Chapter 9
Psychiatric Issues

Joyce Seiko Kobayashi, MD

I. Introduction  TOP

While healthcare providers for women living with HIV focus primarily on the physical manifestations related to HIV, understanding the emotional experience of the woman and the potential psychiatric problems associated with HIV is important to optimize care.

The health care provider can provide significant comfort during normal adjustment phases and common emotional transitions through skilled emotional support, assessment of coping skills, patient education, and empathy. When normal adjustment issues give way to formal psychiatric or neuropsychiatric disorders, accurate diagnosis and appropriate treatment are required.

Further care may require referral for substance abuse treatment or psychiatric evaluation, or referral to programs of social support, housing, case management, and other services, depending on the needs of the individual. Care providers who develop a comprehensive treatment plan for the HIV-positive woman that includes emotional support and psychiatric treatment for comorbid psychiatric conditions help her to feel that the entirety of her pain and suffering is being addressed.

For a more detailed discussion of the neurological manifestations of HIV, see chapter IV; and for more discussion about substance abuse and treatment, see chapter X.

This chapter will address a range of psychiatric issues relating to HIV disease in women, from normal adjustment issues to psychiatric disorders, and will make specific recommendations for provider and program response, evaluation, and management.

II. Perspectives On Being A Woman With HIV  TOP

Three different perspectives are important to develop a more comprehensive view of the woman experiencing HIV: 1) the individual perspective as the woman journeys through the common emotional milestones of HIV; 2) the perspective of women as a group, because women, in contrast to men, tend to cope with HIV within the context of their most important relationships; and 3) the contemporary context of the majority of HIV-infected U.S. women who are members of racial or ethnic minorities, living in poverty, affected directly or indirectly by substance abuse, and often with personal experiences of adult victimization and/or childhood abuse. The experience of the woman infected with HIV at any given time may be more influenced by one or another of these dimensions.

For example, the initial shock of an HIV diagnosis may be experienced with personal fears of stigma and suffering; or with common concerns about rejection and abandonment by a partner; or simply experienced as further victimization in the context of a traumatic history and daily struggles to survive. The way women face the challenges of HIV personally, as women, and in the context of their past histories is a strong predictor of psychiatric co-morbidity (Sherbourne, 2003). The goal of skilled support is to facilitate positive transformation of this experience.

A. EMOTIONAL MILESTONES: THE EXPERIENCE OF THE INDIVIDUAL HIV-POSITIVE WOMAN

The emotional adjustment after learning that one is HIV-positive, including coping as an individual on a daily basis with the demands of having HIV and becoming an HIV patient, commonly follows a natural course of progression through stages (See Table
9-1). For every “shock” — a new diagnosis, a new symptom, the need to take more pills, more intrusions on daily routines — there is often the “aftershock” of anger and avoidance, fear and denial. While emotional adjustment may vary by culture, race, and ethnicity, by level of social support and caretaking responsibilities, and by age and severity of physical and psychiatric symptoms, these emotional milestones are broadly applicable. With knowledgeable support and timely clinical intervention, these reactions can be transformed into acceptance, with important opportunities for prevention of HIV transmission to others and safer behaviors for oneself.

B. COPING WITH HIV: THE EXPERIENCE OF HIV-POSITIVE WOMEN IN THE CONTEXT OF RELATIONSHIPS

Women experience HIV infection within the context of their various relationships. When examining HIV-infected adults in medical care in the U.S., over one-quarter have children; women are more than three times as likely to have children compared to men and are more than twice as likely to live with their children (Schuster, 2000). In a prospective observational cohort of 871 HIV-positive women, 35% had a family member with HIV infection, including one-half of Latina women, one-third of black women, and one-fifth of white women; in 38% this was a sibling, 24% a husband, and 27% had more than one family member with HIV (Fiore, 2001). In a clinic-based sample in Connecticut (N=68), nearly three out of four of the HIV-positive women knew at least one person who had died of AIDS (Ickovics, 1998).

Developmental psychologists have characterized fundamental differences in the way women and men think about themselves (Gilligan, 1993), with significant implications for clinical practice. Although any generalization about gender may be wrong in the individual case, two overarching observations derived from this research are important to understand the ways women and men tend to differ in their reaction to being HIV-positive. First, women more frequently define themselves in the context of their relationships to others; and second, while men more frequently fear intimacy, women more often fear separation (Surrey, 1982). Whether these differences are more evolutionary and transcultural, or derive from socialization and economic forces, an understanding of these differences is important to increase providers’ sensitivity and to enhance their effectiveness in working with women living with HIV.

