Mr. A., a 26-year-old gay White man, requested HIV testing after learning that a former partner was ill with AIDS. For the first 6 months after receiving the positive test result, Mr. A. went about his life as if nothing had changed. Eventually, with persistent encouragement by a friend, he made an appointment with an infectious disease specialist. The week before his first appointment he experienced the first in a series of panic attacks.

Denial and avoidance are common responses to learning one’s HIV status. Persistent denial may have major implications, such as ongoing high-risk behaviors that involve exposure to HIV, hepatitis, and other sexually transmitted infections (STIs) and the delay of medical care. Denial may be a defensive alternative to emotional flooding. Despite widespread public knowledge of
treatment advances, it is not uncommon for newly diagnosed individuals to fear that death is imminent. As denial erodes, new symptoms of anxiety or depression may emerge.

Other common responses to one’s initial awareness of HIV serostatus are anger, outrage, and feelings of betrayal. Transient suicidal or homicidal feelings may develop. Effective pretest and post-test counseling helps patients anticipate and cope with their initial responses to HIV infection. Pretest counseling may identify individuals who would benefit from psychotherapy to shore up psychosocial functioning before HIV testing. Similarly, post-test counseling provides an opportunity for referral to a mental health provider.

There is a high rate of HIV infection among people with chronic mental illness. The risk of exposure to HIV is increased by the impulse control difficulties and hypersexuality present with mania, the poor reality testing associated with psychosis, the low self-esteem and poor self-care common to depression, and the impaired judgment that accompanies substance abuse disorders. Some patients may already be in mental health care when they become seropositive. Entry into the health care system for HIV disease care may encourage other patients to seek mental health care for preexisting but untreated psychiatric disorders. Psychiatric treatment is often a necessary precursor for adherence to the complexities of medical treatment. In addition, psychoeducation to convey the importance of and enhance the skills required for safe sex and safe needle use is important for both patient safety and public health. The combination of psychotherapy and psychopharmacology has repeatedly been demonstrated to be more effective than psychopharmacology alone for a variety of chronic psychiatric conditions, including schizophrenia, bipolar disorder, major depression, and anxiety disorders.

Psychotherapy plays a vital role in adjustment to medical illness. Psychosocial variables that have been demonstrated to predict a higher level of well-being and a lower level of depressed mood in HIV-infected patients include social support, problem-focused coping, and the attribution of positive meaning (i.e., appraising HIV as having created an opportunity for personal growth).¹ Consider the following case example of Ms. B.

Ms. B., a 34-year-old mother of two with major depression who had abused cocaine for 12 years, entered both mental health and substance abuse treatment after learning she was HIV-positive. Twelve months into treatment, abstinent and euthymic, she declared, “HIV is the best thing that has happened to me. It scared me into treatment because I realized I had to get my act together. Now I’m a happier person and a better mother.”

People living with HIV disease mourn the loss of their health, appearance, mobility, career and financial security, and ultimately the loss of life. Many have experienced the HIV-related deaths of spouses, partners, children, friends, and other members of their social network. “Bereavement overload” occurs when a fresh loss interrupts the grieving process, making it impossible to grieve each loss completely.² Multiple losses may alter a person’s ability to trust or to form new relationships and may affect the ability to engage in psychotherapy. Therapists will be faced with talking about loss and death and will encounter their own grief.

The social isolation of people living with HIV disease or AIDS, which stems mostly from stigma, is a psychological death experience that precedes the physical death.² HIV infection
often is associated with gay men and intravenous drug users, groups that are often judged negatively and rejected by others. Patients are frequently afraid or ashamed to disclose their serostatus, and when they do reach out they are vulnerable to discrimination and rejection, as well as others’ irrational fears of infection.

In the 1980s and early 1990s, the psychiatric literature on HIV disease and AIDS focused on depression, dementia, death, and dying. At that time, most people with HIV infection expected to die within 2 to 3 years. After protease inhibitors became available in 1996, HIV infection shifted from a fatal illness to a chronic illness for many, but not all, patients. Survival is contingent upon strict, lifelong adherence to complex multidrug regimens, and patients are subjected to chronic anxiety that their regimens may fail. Psychotherapy may help patients identify and ameliorate the environmental and psychological barriers to adherence.

Ms. C., a 40-year-old woman with dysthymia and HIV infection, was referred to a therapist by her primary care provider because of repeated refusal to take antiretroviral medication despite a falling CD4 count, rising viral load, and mounting fatigue. In therapy she recognized that her chronic low self-esteem and feelings of hopelessness were worse every time she came to the clinic or thought about her HIV status. She believed that taking medication twice daily would represent an intolerable reminder of her seropositivity and that she would become suicidal. She also worried that the antiretrovirals would not work for her, in which case she would feel more despair than she could endure. To her, to not take antiretrovirals and become ill seemed better than to fail the antiretroviral therapy having tried to stay well. With psychotherapy and antidepressants, she tentatively agreed to a trial of antiretroviral medication. Pleased with the improvement in her energy level brought about by suppressed viral replication, she found it easier to commit to ongoing antiretroviral therapy.

