Epidemiology
Margarita Alegría
Doryliz Vila
Sarah Train
Sandra Williams
Nabila El-Bassel
This chapter provides an overview of the epidemiology of the human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) and its co-occurrence with psychiatric morbidity. It is organized into six general topics: (a) the epidemiology of HIV; (b) the psychiatric epidemiology and types of co-occurring psychiatric disorders of patients with HIV; (c) psychiatric morbidity and HIV disease progression and mortality; (d) factors associated with increased psychiatric morbidity or psychological distress in persons living with HIV/AIDS; (e) the social, psychological, and contextual challenges of living with HIV; and (f) epidemiologic implications for the delivery of mental health and substance abuse services. It is critical to identify and treat comorbid mental illness among people living with HIV/AIDS, for such identification will improve their quality of life, increase their health outcomes, and augment their survival. The elevated risk for psychiatric conditions may be directly caused by HIV/AIDS, be exacerbated by the illness, or be a precursor to the HIV disease. Understanding the manifestations and challenges of the co-occurrence of psychiatric disorders and HIV/AIDS will help practitioners provide strategies to persons with these co-occurring disorders so they can adapt well to the challenges, avoid disease progression, and receive appropriate care.
Epidemiology and Risks
According to the Centers for Disease Control and Prevention (CDC) HIV/AIDS surveillance report through 2003, approximately 850,000 to 950,000 persons in the United States are living with HIV and an estimated 929,985 (749,887 cases in males and 170,679 cases in females) have a diagnosis of AIDS.1 Worldwide, 38 million people are living with HIV. U.S. surveillance reports from 2000 to 2003 indicate that the overall annual rate of diagnosis of HIV/AIDS has remained stable over this period, with an increase of 3% in the annual rate in males and a decrease of 3.7% in the annual rate in females.2
The ranking of transmission using age-adjusted rates demonstrates that men who have sex with men (MSM), injection drug users (IDUs), those who are both MSM and IDU, and people exposed to high-risk heterosexual contact had the higher annual rates of diagnosis in
2000 to 2003. The transmission categories with the largest proportion of males with HIV were MSM (61.2%), high-risk heterosexuals (17.3%), and IDUs (14.6%); the transmission categories for the largest proportion of women were high-risk heterosexuals (77.7%) and IDUs (19.4%).2
2000 to 2003. The transmission categories with the largest proportion of males with HIV were MSM (61.2%), high-risk heterosexuals (17.3%), and IDUs (14.6%); the transmission categories for the largest proportion of women were high-risk heterosexuals (77.7%) and IDUs (19.4%).2
There is a disproportionate incidence of HIV by race and ethnicity. Incidence of HIV is greater in minority men compared with that in White men, independent of the route of transmission.3 The disparity in the HIV rate of non-Latino Black women is 19 times higher than White women.2 A change in annual age-adjusted rates from 2000 to 2003 shows that the rates among non-Latino White males (6.2% change) and Asian Pacific Islander males (39.7% change) are increasing while the rate for non-Latino Black females is decreasing (6.0%), with no statistically significant change in the other racial or ethnic groups.2 However, it should be noted that non-Latino Black women accounted for 13% of the population included for surveillance purposes but represented 51.3% of the HIV/AIDS diagnoses during 2000 to 2003. Women also account for an increasing percentage of all AIDS cases (6.7% in 1986 to 18% in 1999),4 with a disproportionate increase for Black women living in the South. Also of importance is the finding—using trends of AIDS surveillance data to estimate the past incidence of HIV infection—that 66% of HIV-infected young people who had acquired the infection heterosexually were minorities, although they represented only 27% of the total U.S. population born during 1988 and 1993.3
Homosexual contact appeared as the major means of transmission among young men, whereas heterosexual contact was the key mode of infection for young women.3 In White, Black, and Latino male teenagers and young adults, risk of HIV transmission through homosexual contact was considerably higher during the adolescent years but decreased as they became young adults. HIV incidence ascribed to heterosexual contact was found to be rising or constant in the successive birth cohorts, particularly among women. While HIV prevalence dropped approximately 50% for White young men aged 20 to 25, HIV prevalence increased 36% to 45% for women in that same age cohort.
