New or Unmanaged HIV Can Be a Symptom of Poor Mental Health

New research shows that depression undermines treatment, requires intervention.

Posted Feb 22, 2018

Gay men experience depression at three times the rate of the general adult population. They account for 70 percent of new HIV infections, and more than half of all people living with HIV, in the United States.

A large new study reported in JAMA Psychiatry finds that people with depression who are living with HIV have a higher risk of missing medical appointments for HIV primary care, and are more likely to have a detectable viral load—meaning they likely do not have, or are not properly adhering to, medication—or die.

Despite the well-known frequency of depression among adults with HIV and its complications for managing the virus, the researchers note that little attention has been paid to developing screening and interventions to shorten depressive episodes. In fact the main conclusion from this study of 5,927 patients, at six geographically dispersed U.S. academic medical centers, is this: such protocols are needed.

Depression doesn’t only derail HIV treatment for those with the virus, but it also undermines HIV-negative gay men’s ability to make healthy sexual choices that protect them against infection.

Clearly, any intervention aimed at supporting either HIV treatment adherence or prevention must address depression—and other so-called ‘upstream’ mental health drivers of risk behavior.

Addressing these challenges requires holistic approaches, as Perry N. Halkitis, PhD, MS, MPH, pointed out in a “call to action” for research and clinical psychologists in American Psychologist. Halkitis, dean of the Rutgers University School of Public Health and professor of biostatistics, social and behavioral health sciences, has largely focused in his research on how psychiatric and psychosocial factors impact HIV/AIDS, drug abuse, and mental health disease. “A new framework for HIV prevention,” he wrote, “must give voice to gay men; must consider the totality of their lives; must delineate the underlying logic, which directs their relation to sex and HIV; and must concurrently respect their diverse life experiences.”  

In an interview for my book Stonewall Strong, Halkitis said, “Gay men’s health cannot be HIV health.” He explained, “HIV is more than about the transmission of a pathogen. It is as much, if not more so, a socially constructed phenomenon as it is a biological or psychological phenomenon. If it was a purely biological phenomenon, the epidemic would be over.”

Stigma and discrimination contribute to depression, which in turn contributes to the behavior that leads to transmission of the virus—or smoking or using crystal meth—by undermining our ability to make healthy choices. 

“There is this syndemic of violence, STIs, HIV, mental health, and they all fuel each other,” said Halkitis. “But at the end of the day the behaviors that lead to HIV infection or substance addiction all come because someone’s social or psychological well-being is diminished. When things are wrong, you do things to medicate the pain.” 

That goes for gay men, and many millions of people, regardless of their HIV status. 

In fact, Halkitis noted that data show that many gay men who use crystal meth begin using the drug after they seroconvert. “That gets to untreated mental health issues, especially depression,” he said. “You will only eradicate HIV in this country if you address the social, biological, and psychological, all three. You use three classes of drugs to treat HIV. Why wouldn’t you attack the epidemic from these three fronts?”

Twenty years ago, the late, noted gay activist Eric Rofes wrote in his book Dry Bones Breathe: Gay Men Creating Post-AIDS Identities and Cultures, “Prevention for gay men is at a turbulent crossroads.” Only two years after the drug “cocktail” finally made it possible to live with HIV rather than develop AIDS and die, he wrote in 1998, “AIDS prevention efforts targeting gay men should be reconceptualized, restructured, and reinvented as multi-issue gay men’s health programs that include strong components concerned with substance use, basic needs (food, housing, and clothing), and sexual health (broadly defined).” These programs, he said, “would no longer take as their central mission limiting the spread of HIV, but instead aim to improve the health and lives of gay men.”

It’s been clear for at least two decades that there is one bottom line for both HIV prevention and treatment adherence: Support gay men’s mental health—or anyone’s for that matter—and they are far more likely to be able to avoid, or live well with, HIV.

Don’t and they won’t.

John-Manuel Andriote/photo
Source: John-Manuel Andriote/photo