|Year : 2012 | Volume
| Issue : 1 | Page : 55-60
Psychosocial correlates of human immunodeficiency virus infected patients
Megha Agrawal1, Kalpana Srivastava1, Sunil Goyal1, Suprakash Chaudhury2
1 Department of Psychiatry, AFMC, Pune, India
2 Pravaara Institute of Medical Sciences, Rural Medical College and Pravara Rural Hospital, Loni, Ahmednagar, Maharashtra, India
|Date of Web Publication||22-Apr-2013|
Department of Psychiatry, Pravaara Institute of Medical Sciences, Rural Medical College and Pravara Rural Hospital, Loni 413 736, Ahmednagar, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Reactions of people to a diagnosis of HIV and its effect on well-being vary greatly. There is paucity of Indian studies in this area. Aim: To assess the level of anxiety, depression and quality of life in HIV seropositive individuals. Materials and Methods: It was a descriptive cross-sectional study with a sample size of 50 seropositive individuals. They were assessed using a specially prepared proforma containing several questions pertaining to their demographic profile, details of HIV status and high-risk behavior, questions on family support and discrimination. In addition, all subjects were evaluated with WHO well-being index, General Health Questionnaire (GHQ), and Hospital Anxiety, and Depression Scale. Results: Anxiety was noted in 54% of the individuals whereas only 30% suffered from depression. GHQ showed psychological morbidity in 44% individuals. WHO well-being index noted poor psychological well-being in 46% of individuals. Conclusion: The high level of anxiety and depression in HIV seropositive subjects reiterates the importance of psychological counseling in HIV afflicted individuals in conjunction with suitable pharmacotherapy.
Keywords: Anxiety, depression, human immunodeficiency virus, psychological well-being, psychosocial correlates
|How to cite this article:|
Agrawal M, Srivastava K, Goyal S, Chaudhury S. Psychosocial correlates of human immunodeficiency virus infected patients. Ind Psychiatry J 2012;21:55-60
Acquired Immunodeficiency Syndrome (AIDS) has emerged as one of the major challenges of the modern world. In spite of, awareness and education about this disease, a HIV patient is still considered to be a social outcaste and is treated bitterly by the community at large. AIDS has become a serious cause of concern globally because of the extent of its spread and the impact it has on those affected. There is a decline in the rates of HIV infection globally; there were an estimated 34 million (31.4-35.9 million) people living with HIV in 2011. The annual number of new HIV infections declined from 3.0 million (2.6-3.5 million) in 2001-2.5 million (2.2-2.8 million) in 2011. Overall, 1.7 million (1.5-1.9 million) people died due to AIDS in 2011, compared with an estimated 1.7 million (1.5-2.3 million) in 200. However, the number of people living with HIV worldwide continued to grow in 2011. In fact, the total number of people living with the virus in 2011 was more than 20% higher than the number in 2000, and the prevalence was roughly threefold higher than in 1990.  In India, the revised estimates showed that in 2011, some 2.39 million people were living with the virus and that HIV prevalence among adults was around 0.31%.  The epidemic proportion of this disease has created an alarm worldwide. Although important progress has been achieved in preventing new HIV infections, and in lowering the annual number of AIDS related deaths, the number of people living with HIV continues to increase. AIDS-related illnesses remain one of the leading causes of death globally, and are projected to continue as a significant global cause of premature mortality in the coming decades. Apart from, the decrease in immunity leading to opportunistic infections, HIV has been known to have serious psychological and social impact on the people who are affected. People suffer from intense emotional conflicts when they come to know about their disease status. Those infected with HIV struggle with issues of disclosure to others, particularly when first diagnosed. Most patients with serious, progressive illness confront a range of psychological challenges, including the prospect of real and anticipated losses, worsening quality of life, the fear of physical decline and death, and coping with uncertainty. At specific times during the course of HIV diseases, patients are particularly vulnerable to acute distress, such as when first notified of a positive HIV status, the initial onset of physical symptoms, a sudden decline in the number of clusters designation 4 (CD4) cells, the first opportunistic infection, or the first hospitalization. Most studies bring out anxiety, depression, and suicidal tendencies as the commonest psychiatric morbidity among affected people. Psychiatric illness in the context of HIV infection can contribute to diminished health outcomes, increased substance use, poor treatment adherence, increased risky sexual behavior, or other maladaptive behaviors.  In the social context, HIV seropositive patients suffer from isolation from the community and lack of support from the family members. It may also lead to broken marriages and loss of jobs.
