Introduction
As the story goes, Mr X had HIV post exposure prophylaxis (better remembered as HIV PEP) after a risky sexual exposure. He couldn’t quite remember how many times he had HIV PEP, and this was probably the umpteenth time. This time, the prophylaxis failed. He was tested HIV positive 3 months after completion of his HIV PEP course.
Mr Y has multiple sexual partners, and occasionally he takes a gamble and conveniently forgets protective measures with commercial sex workers. He had always tested negative for HIV, and he knows HIV microbiology, HIV testing window period, and the various HIV tests available like the back of his hand. This time in Singapore, his HIV P24 antigen antibody test (also known as the HIV Combo or Duo test) came up positive.
For Mr X and Mr Y, their family physicians frantically referred them to HIV specialists in Singapore where further investigations and treatment can be initiated. But in due time, both Mr X and Mr Y went back to consult their family physicians for various medical issues.
So how should the family physician manage the HIV seropositive patient? Are there distinctive psychosocial issues to consider in their holistic management?
The Psychosocial Aspects of Living with HIV
The psychological hurdles and turmoil of a HIV seropositive patient cannot be overemphasized. Any chronic disease is difficult to manage in the emotional and psychosocial sense. However, this difficulty is further compounded by social stigmas, worsening quality of life, anticipated losses, fear, and uncertainty in the case of patients living with chronic HIV infection.
Patients diagnosed with a HIV positive status may respond with a wide range of negative emotions and reactions. They may feel guilt, denial, anger, numbness, shock, hopelessness and so on. In many ways, the patient might perceive an intense loss after receiving this diagnosis. The patient is, in fact, truly experiencing a loss – a loss of their previous lifestyle, good health, self-confidence, future plans and so on.
Depression
Depression is a fairly common psychological complication of living with HIV. In a project that explored the lives of women diagnosed with HIV, it was seen that all of them showed symptoms of clinical depression (Hackl, Somlai, Kelly & Kalichman, 1996).
There are different depressive symptoms that can manifest during the different stages of HIV disease. Certain symptoms of depression like poor appetite or insomnia can overlap with symptoms of HIV infection. Side effects from antiretroviral therapy can also be misconstrued as depressive symptoms.
Patients with poorer quality of life have a higher risk of depression. An important clinical variable that directly affects the quality of life of HIV patients is HIV staging (or more specifically, the CD4 count). Whether the patient has HIV infection with symptoms, asymptomatic infection, or full-blown AIDS was an important factor in their life quality. Hence the quality of life, and therefore the risks for depression, is different for different patients depending upon their clinical state (Nunes, Raymond, Nicholas, Leuner & Webster, 1995).
It must be emphasized that depression in itself has a potent, negative effect on patients living with HIV. For example, it has been linked to non-adherence or non-compliance to medication (Gonzalez et al., 2004). Therefore, family physicians managing their patients’ exposure risk with HIV post-exposure prophylaxis (HIV PEP) and HIV testing algorithms must remember to treat the patient holistically when making the unfortunate diagnosis of HIV seropositivity.
Social stigma
An important factor to consider when talking about HIV is the stigma associated with it. Stigma is a social construct, but nevertheless, it does have a powerful influence on the life of the patient, their loved ones and friends. It is a negative perception of the disease from society, and sometimes from the patients themselves, which creates a cause for discrimination.
It’s been suggested that the stigma related to HIV often is related to pre-existing prejudices against people of certain race, gender or sexual orientation (Parker & Agleton, 2003). Populations with negative societal attitudes toward HIV disease are more prone to acts of discrimination toward people living with HIV. These include populations that know little about the disease, or are not open to discussions concerning HIV and AIDS. Places with a low prevalence of HIV or where there is a lack of available resources for treatment have a higher likelihood of discrimination.
HIV and STD clinics in Singapore dealing with HIV post-exposure prophylaxis (HIV PEP) and HIV testing programs must be aware of local demographics and cultural sensitivities. Discrimination has a profoundly negative impact on the emotional and psychological state of patients living with HIV. It is a sociological factor that contributes to continued depression and decreased quality of life for HIV patients. Therefore, interventional programs that educate the population about HIV can reduce societal negative attitudes and discrimination, contributing to better life quality for HIV patients (Genberg et al., 2009).
Stigma doesn’t originate only from the outside, as patients can also experience internalized stigma that contributes negatively to their perception of the disease and their perception of themselves. Patients with a higher degree of internalized stigma are usually those who have recently received a positive diagnosis. These patients are more likely to have families that are less accepting of their disease. Also, these patients are less likely to attend HIV support groups, or know other people living with HIV. They are also more worried about spreading HIV to their loved ones. Internalized stigma likewise contributes to more severe depression, anxiety and hopelessness (Lee, Kochman & Sikkema, 2002).
People living with HIV have to deal with many issues relating to their illness, such as the possibility of a shorter life span, and the necessary changes they have to make in their lives.
With the development of better antiretroviral drugs, the HIV disease has also undergone a process of change. While it was previously seen as an acute ailment with little reason for optimism, it has now moved on to the category of subacute and chronic disease. The lifespan of HIV positive patients has significantly increased, so nowadays it’s highly achievable for them to live longer (Brown, Lourie & Pao, 2000).
Spirituality and social support
Spirituality is an interesting psychosocial aspect for physicians to consider. Amongst various personality traits and behaviors that can improve the psychological state of the HIV patient, it was assessed that spirituality could have a profoundly beneficial effect for HIV patients.
