications.
Psychotropics used to treat the psychiatric conditions
may interact with the antiretroviral medications
complicating the picture. The most commonly used
drugs are antidepressants, mood stabilizers and
antipsychotics.
Treatment of depressive symptoms in patients with
HIV has a favourable impact on psychosocial
functioning. Antidepressants can alleviate depressive
symptoms and improve quality of life. Several
randomized controlled studies have demonstrated the
efficacy of tricyclic antidepressants   but have reported
high drop out rate due to adverse effects44. Studies
have also been conducted to demonstrate the efficacy
of selective serotonin reuptake inhibitors (SSRIs) in
treatment of depression. Fluoxetine has been
evaluated in a double blind randomized controlled
study for depression in patients with HIV-AIDS and
has been found to be effective 45. The effect of
imipramine and fluoxetine has also been studied on
the immune status in depressed patients with HIV
illness46 with no negative effects being noted. One
needs to be aware of the drug interactions of protease
inhibitors and reverse transcriptase inhibitors that
decrease the activity of cytochrome, interfering with
the metabolism of SSRIs. Newer antidepressants
have also been studied in the treatment of depression.
Venlafaxine has been found to be effective and also
has minimal potential for interaction with other drugs.
Nefazadone, bupropion and reboxetine have also been
found to be effective in open label studies47-49.
A significant number of HIV infected persons may
need treatment for mood disorders. Several factors
must be taken into account when using mood
457
stabilizers in HIV infected patients. A study reported
that valproate increased the HIV-1 replication in vitro50.
However, clinical evidence indicates that valproic acid
therapy does not affect viral load  in vivo in HIV
infected patients receiving adequate antiretroviral
therapy49,50. However, blood levels must be closely
monitored. In addition to treatment with valproic acid,
there is evidence of bi-directional interactions of
carbamazepine and antiretroviral agents at the level
of the CYP 450 enzymes. On the one hand,
carbamazepine is a potent inducer of the CYP 3A
enzyme system, increasing the metabolism of protease
inhibitors such as indinavir, and non-nucleoside reverse
transcriptase inhibitors. Ritonavir is a potent inhibitor
of the same enzyme that increases the risk of
carbamazepine toxicity51. Parenti et al52 treated a
group of 10 HIV positive men with lithium and seven
had to discontinue the treatment due to side effects.
However, no significant changes were noted in CD4
counts while there was a significant decrease in the
mixed lymphocytic reaction.
Treatment of psychotic conditions has been less
well studied compared to mood disorders. Special
precautions must be taken when treating psychosis
in HIV infected individuals. It has been noted in
several reports that they might be more sensitive to
the extrapyramidal side effects associated with
dopamine receptor antagonist. In a case series of 20
patients with psychotic symptoms, risperidone was
found to be efficacious and to possess fewer side
effects than conventional antipsychotics53. Literature
in this area is completely lacking from India.
Suicide and HIV
Suicide is a complex biopsychosocial outcome of
depression, hopelessness, isolation and lack of
support. HIV infection with all its negative
connotations and discrimination can be a harbinger
of future suicidal ideation or completed suicide.
Several factors have been associated with suicidal
ideation among persons infected with HIV.
Homosexual orientation, partner’s HIV status, loss
of an infected partner, past history of deliberate self
harm and presence of physical symptoms have been
reported as risk factors54,55. Some of the psychiatric
variables predicting suicidal ideation include
concurrent substance abuse, past history of
depression and presence of hopelessness56.
Stigma has been considered as an important
variable in predicting suicide and has important
implications for India. There is sparse literature on
suicide and HIV infection from India, though Indian
newspapers have often carried reports of HIV
infected persons attempting suicide either due to
discrimination or a fear of it.
One study quoted earlier12, assessed suicidal
ideation and history of attempted suicides in addition
to depression among 51 HIV infected persons. The
findings revealed persistent suicidal ideations in 14
per cent, death wishes in 20 per cent and suicidal
attempts in 8 per cent. The study had a small sample
size and may not be representative of the larger HIV
infected population in India.