In addition, psychosocial correlates have a direct link to the prognosis of the disease as well. Positive thinking like beliefs (optimism, finding meaning, spirituality), behaviors (active coping, altruistic behaviors, expressing emotions with processing), personality, and social support have a major impact on the lives of the affected individuals. , Several studies have emphasized that a positive way of living was directly related to a good immune status of individuals and thus, to longer survival time.
Psychological wellbeing has a major impact on patient's compliance to the medication also. A study, examined the relationship between perceived psychological well-being and three measures of adherence: Medication adherence; adherence to advice and instruction; and adherence to appointments for visits, procedures and treatments. Aspects of psychological well-being were related to each of the adherence measures. It was suggested that people who feel well care for are more likely to be adherent.  In view of the paucity of Indian data in this area, this study was conducted to find out the impact this disease had on the personal as well as the social forefront of the affected individuals, their quality of life and the levels of anxiety and depression among them. It becomes extremely crucial for all the Health-Care Providers to take care of the psychological and social well-being of a HIV patient along with the routine pharmacotherapy. Disclosure of the HIV seropositive status, social support, job and financial aspect, adherence to therapy and a healthy lifestyle are crucial areas, which must be dealt with carefully.
| Materials and Methods|| |
This descriptive cross-sectional study was conducted at a large 1200-bedded tertiary care hospital at Pune. The study was approved by the Institutional Ethical Committee.
A total of 50 consecutive adult HIV seropositive individuals were included in the study after obtaining informed consent. The minimum age was 24 years, and the maximum age recorded was 73 years HIV seropositivity was confirmed by two different Enzyme-linked immunosorbent assay (ELISA) methods. Staging of HIV seropositive case was carried out as per Centers for Disease Control (CDC) classification. The eligible cases were assigned to either stage II or stage III of CDC. Patients in stage IV were not eligible for the study.
Subjects more than 18 years of age with confirmed HIV seropositivity who were physically asymptomatic in stage II or III of CDC.
Subjects with past history of head injury with loss of consciousness, central nervous system (CNS) disorders, psychiatric illness and those who qualify for AIDS defining criteria were excluded.
All subjects were interviewed on a one to one basis. Demographic profile was studied through a psychosocial questionnaire. The questionnaire was divided into several parts like patient's particulars, details of HIV status and high-risk behavior, questions on family support and discrimination. Personal particulars included questions on age, sex, occupation, residence (rural/urban), education, income, marital status, years of marriage, and number of children. Details on HIV status like the reason, time and place of diagnosis and immediate reaction of the individual after knowing about his illness were included. Questions on high-risk behavior like the mode of transmission, status of disclosure, and knowledge about the sources of infection were asked. Further, the reactions received on disclosure at home and workplace along with the support levels was interrogated to assess the family support and discrimination.
In addition, all subjects were assessed with the following rating scales.
General Health Questionnaire
The GHQ  is a self-administered screening test, which is sensitive to the presence of psychiatric disorders in individuals presenting in primary care settings and non-psychiatric clinical settings. The GHQ is not designed to detect symptoms that occur with specific psychiatric diagnose rather; it provides a measure of overall psychological health or wellness. The GHQ has reasonable test-retest reliability and both content validity and construct validity. In the present study, the shorter version containing 12 items - the GHQ-12 - was used. The GHQ-12 has a sensitivity of 89% and specificity of 80%. The GHQ has been translated into 38 languages and used in diverse cultural groups. As it is primarily concerned with the detection of "psychological illness," the items appear to have cross-cultural relevance despite cultural variations in the expression of mental illness.
Hospital anxiety and depression scale
The HADS  was developed as a self-report questionnaire to detect adverse anxiety and depressive states. Subjects are asked to choose one response from the four given. The questions relating to anxiety are marked 'A' and to depression 'D'. It has 14 items, 7 related to anxiety and 7 to depression. Scoring is from 0 to 3 for each item. Possible scores range from 0 to 21 for each sub scale. An analysis of scores on the two sub scales supported the differentiation of each mood state into four ranges: "Mild cases" (scores 8-10), "moderate cases" (scores 11-15), and "severe cases" (scores 16 or higher). The norms give an idea of the level of anxiety and depression.