Spirituality was linked positively to greater social support, quality of life and coping strategies (Tuck, McCain & Elswick, 2008). The patient gradually develops the ability to deal optimistically with one’s disease. By seeing the spiritual dimension and meaning in life, the patient might be better equipped to handle his new HIV status, and even perhaps possible death in the far future.
Another psychosocial variable that seems to have a helpful effect is social support. Better social support was linked to better medication adherence and compliance (Gonzalez et al., 2004). Likewise, it is a strong predictor of a patient’s better quality of life (Nunes, Raymond, Nicholas, Leuner & Webster, 1995). The lack of social support, on the other hand, becomes a risk factor, especially in the case of children and teenagers. Those who are deprived of social support are usually those who live in poverty. Together with other psychosocial risk factors like inadequacy of medical resources and unemployment, the lack of social support can lead to a poorer outcome for the HIV patient (Brown, Lourie & Pao, 2000).
Sexual Relationships Post-Diagnosis
An important psychosocial aspect for physicians to address is the relevant, appropriate and responsible advice given concerning sexual behavior after a diagnosis of HIV seropositivity. A study in the United States concerning sexual activity among HIV positive people revealed that most unprotected sexual intercourse occurred with other HIV positive patients. However, around 19% of women, 15.6% of men who have sex with men (MSM), and 13.1% of heterosexual men would engage in unprotected sexual intercourse with those who are not HIV positive. This risky behavior would result in a significant number of new HIV infections. The study concluded that these figures were an underestimation of the actual prevalence of high-risk sexual behavior occurring with uninfected partners (Weinhardt et al., 2004).
Relevant advice from physicians to patients would help to reduce the public health concerns involved. Beside protecting uninfected partners, the use of condoms would help to prevent the spread of drug-resistant strains of HIV to other HIV positive patients.
A negative emotional state can be linked to risky behaviors like unprotected sex. Patients who experience negative emotions like shock or denial may not take the necessary precautions to protect themselves or their partners. It becomes necessary for physicians to address the mental state of the patient in order to stem the transmission of HIV.
Conclusion
As mentioned above, it is apparent that psychosocial aspects of management must be considered in dealing with HIV positive individuals holistically. Most people living with HIV have clinical depression or depressive disorders, and these psychiatric conditions need proper management and treatment in order to optimize health and antiretroviral treatment compliance.
Depression can be associated with stigmas, both internalized stigma (felt stigma or self-stigmatization) and external stigma (enacted stigma) due to societal discrimination towards the patient. Discrimination and harmful attitudes, in turn, have a destructive impact on the person’s emotional and psychological states. Patients with clinical depression may also be less compliant to treatment, thereby negatively affecting their physical health directly.
We have seen that social support is very important for people living with HIV. Social support has been linked to better adherence to treatment and quality of life. Another positive attribute was patient spirituality.
It should be noted that negative psychosocial factors usually co-exist. For instance, it’s common that HIV patients with poor social support will also possess a higher degree of internalized stigma and experience more depression. It’s also more likely that these HIV patients have limited access to medical care, be unemployed, or live in poorer conditions.
It is paramount for physicians to address the psychological and emotional states of HIV patients. It ultimately determines their adherence to antiretroviral treatment and their willingness to engage in safe sexual practices. In due course, this benefits the health of the patients and their partners.
References
Brown, L., Lourie, K. & Pao, M. (2000). Children and Adolescents Living with HIV and AIDS: A Review. Journal of Child Psychology and Psychiatry, 41 (1), pp. 81-96.
Genberg, B. et al. (2009). A comparison of HIV/AIDS-related stigma in four countries: Negative attitudes and perceived acts of discrimination towards people living with HIV/AIDS. Social Science and Medicine, 68(12), pp.2279-2287.
Gonzalez, J. S.; Penedo, F. J.; Antoni, M. H.; Durán, R. E.; McPherson-Baker, S.; Ironson, G; Fernandez, I.; Klimas, N.G.; Fletcher, M. & Schneiderman, N. (2004). Social Support, Positive States of Mind, and HIV Treatment Adherence in Men and Women Living With HIV/AIDS. Health Psychology, 23(4), pp. 413-418
Hackl, K.L., Somali, A.M., Kelly, J.A. & Kalichman, S.C. (1996). Women Living with HIV/AIDS: The Dual Challenge of Being a Patient and Caregiver. Health Social Work, 22(1), pp. 53-62.
Lee, R., Kochman, A. & Sikkema, K. (2002). Internalized Stigma Among People Living with HIV-AIDS. AIDS and Behavior, 6(4), pp. 309-319.
Nunes, J., Raymond, S., Nicholas, P., Leurner, J. & Webster, A. (1995). Social Support, Quality of Life, Immune Function, and Health in Persons Living with HIV. Journal of Holistic Nursing, 13 (2), pp. 174-198.
Parker, R. & Agleton, R. (2003). HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Science, 57 (1), pp. 13-24.
Tuck, I., McCain, N. & Elswick, R. (2008). Spirituality and psychosocial factors in persons living with HIV. Journal of Advanced Nursing, 33(6), pp. 776-783.
Weinhardt LS et al. (2004). HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States. Journal of Acquired Immune Deficiency Syndromes, 36(5), pp.1057-66.
Note: I hope this article serves as a timely reminder to all family physicians that manage HIV seropositive patients. Likewise, these psychosocial factors should be considered in the event that their HIV seronegative patients become HIV positive. It is, of course, hoped that with advanced antiretroviral regimes, HIV post exposure prophylaxis (HIV PEP), and proper HIV and STD testing algorithms, these cases would not continue to increase.