A recent study on suicidal ideation in Bangalore56,
assessed systematically among 100 HIV infected
persons admitted to a care center, reported a higher
prevalence of 41 per cent. Demographic risk factors
for suicidal ideation reported in this study included
female sex (56% of suicidal subjects were females
compared to 24% in non-suicidal subjects), lower
education level (mean education=5.68 yr in suicidal
subjects compared to 8.58 yr in non-suicidal subjects),
lower monthly income level (1938 rupees versus 3175
rupees) and presence of physical distress (mean score
15.83 versus 11.75). Psychiatric variables
significantly associated with suicidal ideation were
similar to those found in western studies and include
presence of depression (73% of suicidal patients),
hopelessness (mean score on Beck’s hopelessness
scale=11.07) and anxiety (29% of suicidal patients).
An important finding of this study that has implications
for policies and training was the finding that health
care related stigma was highly correlated with suicidal
ideation and its severity56.
Quality of life and HIV infection - Cross cultural
methods of assessment
Quality of life assessments are important for
evaluating treatment response, policies on
management and for developing services; however,
CHANDRA et al: HIV & PSYCHIATRIC DISORDERS
458 INDIAN J MED RES, APRIL  2005
these need to be relevant to the culture and context
in which these are being studied. The WHOQOL HIV
group has evolved a measure of assessing quality of
life, keeping cross-cultural relevance as its primary
objective and overcoming problems related to using
tools developed in western models of care. Items
important for quality of life were derived from focus
group discussions with different groups of HIV
infected individuals, their families and health care
providers. Two centres in India, Bangalore and New
Delhi, were involved in the development of the tool
and the WHOQOL HIV in long and brief forms is
currently available in Hindi and Kannada
languages57,58.
Analysis of the WHOQOL HIV field test
instrument, which was given to 1,334 individuals
infected with HIV, from seven culturally diverse
centres (Australia, Brazil, Italy, Thailand, Ukraine and
two centres in India: Bangalore and New Delhi) 58
revealed good psychometric properties and good
discriminant validity of the instrument, with poorest
quality of life found for those who reported that they
were least well. Men reported poorer physical well-
being and level of independence, while women
reported poorer environment, social support and
spirituality. The instrument provides a promising
means for quality of life assessment for patients with
HIV/AIDS in diverse cultural settings.
Severe mental illness and HIV - double jeopardy
The bidirectional nature of relationship between
severe mental illness and HIV has been well
documented. Psychiatric patients are at high risk for
acquiring HIV59,60. On the other hand, patients
infected with HIV are more susceptible to develop
psychiatric illnesses. A large amount of literature has
been published worldwide supporting the concept that
the psychiatric population as a whole is more
vulnerable to contract HIV infection. Several factors
such as sexual abuse, homelessness and impaired
judgment regarding sexual relationships make them
at high risk for HIV. Additionally, use of alcohol and
other drugs of abuse make them vulnerable to enter
casual or coercive sexual relationship. Studies
conducted in Europe and the USA have documented
the infection rate among patients with severe mental
illness ranging from 4 to 23 per cent, which is much
higher than that documented for the general
population61,62.
Among psychiatric inpatients having high risk
behaviour the seroprevalence rate was reported to
be 3.4 per cent63. In a prospective study conducted
on psychiatric inpatients in India, the seroprevalence
rate was found to be 2.11 per cent in a sample of
2283 patients tested for HIV64. Though this rate is
lower when compared to that in the west, more
alarming is the fact that the seroprevalence rate
showed an increase from 0.47 per cent in 1993 to
5.33 per cent in 1997, in keeping with increase in
HIV infection in general population. In the study 43
patients were found to be seropositive though none
of them were earlier documented to be so. Of these
43 patients, 14 per cent were women; 81.4 per cent
of these seropositive cases had a primary psychiatric
illness while 18.6 per cent were diagnosed to have
psychiatric illness secondary to HIV infection.
Further analysis found that the group with primary
psychiatric illness consisted of non-affective
psychosis (14%) (schizophrenia, unspecified
psychosis and drug induced psychosis), bipolar
affective disorder (9.3%), depression (14%) and
alcohol dependence syndrome (44%). Notably, 21
per cent of the total seropositive cases were also
diagnosed to have a co-morbid personality disorder
in the form of antisocial personality disorder or
anxious avoidant personality disorder. Though 44%
were diagnosed to have only alcohol dependence
syndrome, this percentage rose to 69.7 per cent
when patients with dual diagnosis (alcohol
dependence syndrome with any other psychiatric
diagnosis) were also included. Multiple sexual
contact was the commonest route of transmission
(65.2%). The impact of psychopathology was
evident in two women who reported high risk sexual
behaviour only during their psychotic or manic states,
whereas 44 per cent reported to have exhibited high
risk behaviour under the influence of alcohol. These
data indicate that the psychiatric patients are more
liable to contract HIV when they are under the
influence of alcohol, are actively psychotic or have
a combination of the two since these factors enhance
the chances of a person to engage in risky and
unprotected sexual behaviour65.