Although there are universal fears about dying alone and being abandoned when ill, it is not uncommon to hear HIV-positive men express fears about becoming dependent on others, whereas HIV-positive women tend to worry more about those who are dependent on them as their illness progresses. Men often lose self esteem if they are not able to continue working, or feel anger and may wish to distance themselves from others whom they feel obligated to support; women more frequently lose self esteem if they are unable to continue taking care of others. Many women with HIV are single mothers and feel shame or guilt if they are unable to take care of their children as they feel they should.

These reactions may lead women to accept being the target of anger or abuse, or to suppress their own anger, in order to avoid finding themselves alone; they may continue to use drugs for fear of losing a substance-using partner; or they may feel guilty about taking time away from responsibilities for others in order to address their own needs. It may be difficult to self-motivate and establish good self-care independently when “no one” will benefit from these efforts except for the woman herself. In a study of delays in seeking care among HIV-positive individuals, women were 1.6 times more likely to delay medical care than men; having a child in the household increased the likelihood of delay (Stein, 2000). Women who have been abused, are poor, or have in other ways experienced powerlessness in their lives may be even less convinced that they are “worth it.”

On the other hand, the motivation to take care of others may encourage some HIV-positive women to undertake major changes in their own behavior, such as giving up longstanding drug dependencies during pregnancy, or engaging in discussions that frighten them, such as about permanency planning or advance directives. Other women with HIV may take on the responsibility of bringing their children or partners into medical care despite significant barriers, including their own fatigue or ill health, and may demonstrate remarkable resourcefulness in seeking out additional avenues of support.

The clinician should show respect for the degree of caring the woman demonstrates, and acknowledge the impact HIV has on the people she cares about. These are clinical opportunities to build trust and strengthen an alliance around common concerns. Giving permission for the HIV-positive woman to attend to her own needs, and in other ways “empowering” her, may over time be as important as instructions about what specific health behaviors to follow. The health care provider who first acknowledges her priorities in taking care of others, and then reminds her that she will not be able to continue that care unless she first takes care of her own health, is likely to be more successful in terms of her health outcomes. When the woman feels her values have been respected, and when sufficient trust has been established, the provider’s concerns will be experienced as caring and supportive, rather than as rejection or criticism.

In certain circumstances, such as in negotiating safe sex with an unreceptive partner, the provider may even be more directive, and encourage a woman to develop the necessary skills to be more assertive about her own health concerns. Developing these skills may also be helpful within the healthcare setting. In the HIV Cost and Services Utilization Study (HCSUS) of HIV-infected U.S. adults in medical care, women with CD4 counts below 200 cells/mm³ were less likely to receive effective combination antiretroviral therapy than men (Shapiro, 1999).

C: SURVIVING WITH HIV: HIV-POSITIVE WOMEN IN THE CONTEXT OF POVERTY, SEXUAL ABUSE, AND SUBSTANCE ABUSE

Poverty

The majority of women with AIDS in the United States are unemployed, and 83% live in households with incomes less than $10,000 per year. Only 14%, aged 15-44 years, are currently married, compared to 50% of all women in the United States. Twenty-three (23%) of HIV-positive women live alone, 2% live in various facilities, and 1% are homeless. Approximately 50% have at least one child less than the age of 15 years. The majority of women with AIDS in the U.S. are from minority racial and ethnic groups, with African Americans and Latinas comprising over three-quarters of cases. (Bozzette, 1998; Shapiro, 1999; Barkan, 1998) (See Table 9-2 for a comparison of women and men in HCSUS.) They are frequently without easy access to medical care. Poverty and the related experiences of racism, sexism, and stigmatization are the dominant themes in their lives.

Poverty and homelessness can be as devastating to the person and personality as the physical sequelae of HIV. For many women who are living on the street or in transient residences, are feeling overwhelmed by the needs of their children, or are battered within their relationships, illicit drugs may seem to be the best antidote. In the book Women, Poverty and AIDS (Farmer, 1996), which contains a comprehensive discussion of these issues, Shayne and Kaplan state that “safe sex is an economic compromise for many poor women who rely on sex as a source of employment, as a means to establish ownership or proprietary rights in relationships, or as a means of getting tangible supports, generally short in supply."

