Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) together are a worldwide pandemic that continues to be a major health problem despite treatments that bring lengthy periods of remission. It does not affect all segments of the U.S. population equally. AIDS is now the number one cause of death for African Americans between the ages of 25 and 44.¹ African-Americans represent only 12% of the total U.S. population, yet almost half of all new AIDS cases reported in 2003 were African Americans. Over three quarters of all women with AIDS were Black or Hispanic, and 81% of all children with AIDS were Black or Hispanic.¹ Thus African-American women are 23 times more likely to be infected with AIDS than White women.² African-American men are almost 9 times more likely to be infected with AIDS than White men. Moreover, from 1999 to 2003 the numbers of HIV infection and AIDS diagnoses were consistently higher among non-Hispanic Blacks than among other races and ethnicities. In the 32 states with HIV infection reporting, the HIV infection and AIDS diagnosis rate in 2003 was 74 per 100,000 for Blacks, 25 per 100,000 for Hispanics, 11 per 100,000 for American Indians/Alaska Natives, 9 per 100,000 for Whites, and 7 per 100,000 for Asians/Pacific Islanders. The rates for persons living with HIV disease or AIDS at the end of 2003 were highest for Blacks (765 per 100,000) and Hispanics (220 per 100,000).³

The pattern of how the disease is acquired appears to differ by ethnicity. African Americans appear to be at greater risk of heterosexual and substance abuse spread rather than men with men. The majority of Black women with HIV contracted it from heterosexual sex.² However, a disproportionate number of their partners also had male partners, were substance abusers, or both. A survey of low-income women found that AIDS was ranked as the most important health concern.⁴ There continues to be a steady rate of increase of new cases, especially among teenagers and those in their twenties. This suggests that current efforts in HIV prevention strategies have failed in the African-American communities.

We will present a case report that shows the complexity of these issues.

At first glance, the major risk factor seems to be a history of substance abuse. Injectable agents such as opioids contribute to spread because of their risk for intravenous transmission. Cocaine and even alcohol or marijuana can increase the risk of contracting AIDS because they can increase the likelihood of high-risk sexual behavior. However, there is another factor that George admitted almost as an afterthought, and which contributed to his anxiety. He had had male sexual encounters. He fervently denied being gay.

George is one of many African-American men living “on the down low,” which along with having addicted partners, probably contributes to significant heterosexual spread of AIDS and the increased risk of infection for African-American women.⁵,⁶ The down low represents a secret sexual lifestyle for Black men who are married or have girlfriends, but are also secretly sleeping with men. Down low men distinguish themselves from gay men by not embracing the gay culture, and not being in “relationships.” Down low refers to “gratification not orientation”; that is, the desire to have male-to-male sex. There are perhaps several reasons for the secrecy. One is the taboo of homosexuality in the African-American community; a taboo that visits shame on the family and implies weakness of character for the homosexual member. Also, many African-American women see men who choose a gay lifestyle as reducing the pool of available African-American men at a time when there is a shortage of potential male sex partners.⁷ This openly discriminatory attitude, pervasively practiced within the African- American community, invokes fear of disclosure of one’s sexual orientation.

In addition, many African-American men who see themselves as heterosexual may participate in homosexual behavior for opportunistic reasons, which may be a factor in the development of the down low culture. Men in settings where there are no women available, such as the correctional system, may participate in such sex and continue the behavior once they are released.

African-American men make up 50% of correctional system inmates and are far more likely to be incarcerated than their White counterparts.⁸ Some of the highest rates of HIV infection are found among jails and prisons because of the high frequency of drug-related sentences and high-risk behaviors that occur within these institutions. When former felons are released to the community, they may continue this high-risk sexual behavior and become infected or they may already be infected. The result is a public health concern and an important contributor to the heterosexual spread and risk for women and their children.