459
A recent study assessing HIV seroprevalence
among psychiatric outpatient population in a general
hospital setting in south India66 found that the rate
was 1.03 per cent which was not very high when
compared to the national seroprevalence rate (0.7%)
and was less than the seroprevalence rate among
the regional community (1.8%)66. However this
result should be seen in the background of the nature
of study population. The study included all psychiatric
outpatients including minor and severely mentally ill.
The whole psychiatric population may not be at high
risk but patients diagnosed to have a mood disorder
or substance use disorder or both are more likely to
have high risk sexual behaviour for contracting
HIV67.
HIV risk among the mentally ill : Nature of risk
behaviour among psychiatric patients was investigated
among inpatients in a population of severely mentally
ill in India60. Though in this study, the sample size
was small, high risk behaviour was observed in
59 per cent of patients with schizophrenia, 48 per cent
of those with affective disorder and 50 per cent of
those with personality disorders. The most frequent
high risk behaviour among men was unprotected
heterosexual intercourse with a commercial sex
worker whereas women patients reported unprotected
sex with their known high risk partners. No relation
was observed between knowledge about HIV/AIDS
and high risk behaviour60. In order to replicate the
study a more systematic study was conducted in a
larger sample of psychiatric inpatients in south India68.
Using a ten item standardized questionnaire to assess
HIV risk (HIV-risk Screening Instrument69) the 618
inpatients with severe mental illness were
interviewed. The subjects were also assessed for
alcohol and other drugs of abuse with Alcohol Use
Disorders Identification Test and Drug Abuse
Screening Test respectively. The sample consisted
of 242 women and 376 men. The results showed that
women were more likely to have been sexually active
over lifetime (72% versus 57%), over past ten years
(66% versus 55%) and over past one year (50%
versus 36%) compared to men. Of the total study
population, 20 per cent reported high risk behaviour
in their lifetime. However, men with severe mental
illness were more likely to report high risk behaviour
over their lifetime (26% versus 11%) and over last
ten years (20% versus 10%) compared to women.
Commonest types of risk behaviours reported
included having a risky sexual partner (a partner
having sexually transmitted disease, IV drug abuse,
having multiple sexual partners), having multiple
sexual partners and exchanging money for sex. The
risk behaviours differed between the two genders.
Women were more likely to have had sexually
transmitted infections or exchanging sex for money
whereas men were more likely to have exchanged
money for sex. A more significant finding was
reporting of more than two risk behaviours by 43 per
cent of the subjects having a history of risky sexual
behaviour. This study did not find IV drug abuse and
needle sharing to be among the common risk
behaviours, which might be a function of the low
prevalence of IV drug use in Bangalore (where this
study was conducted), compared to other areas of
India. Further analysis of these data revealed young
age, married status, diagnosis of mood and/or
personality disorder and drug abuse screening test
(DAST) score >2 as correlates of being sexually
active. Male sex, current use of tobacco, having
DAST score>2 (suggesting risk for a drugs abuse
problem) and having alcohol use disorders
identification test (AUDIT) score >8 (suggesting risk
for an alcohol use problem) were found to correlate
with risky sexual behaviours. The results of this study
reaffirmed the findings of the studies from the
west70,71. The association between risky sexual
behaviour and substance use remains a consistent
finding across the different studies. Evidence points
to the likely role of personality factors and situational
influences or their interaction72,73. There is also some
evidence that reducing substance use may reduce the
risky sexual behaviour74.