Long-term survival exerts other stressors besides those associated with medication adherence. HIV seropositivity forces an adjustment of self-concept as the serostatus is integrated into one’s identity. This is reflected in patients’ language, such as when they say, “I am HIV.” Whether a patient can accept the challenge of this crisis and achieve successful integration depends on ego strength, which is determined in part by early childhood experiences involving separation. One of the therapist’s tasks is to explore earlier experiences with loss, learn how the individual coped with those losses, and help mobilize the patient’s inner resources to adapt to the current challenge to his or her integrity.

In addition to coping with adjustments in identity, HIV-positive patients may experience an acceleration of the usual stages of psychological development. HIV infection challenges young people in the first half of life to take on the developmental tasks of the second half of life. Adolescence and early adulthood are concerned with the developmental issues of separation, identity, independence, establishing relationships, gaining status in society through work, and learning to create and enjoy a meaningful life. HIV infection disproportionately affects people in the first half of life and thrusts them into a confrontation with the tasks of later adulthood and old age. In the second half of life there is a gradual letting go, a decline of aims and ambitions, reflection, awareness and acceptance of the choices and limitations in one’s life, and a passing on to the next generation the experiences and wisdom one has
acquired. Erik Erikson’s final stage of development, Integrity versus Despair, is the fulfillment of the successful negotiation of prior stages, resulting in a sense of having lived a productive and worthwhile life. Some HIV-positive patients achieve remarkable self-understanding and self-acceptance as they accelerate their progression through the developmental stages.

Mr. D., a 37-year-old man who developed multidrug resistance, has run out of antiviral treatment options and knows that death is approaching. He initiates therapy to cope with his anxiety and because he has a goal to “live his dying.” In therapy he resolves his hurt and anger about adolescent and adult encounters with homophobia, achieving a new compassion and understanding for people with narrower views of human behavior. He also develops new compassion for himself, understanding the forces that propelled him to seek community and thus engage in high-risk behaviors. He deepens his relationship with his sister, to whose home he moves to live his last months of life. He and his sister both understand this is a gift they are giving to each other, sharing the intimacy of dying.

Although this process may result in positive growth for some, the challenge of prematurely facing the developmental tasks of old age may overwhelm some patients’ ego capacity. Conversely, an internal renegotiation may be required for those patients who have confronted and accepted their deaths, only to be restored to better health by new treatment options.

An individual’s religious or spiritual belief system may help or hinder the adjustment to a potentially fatal illness. Spiritual beliefs are important determinants of one’s outlook on death. Many patients with HIV infection feel alienated by religious institutions that are intolerant of alternative lifestyles. In the absence of a safe spiritual community, patients may lack opportunities to understand and modify their beliefs about illness and death. In therapy, patients may explore their feelings about God and religion and assess how HIV disease affects their spiritual development.

Mr. E., a 45-year-old man raised as a Mormon, entered therapy because of intolerable feelings of anger, depression, and guilt. He struggled with childhood indoctrination that homosexuality is evil and that HIV infection is his punishment from God. The resulting guilt and shame coexisted with anger at his religion’s belief system, which he rejected at an intellectual level. Psychotherapy helped him reframe the meaning of his HIV infection and reduced his feelings of shame and anger.

Cognitive-behavioral therapy (CBT) is a short-term, collaborative treatment that was specifically designed to alleviate major depression, but its techniques are equally effective in the treatment of anxiety disorders, insomnia, habit reversal, eating disorders, and other conditions. CBT includes a range of interventions that promote changes in thinking or behavior to alter mood or other symptoms. It includes objectively examining patients’ perception of their problems and by doing so altering their interpretation and response. By simply addressing patients’ perception of their situation with HIV, their response may begin to change. In addition to formal CBT, a variety of CBT-based techniques have been developed, including forms of arousal reduction (biofeedback, guided imagery, progressive muscle relaxation, hypnosis) and coping effectiveness training. Many of these techniques have been studied in men and women with HIV infection and found to reduce stress, anxiety, and depression and improve markers of immune function.³⁴ In addition to reducing psychological distress, CBT diminished pain intensity, pain-related interference with functioning, and measures of distress in patients with HIV disease or AIDS with peripheral neuropathy.⁵ A CBT intervention was used successfully to improve antiretroviral medication adherence.⁶