Throughout the course of HIV exposure, infection, diagnosis, and treatment, there are several stressful milestones that can produce normal anxiety responses. It is important to be aware of the anxiety-provoking nature of these events not only because of their treatment implications,
including the increased risk of suicide, but also because they may present opportunities to make meaningful mental health interventions.

Getting tested for HIV is one of the first milestones in HIV disease. Patients with high-risk behaviors should be encouraged to get HIV tested and to follow up on the results of testing. New, rapid methods of testing decrease the time from test to result, prevent patients from being lost to follow-up, and decrease the period of anxiety associated with waiting for results. This allows for earlier education about the disease, transmission, and treatment. As stressful as HIV testing is for the general population, HIV-exposed health care providers face unique choices in having to weigh the risks and benefits of taking postexposure prophylaxis for HIV (see Chapter 3).

After the diagnosis of HIV is confirmed, patients commonly experience a series of milestones as they adapt to and cope with their diagnosis and disease progression. These events can be classified into early, middle, and late phases of HIV disease; however, anxiety disorders can and do occur at any phase of illness, and providers should be ready to address them when they arise. When working with patients whose disease is progressing, providers should initiate discussions of the more difficult topics, such as loss of physical and mental health, lack of treatment response, and planning for death, if they do not naturally arise in the course of treatment⁶ (Table 9.1).

In the early phase of HIV diagnosis, stresses include adjusting to the diagnosis of HIV seroconversion, disclosing to others, adopting safer sexual and drug-using behaviors, and accommodating to medical treatment. Patients may experience fear of imminent death, guilt of infecting others or the risk thereof, and resentment at having to adapt their behaviors to their illness. Providers can help through this phase of illness by educating patients on the disease and making referral to education classes, peer-support groups, or other psychotherapies as appropriate (see also Chapters 7 and 8).

In the middle phase of HIV diagnosis, stresses include accommodating work and family needs to the physical and emotional impact of illness, learning about the illness and potential treatments, and adherence issues. Patients can face difficult decisions related to the uncertainty of the progression of illness and for some this can manifest as premature grief or traumatic death anxiety.³ Cognitive behavioral therapy, coping skills training, and individual psychotherapy can be particularly helpful to address these feelings. When patients begin antiretroviral treatment, they are faced with the challenges of medication side effects, they must adapt to living “by the numbers” of CD4 cells and viral load, and they adapt to the side effects of the medications, including fatigue and depression. Patients may have body-image problems related to lipodystrophy and wasting that may serve as constant reminders, to themselves and others, of their disease and add to their fear and anxiety. Treatments for HIV infection may physiologically induce anxiety and can cause a relapse to premorbid anxiety disorders, such as post-traumatic stress disorder (PTSD) or panic disorder, that had been considered to be in remission.⁷