There is a growing recognition of the necessity to identify social and structural factors that have an impact on HIV risk. Isolating the risk environments (i.e., those risk factors that are exogenous to the individual but place the individual at risk for the disease)5 is critical because these environments appear linked to variation in population behavior in response to divergent social, cultural, economic, and political forces.6 For example, residence in neighborhoods where there is a preponderance of sex work and crack cocaine is a predictor of increased HIV risk.7 However, this finding may be a surrogate for “risk that an individual’s sex partner is HIV positive” rather than represent an environmental risk.
There are many independent predictors of HIV infection in community samples: having a history of sexually transmitted diseases (STDs), Latino having multiple sexual partners, and exchanging money or drugs for sex.7 The main risk factors may differ among groups. A recent case-control study of older adults found that in this population a history of STDs, positive hepatitis B status, and certain medical history parameters (including the albumin to globulin ratio) were more likely in HIV-positive adults than in controls.8 A study of 1,800 IDUs found that risk factors for HIV differed by gender. For males, drug-related risk factors (such as needle sharing) and homosexual activity were the most important predictors, but for females, factors related to high-risk sexual activity were the most important predictors.9
Psychiatric Epidemiology and Types of Co-Occurring Psychiatric Disorders
Psychiatric morbidity in persons with HIV was detected early in the epidemic.10 A 1996 epidemiological study of a nationally representative sample of adults (aged ≤ 18 years) receiving care for HIV in the United States showed that 47.9% demonstrated positive status for at least one psychiatric disorder on screening in the previous 12 months.11 More people
receiving care for HIV demonstrated positive status for major depression (36.0%) and dysthymia (26.5%) than for generalized anxiety disorders (15.8%) and panic attacks on screening in the previous 12 months (10.5%).11 The positive screen rates for current psychiatric disorder in HIV-infected persons receiving medical care compared to rates in the general population were eight times greater for generalized anxiety disorder, five times greater for major depression, and four times greater for panic attacks.11
receiving care for HIV demonstrated positive status for major depression (36.0%) and dysthymia (26.5%) than for generalized anxiety disorders (15.8%) and panic attacks on screening in the previous 12 months (10.5%).11 The positive screen rates for current psychiatric disorder in HIV-infected persons receiving medical care compared to rates in the general population were eight times greater for generalized anxiety disorder, five times greater for major depression, and four times greater for panic attacks.11
Estimates of the lifetime and past year prevalence of psychiatric disorders in persons living with HIV/AIDS may differ substantially depending on the sample and comparison groups. Data on HIV-infected women at the South Texas AIDS Center for Children and Their Families demonstrated that over 60% met criteria for at least one current Axis I psychiatric disorder, with major depressive disorder and substance disorders being the most prevalent.12 However, studies of gay men have established few differences in current psychiatric disorders between infected and uninfected gay men.13 A study of inmates diagnosed with HIV infection revealed that psychiatric disorders were significantly more common among the HIV-infected inmate population (89% men) than their noninfected counterparts, even after age, gender, and race adjustments: current major depression (6.05% versus 2.21%), dysthymia (3.24% versus 0.72%), bipolar disorder (1.51% versus 0.98%), and schizoaffective disorders (1.12% versus 0.53%).14
A wide spectrum of psychiatric disorders have been directly or indirectly associated with HIV/AIDS: delirium, HIV-associated dementia, HIV-associated mania, minor cognitive motor disorder, adjustment disorders, anxiety disorders, mood disorders, personality disorders, psychotic disorders, sexual disorders, sleep disorders, and substance disorders. Some investigators argue that the high prevalence of psychiatric disorders among persons with HIV may reflect high rates of preexisting affective and substance abuse disorders or increased risk for HIV infection among those with mental disorders and drug abuse. Others posit that anxiety, depression, and emotional distress may be, for some, a response to learning that they are seropositive or to subsequent symptoms and disability associated with HIV15
Major depression and substance disorders appear as frequent co-occurring psychiatric disorders in persons living with HIV/AIDS. In a longitudinal cohort study of HIV infection in women, a diagnosis of current major depressive disorder was four times greater in HIV-seropositive compared to HIV-seronegative women (19.4% versus 4.8%).16
There is evidence of increased risk of suicidal ideation and attempts in people with HIV/AIDS, particularly among HIV-positive women.17 Data from Project WAVE (Women, AIDS, and Violence Epidemic) revealed that HIV-positive women were five times more likely than HIV-negative women to have ever attempted suicide.18
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