In comparison to the general population, people living with HIV/AIDS are nearly twice as likely to be diagnosed with personality disorders or other serious mental illnesses. In fact, a four-year longitudinal study with 288 HIV-positive adults conducted by California State University, Los Angeles, psychology professor Ramani Durvasula, PhD, found that at some point in their lives, 92 percent of participants had experienced depression, substance use disorder or another Axis-I disorder.
In addition, she found nearly half met criteria for at least one Axis-II disorder, primarily antisocial personality disorder, borderline personality disorder or narcissistic personality disorder.
At an APA 2009 Annual Convention session, Durvasula and others discussed how psychologists' interventions can improve care for these patients—and prevent them from engaging in virus-transmitting behaviors.
"What often happens in treating these patients is that we address the acute Axis-I disorders and then walk away," Durvasula said. "But often it's the chronic personality disorder symptoms that contribute more to risk behaviors, such as not choosing partners wisely and not using condoms."
Simply providing prevention education to these patients can help dramatically, said Boston University School of Medicine psychologist Stephen Brady, PhD. He presented data from a pilot study that included an HIV-prevention intervention for 53 participants with serious mental illnesses. Those with borderline personality disorder and antisocial personality traits had higher base rates of risk behavior than other participants but were just as likely to make changes and maintain behavior change, Brady said. Over the course of six months, participants quadrupled their instances of protected sex and halved their overall number of sexual encounters.
Anecdotally, Brady said, substantial numbers of participants reported that they were unaware before the intervention that unprotected anal sex was a higher risk than unprotected vaginal intercourse, and many eliminated the practice after receiving this knowledge.
"We often turn our noses up at the idea of information being important, but there are groups for whom information is still pretty powerful and can lead to behavioral change," Brady said.
Another intervention for this population helps clients keep relationships with friends, family and others intact. That's important, said the speakers, because HIV/AIDS disproportionately affects communities with high rates of crime and interpersonal violence, and patients often face social alienation as a result of their mental illness, making it even harder for them to get the support they need.
"It's like a bunch of mines in a field and everything is blowing up at the same time for these patients," Durvasula said.
One of the best ways to help them keep their social networks healthy and accessible, she said, is to model appropriate social interactions in the clinics. This includes helping clinic staff develop and implement strategies that ensure compassionate and fair treatment and setting rules and boundaries that help patients feel secure, said Stanford University School of Medicine psychologist Cheryl Gore-Felton, PhD. She recommended, for example, establishing a rule that allows drop-in appointments only on particular days, and sticking to that schedule.
"The social and psychological needs of HIV patients often go unmet long before you enter their lives," Gore-Felton said. "Developing a structure that facilitates safety for patients and staff will foster trust"—and lead to better health outcomes.
Psychologists can also help by discussing nutrition and hydration with these clients and encouraging them to establish regular exercise routines to reduce their stress, Gore-Felton said. Working with patients to identify their stress triggers, and teaching coping and relaxation techniques, can also help them manage traumatic events, Durvasula said.
Amy Novotney is a writer in Chicago.
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