Coercive experiences among women with mental
illness and HIV risk: When HIV risk behaviour is
looked for especially among women, another aspect
that emerges is the occurrence of sexual coercion
and abuse of severely mentally ill. In an inpatient
sample of 146 female patients, a recent study75 found
that 30 per cent of the sample reported sexual
coercion. About 7 per cent reported child sexual
460 INDIAN J MED RES, APRIL  2005
abuse, 16 per cent reported adult sexual abuse
whereas 7 per cent reported having been abused
during childhood as well as adulthood. Importantly
abuse incidents for such women were not isolated
events as majority of the women reported to have
been abused at least four or more times. In addition,
some women reported having been abused by more
than one person. Comparison of women who reported
sexual coercion with those who did not indicated that
abused women were more likely to report high risk
sexual behaviours. When the abused subsample was
divided into severe versus milder coercion
experiences and compared, those who reported
severe coercion also had higher prevalence of HIV-
related risk behaviour over lifetime, over last ten
years and over last one year 75. Indeed, it is
increasingly recognized that most women infected with
HIV became infected through heterosexual
intercourse with their primary partner76. The women
who reported more severe coercion were more likely
to be diagnosed with bipolar affective disorder.
Extrapolating from the findings of an earlier study
by Chandra et al64 where high risk behaviour was
more common during the actively psychotic or manic
phase, it can be inferred that poor judgment, poor
negotiation skills and lack of control over sexuality
may underlie their high risk behaviours. This study
also reflects the importance of assessing
psychiatrically ill patients, especially women, for
history of sexual coercion during adult life as it tends
to demarcate the population at high risk for
contracting HIV infection. A surprising finding of this
study was that out of 40 women with history of abuse
whose clinical records were reviewed, only 5 records
mentioned that the patient had undergone sexual abuse
or coercion. This finding underlines the
underreporting of sexual abuse or coercion during
routine clinical interview and emphasizes on the need
for clinically sensitive and routine inquiry about it. The
other aspect of the interrelationship between HIV and
severe mental illness is the appearance of new
psychotic illnesses during the course of HIV infection
and its clinical manifestations. The emergence of new
psychotic/dementing illness in a seropositive person
can be due to a variety of reasons including the effect
of HIV infection, opportunistic infections,
complications of the treatment being given to the
patient and other complications of AIDS. Western
data indicate a variety of manifestations resulting from
psychiatric complications of HIV infection and AIDS.
Acute psychosis, mania and dementia frequently
occur in conjunction with HIV infection77-79. In the
study by Chandra  et al64 HIV related organic
psychiatric diagnoses were observed in 8 of the 43
seropositive psychiatric inpatients.
The studies cited above emphasize the need to
assess high risk behaviour in the psychiatric population
and to consider testing for possible HIV infection and
STDs for better treatment, rehabilitation and
counselling. The findings with respect to sexual abuse
of mentally ill women reemphasize the need for
clinically sensitive interviews for possible abuse and
its consequences in form of HIV infection as well as
mental health. Some of the issues that need further
study are the issue of informed consent in such
patients, handling dual stigma of mental illness and
HIV and occupational hazards of dealing with mentally
ill infected with HIV. In addition, dealing with HIV
testing in the mentally ill and the management of HIV
positive mentally ill requires special expertise. This
fact underlines the importance of manpower
development in this area.
Though we do not have a published Indian study
estimating the cost of treating a severely mentally ill
with a co-morbid HIV infection or AIDS, the western
data indicate that this may be considerably high80.
Given the high cost of treating persons with co-morbid
serious mental illness and HIV infection or AIDS, the
integration of  HIV prevention programmes into
ongoing management for patients with serious mental
illness who are at risk of infection may prove to be a
cost-effective intervention strategy81.
Finally, certain elements of the relationship
between HIV and severe mental illness remain
untouched in Indian context. The impact of different
behavioural programmes to help patients prevent
themselves from contracting HIV remains to be
studied. Though the psychiatric risk factors for HIV
seem to be visible, the impact of psychiatric
treatment of severe mental illnesses on reduction of
461
risk and factors such as their access to health care
facilities remains to be studied.
Substance use and HIV
It does not need to be reemphasized that substance
use especially IV drug abuse is strongly linked to HIV
infection. There has been large amount of research
in the area of drug abuse and HIV infection. In fact,
IV drug abuse using shared needles is the second
most common route of HIV infection. Though risky
sexual behaviour is the commonest reason behind HIV
transmission in India, substance use/dependence
cannot really be discarded as a minor player especially
in the north eastern states of India. One fourth (25%)
of India’s HIV positive cases come from the northeast
states of Manipur, Mizoram, and Nagaland, which
contribute only 3 per cent of the country’s total
population82. The ease of availability of opioids from
across the border along with prevailing psychosocial
factors have definite contribution towards high
prevalence of IV opioid dependence in these states83.
