|
It sometimes feels that an HIV/AIDS bandwagon is passing through Africa, and in order to be ?relevant? and caring, it is necessary to drop all else and join it. This is indeed a danger. Yet, the impacts of the virus are all-pervasive, and combating the epidemic needs thorough understanding from multiple perspectives. Mental health problems are both a risk factor and a consequence of HIV/AIDS, and they may interfere with treatment. In this article, we look briefly at two important interrelationships between HIV/AIDS and mental health and at some recent research results. PEOPLE LIVING WITH HIV
Impaired mental conditions make people more vulnerable to infection. Though current evidence is taken mainly from developed countries, local research increasingly points to a high vulnerability to infection in people with mental disorders, intellectual disabilities or who abuse substances. They may be susceptible to infection through decreased responsiveness to ?mainstream? educational messages, and, for some, greater impulsivity and an impaired ability to assert and protect themselves. From preliminary data collected by the HSRC?s Social Aspects of HIV/AIDS and Health Research Programme (SAHA) it also appears that the shock of a positive HIV diagnosis, and the ongoing depression linked with a positive status, make some people particularly vulnerable to reinfection. Following the diagnosis some people care little about their future and engage in risky behaviours while others may even seek a generalised ?revenge?. In this state, they may put others at risk of infection. The HI virus infects the central nervous system of a significant number of people. AIDS dementia and other cognitive disorders have been detected in as many as 50% of infected individuals. Psychosis may also be present in a proportion of people with advanced AIDS. Living with HIV/AIDS can be highly distressing and stressful. For some people this may be short-lived, cyclical and result in ?despondency? rather than a frank mental disorder. For others, disorders such as depression or anxiety resulting from their status may be serious enough to fundamentally impair functioning. This stressful condition is made more difficult by stigma and discrimination, difficulties in disclosure, lack of social support, difficulties with establishing and maintaining relationships, and inadequate services to deal with mental health problems. A large prevalence study currently in progress within SAHA should provide important additional information on a number of the above issues. Treating people with antiretroviral therapy (ART) has, together with ongoing prevention programmes, become the major health intervention for people living with HIV/AIDS. But rolling out treatment is a highly complex process. For example, it requires skilled health workers, access to high-quality laboratory services, an ongoing supply of low-cost drugs, and people to support the patient. In addition to the external or environmental factors needed for a successful rollout, it also needs people who are ready and able to start and sustain treatment. The ?internal? world of the person must be as robust and prepared as the external factors. If someone suffers from poor mental health ? and this is probably more than half of all people starting ART treatment ? the likelihood of them sustaining an ART programme is reduced. Again, one needs to rely mainly on research conducted in developed countries, but there is sound evidence that people with mental health problems are poor adherers to chronic medication ? including evidence of being poor adherers to ART. As a result of this a number of programmes exclude HIV sufferers, with substance abuse and mental disorders, from ART treatment. While this may be understandable, it is discriminatory and paradoxical to exclude people on the basis of direct or indirect symptoms of HIV/AIDS itself. Logic suggests that treating the mental health problem will increase the chances of better adherence, but thus far the scientific evidence is lacking. The HRSC and international researchers are currently planning a randomised, case-controlled study to investigate this. ORPHANED AND VULNERABLE CHILDREN
A second fundamental area where HIV/AIDS affects mental health is through parental illness and death. It has been projected that without major shifts in behaviour and comprehensive treatment programmes by around 2015 as many as one third of all children in South Africa will have lost one or both parents. The mental health impact of this is difficult to measure or even to imagine. Some research has started in African countries such as Uganda, Tanzania, Zimbabwe, Zambia and South Africa but the scope and approach of the research are not adequate to lead to clear policies and interventions. The peak of orphanhood in most countries is still some years off, and studying current mental health impacts may not reflect the cumulative problems that may arise when a much larger number of children are left without parents. It is true that many children have high levels of ?resilience? in the face of adversity and that predicting a mental health disaster for children is neither likely to be empirically correct, nor helpful. On the other hand, without stable homes and families in which to grow up, the emotional health of many children is likely to be severely compromised and interventions to prevent this are needed. Possibly the best intervention for children who have lost parents would be to place them in a family environment which will provide the nurturance and support critical to healthy development. A problem, though, is that as numbers of deaths of people of childbearing age increase, so do the pressures on older people and the availability of potential younger foster/adoptive parents decreases. Recent SAHA research, Guardianship in the Time of HIV/AIDS ? Realities, Perceptions and Projections. A mental Health Perspective, shows an extraordinarily high willingness, or ?in principle? agreement among family members to take orphans into their homes if needed. But the research also shows deep levels of poverty that will, in all likelihood, impede the good intentions of many. Old age is also likely to be an inhibiting factor. Pressures of number are likely to push many families to breaking point and unless assistance is provided, neither the willingness, nor the extended family structures, will save many children from life without an adult carer. Among various other considerations, the research looked at what people would require to ensure that an additional child, or children, would not overburden them. Though the child-care grant of R170 would be some incentive, mainly to the poorest of the poor, most people felt that this would hardly make a difference to their decision on whether to take in a child or not. However, a grant of R600 (similar to a foster care grant), or R1 000, was seen to make a considerable difference. Having education paid for was also seen as a considerable incentive ? in fact, on a par with receiving a R1000 grant. The ?internal? world of the person must be as robust and prepared as the external factors |
Many people also indicated that having a visit from a trained person, and help from time to time, would impact greatly on their decision on whether to take in a child or not. As more and more parents die, the need for government to make clear policies and to intervene to help families in need of assistance is obvious. Other people psychologically affected by HIV/AIDS include close family and friends, and formal and informal carers. Clearly, the relationship between HIV/AIDS and mental health is real and profound. It is also highly neglected. More research, leading to policy and service delivery, is needed in each of the above-mentioned areas to understand the effect of the epidemic on individuals, families and societies. Professor Melvyn Freeman is a Chief Research Specialist and Nkululeko Nkomo a Research Intern in the Social Aspects of HIV/AIDS and Health Research Programme.
|