It is hard to make the medical treatment needs for HIV relevant unless the woman feels her provider recognizes and has some understanding of her daily struggles for survival. Women may feel that their medical providers are simply adding to their burdens by asking them to prevent transmission to others (especially when they may have little choice in safer sex practices) or to adhere to complicated medical regimens.

In one study investigating ways to improve health care utilization, a sample of HIV-positive women from a needle exchange program and from a correctional facility indicated that “shelter and food/clothing ranked first among unmet needs for services” (Thompson, 1995). Poverty and unemployment were also viewed as more serious problems than HIV/AIDS by a group of women in treatment at a state psychiatric facility (Weinhardt, 1998).

More than one-third of a nationally representative sample of HIV-positive individuals in care went without or postponed care at least once in a six- month period for one of four competing subsistence needs: needing the money for food, clothing or housing; not having transportation; not being able to get out of work; and being too sick. Having at least one competing subsistence need was associated with never having received antiretroviral therapy (Cunningham, 1999).

There are many concrete services such as transportation, child care, food programs, income and employment support, and housing that can increase the ability of HIV-positive women to participate in health care. Many women who have substance abuse disorders with psychiatric comorbidity may qualify for entitlement programs that they have not explored. Vocational rehabilitation programs are often facilitated by medical or psychiatric referrals. Community-based programs for people with HIV often include food banks and vans, and sometimes offer childcare or emergency shelter. Lack of housing is a major factor in medical illness and should be considered in developing an individual treatment plan. For example, residential programs that engage clients in substance abuse treatment contracts can provide both housing and incentives to abstinence from substance abuse.

Childhood Sexual Abuse and Adult Victimization

Sexual abuse and domestic violence are experienced within the lifetimes of a significant portion of American women, regardless of their economic status, ethnicity, or HIV status. When childhood sexual abuse is defined as physical contact of a sexual nature with children less than 14 years of age, prevalence estimates range from 28% to 36% (Wyatt, 1986). Although childhood abuse research is limited by the methodology of self-report, sampling, and definitional issues, it shows remarkably consistent high lifetime prevalence rates of childhood sexual abuse and adult physical or sexual assault for women who are HIV-positive or at risk for HIV.

A history of childhood sexual abuse is also associated with multiple HIV transmission and risk behaviors. In a study of 3,346 women, those who had a history of childhood sexual abuse were more likely than those who had not to report problems with alcohol, use of drugs, receiving money or drugs in exchange for sex, unwanted sex, a greater number of unprotected sex acts, a greater number of partners, and a greater proportion of sex acts accompanied by drugs or alcohol in the past 90 days. Analyses suggested that for these women with a history of childhood sexual abuse, participation in non-sexual risky behaviors “may be a bridge to participation in sexual behaviors that increase the risk of HIV infection” (NIMH Multisite HIV Prevention Trial Group, 2001). In a study of street-recruited women from three different major urban sites, with demographics similar to a large portion of the population of women with HIV, 12% of 918 women reported that they had been sexually assaulted in the previous 12 months (Wong, 1993). In comparison with those who were not sexually assaulted, rape was associated with higher rates of sex for drug exchange, reporting more than 100 lifetime sex partners, smoking crack, and twice the likelihood of being infected with HIV and syphilis.

Sexual assault in adult women is estimated to be two to four times as likely for women who are survivors of childhood sexual abuse. A study of 327 women with or at risk for HIV (Zierler, 1991) found that 35% of women with HIV were sexually assaulted as adults. Forty-five percent of women who reported rape as adults had been sexually abused during childhood or as teenagers. Among women with HIV, adult sexual assault was associated with more sexual partners, unprotected sex involving drugs, earlier age of injection drug use, teen pregnancy, sexually transmitted infections, and need for gynecologic surgery.