The situation has been made worse by the poor
availability of mental health services in these parts of
the country82. Though IV drug abusers contract HIV
mostly from shared needles; they pass the infection
sexually to their spouses. In a study of 161 couples,
about 45 per cent of the IV drug abusers  infected
their spouses with HIV84. This horizontal transmission
is not limited to HIV but also involves hepatitis B and
C viruses85. The story does not end here as the
vertical transmission of these infections is bound to
affect the offspring of these couples. Thus
interventions to reduce the risk of HIV transmission
in such populations are direly required. The results
of an outreach intervention programme in north east
India targeting the community and IV drug abusers
has hinted at the efficacy of such interventions in
reducing the risk of HIV transmission among IV
drug users86.
Alcohol and HIV - Paths of linkage
The nation-wide behaviour surveillance survey
conducted by National AIDS Control Organization
(NACO) among clients of female sex workers, found
that nearly three-fourths of the respondents reported
ever having alcohol87. A recent study88 investigating
HIV prevalence and risk behaviours in men who have
sex with men (MSM)  found higher rates of
seroprevalence in MSM compared to non MSM
(6.5% versus 0.9%), and higher self report of ever
having suffered an STD. Use of alcohol and illicit
drugs was strong contributory factor even in this
population88.
Substance use can have a two-fold relationship
with HIV risk. Use of substances like alcohol, opioids,
cocaine etc., can lead to disinhibition and unprotected
sex with multiple partners89. On the other hand, a
common risk factor in form of a personality attribute
may underlie both alcohol use and high risk sexual
behaviour65. There is limited Indian literature on the
association of substance use (other than IV drug use)
and high risk sexual behaviour. A study of IV drug
abusers in Chennai found a significant association
between daily alcohol intakes and risky sexual
behaviour90. Carey et al91 investigated the prevalence
and correlates of HIV risk among 352 men receiving
treatment for substance abuse in India. About 13 per
cent of this sample reported to have engaged in sexual
practices associated with greater risk. Engaging in
risky sexual practices was associated with the
presence of a co-occurring psychiatric disorder and
higher scores on DAST.
Risk taking personalities and alcohol use: Studies
on sensation seeking and high risk sexual behaviour
in the context of alcohol use have shown that higher
sensation seeking is associated with multiple sexual
partners and that alcohol use might be a marker for
individuals who tend to have risk taking personalities
rather than a direct cause of risk taking behaviour 92,93.
Sensation seeking has been shown to have strong
relationship with substance use and risky sexual
behaviour in homosexual men. This indicates that
sensation seeking may be a personality variable, which
may predispose a person both for substance use as
well as high risk sexual practices72. In India, Chandra
et al94 investigated the patterns and level of sensation
seeking in alcohol dependent patients seeking
treatment at a mental hospital of south India. Of the
total 177 patients screened, 53 (30%) reported high
risk sexual behaviour in the last two years. This high
risk group was compared to a group of alcohol
dependent patients matched for age and diagnosis but
CHANDRA et al: HIV & PSYCHIATRIC DISORDERS
462 INDIAN J MED RES, APRIL  2005
without high risk sexual behaviour. In the high risk
group 57 per cent reported sex with commercial sex
workers, 97 per cent reported sexual contacts with
partners who were known for less than a day, while
90 per cent reported that their sexual partners had
other partners as well. All the high risk subjects
reported at least ten risky sexual encounters in the
last two years under the influence of alcohol. None
of the subjects in this group reported using condoms
during such sexual contacts and 47 per cent of them
reported being treated for STDs. The individuals in
this group had much higher total as well as individual
scores on different subscales of sensation seeking
compared to the low risk group. When the high risk
group was stratified into two subgroups based on their
risk scores, the subjects with higher risk scores had
higher disinhibition scores in the scale for sensation
seeking94. This finding emphasizes the relationship
between higher sexual risk taking and sensation
seeking as a personality attribute among the substance
using population.