World Health Organization well-being index
The WHO-5  well-being index is a short, self-administered questionnaire covering 5 positively worded items, related to positive mood (good spirits, relaxation), vitality (being active and waking up fresh and rested), and general interests (being interested in things). It has shown to be a reliable measure of emotional functioning and a good screener for depression. Administering the WHO-5 Well-being Index takes 2-3 min. Each of the five items is rated on a 6-point Likert scale from 0 (= not present) to 5 (= constantly present). Scores are summated, with raw score ranging from 0 to 25. Then the scores are transformed to 0-100 by multiplying by 4, with higher scores meaning better well-being. A score of 50 or below is indicative for low mood, though not necessarily depression.
The scoring of the tests was done as per the test booklet of each scale. The results were tabulated and subjected to statistical analysis using appropriate statistical tests.
| Results|| |
The mean age of the subjects was found out to be 37.92 (±9.41) years. Maximum cases belonged to age group between 31 years and 37 years. 66% individuals belonged to rural background as opposed to 34% who belonged to urban background. 100% cases were males. Around 74% people interviewed in the study were army personnel out of which 62% were working, and 12% were ex-servicemen. 16% were farmers and 10% were of other occupations like banker, goldsmith, teacher etc., Most of the people had completed secondary education. The mean monthly income was calculated as Rs. 7306 with a standard deviation of Rs. 3202.39. Eighty eight percent of the people were married [Table 1].
Most of them were diagnosed HIV positive after getting a blood test carried out for some other disease [Table 2]. In this study, on being asked about the immediate emotional reaction on knowing about the disease status, 30% of the study group felt sad, and 16% reported hopelessness [Table 3]. The influence of knowledge about mode of transmission on high-risk behavior is a moot question. Although the knowledge about modes of transmission of HIV illness was present in 52% of the sample, the disease had already affected them, through high-risk sexual behavior that was reported by 28% of the study group. However, the awareness seems to have reduced the high-risk behavior in the remaining study group [Table 4] and [Table 5]. Disclosure about HIV status is considered to be stigmatizing.  It is interesting to observe that study group had disclosed their seropositive status, most of whom received support and cooperation from their family members. The maximum status of disclosure was to spouses and less to parents and children of the diseased. Most of the individuals had disclosed their status in their workplace, 50% of whom were of the opinion that they had faced discrimination after disclosure [Table 6],[Table 7],[Table 8] and [Table 9]. Fifty-four percent individuals were suffering from anxiety with 26% people with severe anxiety. Only 30% individuals had depression with 20% of them suffering from mild depression. A relationship was found out between anxiety and depression levels by using the Pearson correlation. The value was calculated as 0.682, which shows a significant correlation between anxiety and depression [Table 10] and [Table 11]. The GHQ revealed that most individuals did not suffer from any psychological morbidity [Table 12]. The WHO well-being index also showed consistent findings as most of the affected individuals had a good score [Table 13].
|Table 8: Support received from parents, spouse and children on disclosure|
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Among psychosocial variables stigma remains the major area of concern. Most researches emphasize that social support is an extremely important indicator of psychological well-being of an individual. In one of the studies, individuals in receipt of quantitatively different levels of support were found to differ in measures of depression, stress, coping efficacy, and self-esteem, while individuals in receipt of deficient levels of support were found to be more depressed.  Findings of the present study revealed internal consistency in respect of scores on GHQ and WHO well-being scale.
| Discussion|| |
In the present study, the majority of the subjects (72%) were tested for HIV at the first instance for investigation of some other disease; 6% were screened during routine medical examination and 8% were found to be seropositive on blood donation; 14% were tested for other reasons like after their wife's HIV positive status getting revealed on antental care (ANC) examination, etc., Primarily because of ignorance 32% of people felt no emotion on being told the positive result. Another large number of people felt sorrow (30%), hopelessness (16%), disbelief (14%), and anger (2%) after knowing about it. Studies suggest that while some individuals may experience psychiatric disorders, the emotional responses to illness (shock, disbelief, grief, sadness, anger, despair, fear, guilt, hopelessness, numbness, panic) are considered normal and appropriate reactions. 