In a study of 230 HIV-positive women in New York City, 50% experienced abuse in childhood, 68% as adults, and 7% reported physical assault or rape in the previous 90 days. History of childhood abuse was significantly correlated with adult and recent trauma (Simoni, 2000). In the HCSUS study, 20.5% of women with HIV in care reported domestic violence or physical harm since diagnosis (Zierler, 2000), and in the prospective HIV Epidemiology Research Study (HERS) cohort, the incidence of abuse among HIV-positive women with CD4 count >350 cells/mm³ was 6.92 per 100 person-years (Gruskin, 2002). Among 357 men and women living with HIV/AIDS, 68% of women (and 35% of men) reported a history of sexual assault since age 15 (Kalichman, 2002). A recent study of 1645 subjects enrolled in the Women’s Interagency HIV Study (Cohen, 2000) found that among both HIV-positive and seronegative, at-risk women, two out of every three women (67% and 66%, respectively) had experienced domestic violence during their lifetimes, and almost one out of three (31% and 27%, respectively) had been sexually abused as children. There was no significant difference in prevalence associated with race, ethnicity, education level, or marital status, although domestic violence was more frequently reported among older, unmarried, unemployed women.

Multiple studies have also established a relationship between childhood sexual abuse in women and adult-onset depression (Weiss, 1999). In a study of 236 women ages 36-45, increasing severity of abuse was associated with increasing risk for depression (Wise, 2001). Both HIV-positive and at-risk women have higher rates of depression than the general population, and depression increases with physical symptoms (See below). HIV-positive men and women who are survivors of sexual assault report greater anxiety, depression, and evidence of borderline personality disorder (Kalichman, 2002).

There are major implications from these findings for medical care, psychiatric and substance abuse treatment, and HIV prevention efforts. HIV-infected and at-risk women who have experienced childhood and/or adult sexual and/or physical abuse or other domestic violence see HIV and their relationship to the health care system through the prism of those experiences. These experiences also influence their likelihood of continuing risky sexual or substance using behaviors.

Women with a history of childhood sexual abuse may be susceptible to a variety of misperceptions. A directive style of recommending medical treatment, for example, may be perceived as coercive. A treatment with major side effects or a surgical procedure may be experienced as abusive intrusions in their lives or bodies. A friendly relationship with a health care provider may take on unwarranted sexual overtones. Efforts at health education may not be heard when the individual is suddenly lost in thought or actually dissociating because of sudden memories of abuse. Pain may be amplified because of experiences of physical abuse and risk being dismissed as drug-seeking.

Clinicians, in turn, may have particular responses to women who have been abused and should understand their vulnerability to unproductive “countertransference” reactions, such as being provoked into becoming the anticipated abusive figure or feeling compelled to rescue the individual. The clinician must ask in order to know. A simple and direct question should be used: e.g., “Would you mind if I ask if you have ever been the victim of physical or sexual abuse?” or “Has anyone ever hurt you physically or abused you sexually?” “Is there anyone in your life right now who makes you feel unsafe?” These questions should routinely be asked as part of the medical history. If there is a positive response, the details of current abuse must be explored. If there is a negative response, the possibility of an abuse history should nevertheless be kept in mind.

Medical care, treatment, and prevention efforts should be conceptualized with attention to the impact of violence and trauma in their lives (Fullilove, 1992). Lack of trust, low self esteem, and feelings of powerlessness are frequently experienced. Supportive measures, such as having a female provider, participation in support groups, receiving supportive psychotherapy or treatment with psychiatric medications, assistance with social resources, or receiving vocational rehabilitation can increase trust and self esteem and ultimately empower these women. Education about prevention should be a part of comprehensive care when there is high risk for continuing transmission behaviors.

Illicit Drug Use

As many as one-third of HIV-positive women exposed to HIV through heterosexual contact use noninjection drugs, and the use of these drugs increases the likelihood of high-risk sexual behaviors (Klein, 1997). Women who use drugs by injection may be more likely to follow as a second user of shared needles, increasing their risk of HIV acquisition, as well as acquisition of hepatitis B and C (Bennett, 2000).

There is a high rate of psychiatric comorbidity among women with HIV who use drugs and/or alcohol (see Chapter X on Substance Abuse). Each factor can exacerbate the other and relapses, in turn, are often associated with increased medical morbidity. In the HCSUS database, co-occurring psychiatric symptoms and drug dependence and/or heavy alcohol consumption were found in an estimated 13% of persons with HIV. Sixty-nine percent of those with substance-related problems also had psychiatric symptoms, and 27% of those with psychiatric symptoms had a substance-related problem (Galvan, 2003). A three-year longitudinal study of HIV-positive intravenous drug users (IDUs) found that 47% had experienced at least four episodes of major depressive disorder, while less than 40% of IDUs with current major depression received treatment (Johnson, 1999).