Substance abuse among the HIV infected : The
impact of HIV infection on substance use has not
been studied in Indian context. Some interesting
findings have emerged from a study from the US95
examining the level of substance use and reduction
in seriousness of substance use in adults living with
HIV. In a sample of 3806 adults living with HIV with
alcohol being the most commonly used substance and
marijuana the most commonly used drug, 63 per cent
of participants had used hard drugs at some time in
their lives95. Almost half of patients living with HIV
(PLH) who had used hard drugs in their lifetime
continued to use hard drugs recently, suggesting the
pattern of substance use was habitual as opposed to
reflecting mere experimentation. Among those
continuing to use substances, 40 per cent reported
frequent use whereas 32 per cent reported occasional
and 28 per cent reported being abstinent. These
findings are troubling given the negative health
consequences to PLH themselves, and the increased
risks of transmission of HIV to others as a result of
unprotected sex. When factors distinguishing the
frequency of use were examined, health emerged as
a significant factor for those who abstained from
substance use. PLH who abstained from substances
reported better physical health. Abstainers were also
distinguished from occasional or frequent users by
their lower levels of depression and better mental
health functioning. In contrast, PLH who used
substances at frequent levels reported a constellation
of unhealthy behaviours. Besides frequent use of
substances, this group of PLH was more likely to be
diagnosed with hepatitis C or D and to have been
convicted of a crime. Further, in general, PLH who
used substances frequently were using drugs of high
seriousness, such as crack and heroin. These data
suggest that there are a significant number of PLH
that are in need of substance abuse treatment. When
the factors associated with the probability of reducing
seriousness in substance use were examined, the most
significant factor that emerged was time since HIV
diagnosis. The longer the PLH knew their HIV
positive status, the more likely they were to reduce
the seriousness of their substance use. Reduction in
the seriousness of substances used was most often
made by women. This probably reflects the greater
sensitivity of female gender for the therapeutic
intervention95.
Given the health risks posed by substance use
and its association with reduced medication
adherence, data suggest that substance abuse
treatment is essential in the care of PLH. Therefore,
screening and identification of substance misuse and
abuse, as well as referral for additional services,
should be included in all interventions aimed at
improving the physical functioning, mental health,
and quality of life of those living with HIV. It has
been reported that HIV infected persons with alcohol
problems who were engaged in stable substance
abuse treatment services, had reduced odds of
emergency department attendance. The authors
argue that such patients may have decreased intake
of alcohol which renders them less vulnerable to
develop acute complications. On the other hand,
homelessness was associated with more frequent
visits to the emergency department which probably
might result from poor adherence to substance
abuse treatment services and/or poor social support
systems96. These findings do not prove a causal link,
but suggest that substance abuse treatment providers
and primary care providers should work to link HIV
infected persons with alcohol abuse problems to
substance abuse treatment.
463
Conclusions
Despite the fact that the first report of psychiatric
disorders in HIV infection from India was published
more than a decade ago, it is only in the last few
years that systematic data have been collected and
published.
What we know- It is evident from the literature
reviewed that some aspects of psychiatric problems
and HIV infection are common to India and the rest
of the world, while there are certain factors that
acquire special importance. Rates of anxiety and
depression appear to be similar to the west. Suicide
appears to be a major mental health concern and so
do gender issues in psychiatric morbidity. Particularly
in the context of women, HIV risk seems to be high
in those with severe mental illness and places them
in a vulnerable position both in acquiring HIV and
provision of care. In addition, substance use and HIV
infection share links in the same manner as in the
West. In certain parts of the country, alcohol use
appears to be a major risk for HIV infection while
IVD use plays a major role in some parts of the country.
Factors that impact quality of life have been delineated
largely due to studies done by the World Health
Organisation and tools are available in local languages
to assess QOL. In addition, disclosure related issues
appear to link closely with psychiatric morbidity.
What we need to know- There are several gaps
and questions in the area that remain to be answered.
Some of the key culturally relevant areas needing
enquiry include  the role of stigma and disclosure in
psychiatric morbidity, the role of spirituality as a
protective coping mechanism, access to and cost of
health care among those with HIV infection and co-
existing psychiatric problems, and the utility of simple
pharmacological and psychological interventions in
management.
The next decade of research needs to build on
what we already have and answer more specific
questions related to interventions. The challenges that
HAART will bring among HIV infected in India, with
regard to treatment adherence and psychiatric side
effects is another area that will assume importance.
So far, behavioural research in India has not involved
the study of immunological parameters and this is
another area that needs attention.
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Health & Neurosciences, Bangalore 560029, India
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