Wainberg et al. note that mental disorders in HIV-positive individuals are often comorbid with one another; therefore, HIV-positive individuals with one type of mental disorder should be screened for other types of mental disorders, especially alcohol and substance use disorders. However, the majority of studies described have been conducted in high-income countries (HICs). Given that the burden of both common and severe mental disorders is greater in LMICs than in HICs, there is an urgent need for more research to delineate the epidemiology of mental disorders amongst HIV-positive populations in LMICs.

The relation between HIV/AIDS and mental disorder is bidirectional. Some studies have examined mental disorders in those with HIV/AIDS whilst others have examined HIV infection in those with mental disorders. The mechanisms that underlie this relationship are complex and are not completely understood [2]. Nevertheless, the distinction between HIV-related mental disorders and primary mental disorders comorbid with HIV infection where possible would be equally important. For example, studies conducted in Uganda [3, 4] indicated that HIV-positive individuals with secondary mania were older when they had their first episode of affective symptoms, had less education and were more likely to be unemployed but more responsive to psychotropic drugs than HIV-positive individuals with bipolar mania.

In resource-limited settings, detailed demographic and past psychiatric histories may help diagnose the specific manic syndrome. Treatment of early manic symptoms in general medical settings would prevent affected individuals from progressing to severe manic states that may disrupt compliance with their treatment regimens. However, such evaluations can only be realized if co-management of mental health problems is an integrative part of HIV treatment and prevention programs.

Again, most studies of HIV seroprevalence in individuals living with SMI have been undertaken in HICs. A systematic review of such studies showed HIV seroprevalence rates ranging from 3% to 23% amongst patients with SMI [5]. The higher HIV seroprevalence rates amongst people with SMI in LMICs especially Sub-Saharan African countries including Zimbabwe [6, 7], Uganda [8] and South Africa [9, 10] have underscored the importance of giving particular attention to HIV prevention amongst people with SMI in LMICs [11].

Individuals with SMI, particularly those with mood disorders, engage in high rates of sexual risk behaviours associated with HIV infection, including multiple sex partners, unprotected intercourse and sex trade [12]. Research on the mechanisms underlying the association between pre-existing mental disorders and HIV infection is limited. However, it has been hypothesized that symptoms such as impulsivity, disinhibition, poor judgment and hypersexuality may predispose affected individuals to risky behaviours such as unsafe sexual practices resulting in acquisition of HIV infection [13].

Previous epidemiological studies conducted in HICs make it clear that persons living with an SMI are more likely to be victims of sexual coercion and intimate partner violence, to live in risky environments, to have unstable partnerships in high-risk sexual networks, to use substances that impair decision making and to lack the emotional stability, judgment and interpersonal skills needed to avoid risk [14].