A total of 52% people knew about the disease before contracting it whereas 48% did not. 38% people accounted for heterosexual transmission as a cause of their illness of which 28% felt it was not from their spouses. Others said the cause was accidental inoculation (26%), parental blood transfusion (16%) and IV drug abuse (6%). Fourteen percent could not specify the exact mode of transmission.
About 90% people disclosed their seropositive status to their family members. The remaining did not disclose due to sheer neglect or fear of adverse reaction from their family members. On disclosure, maximum people got family support and cooperation (72%). However, 8% felt they faced isolation and neglect from family, and another 10% said they did not get any response, which can be attributed to lack of knowledge and ignorance. Spouses were very cooperative and sympathetic in most of the cases (78%). The patients had disclosed their status, mostly to their spouses (80%) and less to their children (40%) and parents (58%). Majority of the cases had disclosed their seropositive status in their workplace (64%). However, 50% of those who had disclosed were of the opinion that they were facing discrimination.
In the present study, 54% of the individuals suffered from anxiety out of which 26% had severe anxiety. Findings of the present study are in concurrence with the available literature. According to an Indian study, the authors found anxiety disorders manifesting throughout the course of HIV infection, with a general trend for increased prevalence of these disorders as the illness progresses.  Researchers have reported a prevalence range of 29-38%  depending upon the stage of illness. The study states that in comparison to the western studies, the number of individuals diagnosed as having anxiety disorders in an Indian study was higher, however, the sample in the study differed from that in the western studies in terms of recruiting greater number of individuals symptomatic (55% of the total sample) for HIV infection. According to this study, physical suffering, cultural factors like stigma, relative lack of appropriate treatments facilities, poor access to the health-care, and low educational level could have significantly contributed. It further emphasized that since the individuals were assessed for anxiety soon after revelation of HIV status (within 2-3 months), it could also account for the higher incidence of anxiety disorders. In addition, pain, concurrent alcohol abuse/dependence, poor family support, and presence of AIDS in the spouse accounted for 57% of the total variance in the level of anxiety.
In our study, 30% individuals suffered from depression. Furthermore, a significant correlation was seen in people having anxiety and depression. Many studies state depression, anxiety, and suicidal tendencies have been found to be quite prevalent among HIV-positive individuals. In particular, depression is quoted as the most common psychiatric disorder in HIV-infected patients and pharmacological intervention may be warranted.  Rates of depression in HIV seropositive patients from the west have ranged from 5% to 25%. , In earlier Indian studies, prevalence rates of depression among HIV seropositive individuals have ranged from 10% to 40%. , Majority (90%) of the patients who had depressive symptoms also had prominent anxiety symptoms and fulfilled the ICD-10 criteria for generalized anxiety disorder.  The relatively lower prevalence of depression in the present study could be due to the fact that they were evaluated soon after testing positive. Though the figures appear alarming, this could give us insight into concerns of patients. Early reports based on clinical observation or medical record reviews indicated high rates of distress and depressive symptoms among those infected with HIV or who had AIDS. , Later studies, however, used structured psychiatric evaluations and community samples with HIV-negative comparison groups and showed rates of psychiatric disorder to be largely equivalent between HIV-positive and negative people. ,, The methodology and instruments used to measure the symptoms may play an important role. The study carried out by Bing et al. assessed a national probability sample of nearly 3,000 adults receiving care for HIV infection and found that more than a third screened positive for clinical depression, the most common disorder identified during study. 
In this study, 56% individuals do not show any morbidity in GHQ and 54% show a good well-being status in WHO well-being index. These figures show internal consistency. 72% of the individuals received family sympathy and cooperation. These figures throw a light on the importance of social support being an important factor of quality of life.
Most of the studies support the notion that social support is an essential determinant of the well-being of an infected individual. Individuals in receipt of quantitatively different levels of support were found to differ on measures of depression, stress, coping efficacy, and self-esteem, while individuals in receipt of deficient levels of support were found to be more depressed.  Aspects of psychological well-being were related to each of the adherence measures. It was suggested that people who feel well cared for are more likely to be adherent.  The effect of repeated HIV-related bereavements upon an individual's social network and the emotional, social, and physical sequel of bereavement have implications for HIV quality of life research as well. Quality of survival time has become a paramount issue in the context of HIV spectrum disease. 
| Conclusion|| |
Studies have reported depression being the most common psychiatric morbidity among the afflicted individuals. However, in this study, anxiety was found to be more prevalent as compared to depression.