HIV is neuropathic, invading the central nervous system (CNS) early during the initial period of infection. Although HIV does not infect neurons in the CNS, it causes neuronal death by other mechanisms. HIV infection of microglial cells in the CNS causes the elaboration of neurotoxins that, in turn, cause neuronal damage.⁹ Consequently, HIV infection can lead to neuropsychiatric syndromes that can occur at various stages of infection.¹⁰ AIDS has been proposed as a direct contributor to mental disorders because the AIDS virus infects neurons early in the course of the illness. Anxiety disorders are the most common, but other neuropsychiatric disorders may also be seen, including depression, dementia, and psychosis.¹¹,¹²

Awareness of AIDS is also a risk factor for depression and anxiety, as the case report discussed illustrates. AIDS awareness has also been associated with post-traumatic disorder.¹³

Patients with mental disorders can be at greater risk for AIDS because substance abuse is often a comorbid condition with mental illness.¹⁴ Moreover, mental disorders and substance abuse illnesses may lead to high-risk behavior associated with HIV spread.¹⁵

Mental disorders may affect the course of AIDS.¹⁶,¹⁷ Depression may occur in as many as a third of AIDS patients and may be associated with increased morbidity and mortality.¹⁸ It may also contribute to the higher suicide rate associated in gays with AIDS.¹⁶

Mental illnesses can decrease medication compliance and treatment plan adherence. Multiple and timed pill taking are still necessary in AIDS treatment, although highly active antiretroviral therapy (HAART) has reduced many neuropsychiatric complications. However, studies of antiretroviral treatment continue to indicate that near-perfect adherence is needed to adequately repress viral replication. About 95% adherence is necessary to prevent the emergence of resistant strains.¹⁹ The importance of mental health treatment is shown by the finding that depression is associated with poor adherence and the finding that ongoing high- risk sexual behavior is predicted by higher levels of depression and recreational drug use.¹⁵ Moreover, 10% of men with severe mental disorders, such as schizophrenia, reported same- sex sexual encounters, despite denying that they were bisexual or gay, thus suggesting that the mental disorder may affect judgment of high-risk behavior.²⁰

Disparities in the burden of mental illness for African Americans have been well documented. African Americans are more likely to be diagnosed with a severe mental illness, such as schizophrenia, when they have a mood disorder.²¹ As noted above, psychiatric disorders affect many aspects of HIV infection. For example, failure to recognize a psychiatric disorder could result in the missing of a key determinant of morbidity and the course of illness. Mood disorders are often not diagnosed or misdiagnosed in African Americans.²² Yet, as noted, depression has been associated with both a shortened survival and poor adherence.

African Americans are less likely to be treated for mental disorders. The Surgeon General commissioned a study of ethnicity and mental illness, which concluded that ethnic differences in prevalence of mental disorders were relatively small.²³ However, African Americans experienced more illness burden. A subsequent Surgeon General report and a nationwide survey of diagnosis and treatment services found that, for a variety of reasons, treatment is less accessible, especially state-of-the-art treatment.²⁴,²⁵ Psychotherapy is often not provided. Medication or emergency care is more likely to be provided as treatment when services are provided. Antipsychotic medication, in particular, is more likely to be provided in higher doses, which increases the risk for side effects.²⁵ Patient issues are also important because African Americans are less likely to seek mental health treatment because of stigma. Medication is also more likely to be refused, and noncompliance is more common.²⁶ However, provider variables are also important because many ethnic differences disappear when the provider is willing to engage with the patient.²⁷

The number of HIV-positive, mentally ill African Americans has not been reported. Nevertheless, one recent study estimated that 13% of people with HIV disease receiving care in the United States in 1996 had co-occurring psychiatric symptoms and either or both drug dependence symptoms or heavy drinking.²⁸ Sixty-nine percent of those with a substance- related condition also had psychiatric symptoms; 27% of those with psychiatric symptoms also had a substance-related condition. Comorbidity was also more common in heterosexual African-American men. The convergence of these disorders has clearly contributed to the devastation that this virus causes in the African-American community. The combination of stigma associated with AIDS and mental illness, the lack of services for both conditions, and
the under-recognition of both conditions, early in their courses, certainly contribute to the spread and poorer prognosis of HIV infection in the African-American community.

Affective disorders are the most common psychiatric diagnosis among HIV-positive men. Although HIV may have a direct effect on the brain, leading to depression, psychosocial factors certainly play a role, including the loss of loved ones and friends who might have been infected. Moreover, in a well-controlled study, depression was found to contribute both to nonadherence to AIDS pharmacotherapy and to a faster disease progression.²⁹ Mania or frank bipolar disorder has been associated with AIDS and may be directly related to the infection of key areas of the brain.³⁰,³¹ Mania has also been associated with AIDS pharmacotherapy.³² As noted above, anxiety is also common, which is produced either from the virus directly or from the chronic worry associated with having this disease and the resulting disruption in the usual activities of daily living.¹¹