| References|| |
|1.||UNAIDS. Global Report: UNAIDS Report on Global AIDS Epidemic. Geneva: UNAIDS; 2012. p. 8-15. |
|2.||Department of AIDS control. NACO: Annual Report Dept. of AIDS Control 2010-2011. New Delhi: Government of India; 2011. p. 4-6. |
|3.||Remien RH, Rabkin JG. Psychological aspects of living with HIV disease: A primary care perspective. West J Med 2001;175:332-5. |
|4.||Seligman EP. Handbook of Positive Psychology. In: Snyder CR, Lopez SJ, editors. New York: Oxford University Press; 2002. p. 1-3. |
|5.||Ironson G, H'Sien H. Do positive psychosocial factors predict disease progression in HIV-1: A review of the evidence. Psychosom Med 2008;70:546-54. |
|6.||Chandra PS, Deepthivarma S, Jairam KR, Thomas T. Relationship of psychological morbidity and quality of life to illness-related disclosure among HIV-infected persons. J Psychosom Res 2003;54:199-203. |
|7.||Goldberg DP. The Detection of Psychiatric Illness by Questionnaire. Maudsley Monograph No. 21. London: Oxford University Press; 1972. p. 1-156. |
|8.||Woolrich RA, Kennedy P, Tasiemski T. A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury. Psychol Health Med 2006;11:80-90. |
|9.||Bech P. Measuring the dimensions of psychological general well-being by the WHO-5. QoL Newsletter 2004;32:15-6. |
|10.||Medved W, Calzavara L, Ryder K, Haubrich D, Myers T; the Polaris Study Team. Impact of HIV-related stigma and discrimination on disclosure of HIV status and sexual orientation by participants enrolled in Polaris. Can J Infect Dis 2004;15 456. |
|11.||Nott KH, Vedhara K, Power MJ. The role of social support in HIV infection. Psychol Med 1995;25:971-83. |
|12.||Chandra PS, Desai G, Ranjan S. HIV and psychiatric disorders. Indian J Med Res 2005;121:451-67. |
|13.||Perkins DO, Stern RA, Golden RN, Murphy C, Naftolowitz D, Evans DL. Mood disorders in HIV infection: Prevalence and risk factors in a nonepicenter of the AIDS epidemic. Am J Psychiatry 1994;151:233-6. |
|14.||Summers J, Zisook S, Atkinson JH, Sciolla A, Whitehall W, Brown S, et al. Psychiatric morbidity associated with acquired immune deficiency syndrome-related grief resolution. J Nerv Ment Dis 1995;183:384-9. |
|15.||Chandra PS, Ravi V, Desai A, Subbakrishna DK. Anxiety and depression among HIV-infected heterosexuals-A report from India. J Psychosom Res 1998;45:401-9. |
|16.||Krishna VA, Chandra PS. Concerns and psychiatric morbidity among people living with HIV/AIDS. NIMHANS J 1998;17:253-60. |
|17.||Dilley JW, Ochitill HN, Perl M, Volberding PA. Findings in psychiatric consultations with patients with acquired immune deficiency syndrome. Am J Psychiatry 1985;142:82-6. |
|18.||Nichols SE. Psychosocial reactions of persons with the acquired immunodeficiency syndrome. Ann Intern Med 1985;103:765-7. |
|19.||Perry S, Jacobsberg L, Card CA, Ashman T, Frances A, Fishman B. Severity of psychiatric symptoms after HIV testing. Am J Psychiatry 1993;150:775-9. |
|20.||Rosenberger PH, Bornstein RA, Nasrallah HA, Para MF, Whitaker CC, Fass RJ, et al. Psychopathology in human immunodeficiency virus infection: Lifetime and current assessment. Compr Psychiatry 1993;34:150-8. |
|21.||Bing EG, Burnam MA, Longshore D, Fleishman JA, Sherbourne CD, London AS, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry 2001;58:721-8. |
|22.||Holzemer WL, Inouye J, Brown MA, Powell GM, Corless IB, Turner JB, et al. Psychological well-being and HIV adherence. Int Conf AIDS 1998;12:595. |
|23.||Lutgendorf S, Antoni MH, Schneiderman N, Fletcher MA. Psychosocial counseling to improve quality of life in HIV infection. Patient Educ Couns 1994;24:217-35. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]