Investigators using a National Survey of Veterans found that the combination of substance abuse and post-traumatic stress disorder (PTSD) increased the rate of HIV infection almost 12-fold, compared to those without either disorder (Hoff, 1997). Because of the association between a history of sexual violence, substance abuse and PTSD, a similarly increased rate of HIV may be expected among women with this constellation of conditions.

Active substance abuse has been associated with nonadherence with antiretroviral therapy and general medical care. Medical providers caring for substance-using women with HIV should consider both psychiatric assessment and substance abuse treatment in the plan of care. The combination of psychiatric and substance abuse treatment when there is comorbidity has been shown to be effective (Lyketsos, 1997); if treatment for both problems is not offered at the same time, a relapse in one condition may destabilize the other.

III. Need For Multiservice Clinical Programs  TOP

Women with HIV who have multiple diagnoses and require a variety of services to be adequately supported through their illness. The varied needs of these women require specific multiservice program components (Morrow, 1997) and care provider training (Table 9-3) for effective comprehensive care. The clinical issues in these diverse subpopulations of HIV-positive women with complex histories and comorbidities can be managed best through such programs, which are responsive to both their clinical and concrete needs. Some of these services may be available through community-based AIDS service organizations and require close coordination with medical care.

Optimally, treatment for formal psychiatric and substance use disorders can be available on site (Kobayashi, 2000) and integrated with primary medical care. Savings from unnecessary emergency room visits and preventable hospitalizations may help offset the labor-intensive costs of these multiservice programs. If a broad array of services is not provided for these populations with such a complex layering of needs, routine medical care is likely to be complicated by intermittent follow-up, medication nonadherence, frequent presentations in crisis in emergency room settings, and suboptimal medical outcomes.

IV. Psychiatric Disorders  TOP

Psychiatric disorders among women with HIV infection require diagnosis and treatment. According to the HCSUS, a national probability sample of HIV-positive adults receiving medical care, the prevalence of anxiety and mood disorders, illicit drug use, significant alcohol use, and use of psychotropic medications among individuals with HIV is significantly higher than in the general population (Bing, 2001; Orlando, 2002; Galvan, 2002; Vitiello, 2003). A detailed diagnostic interview of the 57% in this sample who initially screened positive for a psychiatric disorder or illicit drug use in the previous six months estimated that 29.1% of all HIV-positive patients had a major psychiatric disorder: anxiety disorders (20.3%); mood disorders (17.2%); major depression (15.3%), panic disorder (12.3%), and PTSD (10.4%) (Vitiello, 2003). An analysis of data from 847 women in the HCSUS reported that younger age, having HIV-related symptoms, using avoidant coping strategies, reporting increased conflict with others, experiencing prior physical abuse, needing income assistance, and putting off going to the doctor because of caring for someone else increased risk for psychiatric morbidity (Sherbourne, 2003).

If women with these disorders do not receive appropriate treatment, their participation in medical follow-up or their ability to adhere to complicated medication regimens can be compromised. HIV-positive women with untreated psychiatric disorders may also engage in high-risk behaviors, potentially increasing risk of transmission to others or personal risk of being exposed to other STIs.

A. DEPRESSIVE SYMPTOMS AND MOOD DISORDERS

Women across cultures and around the world have lifetime incidence rates of major depressive disorders twice that of men. In the U.S., the incidence of major depression in the general populations is approximately 10-15% (American Psychiatric Association, 2000). Two large scale longitudinal natural history cohort studies of HIV-positive women (WIHS, HERS) used the Center for Epidemiologic Studies Depression Scale (CES-D) score of 16 or higher to reflect “probable cases of depression.” These studies suggest rates of depressive symptoms or disorders in HIV-positive women (42-51%) that are more than twice the rate found with HIV-positive men or the general population (Cook, 2002; Ickovics, 2001). In the WIHS cohort, HIV-positive women also reported poorer mental health quality of life than either physically well or chronically ill members of the general population or than HIV-positive men across all participating sites.

A longitudinal cohort study of 93 HIV-positive women and 62 HIV-negative women without current substance abuse found that HIV-positive women were four times more likely (19.4%) to meet clinical criteria for current major depressive disorder than HIV-negative women (4.8%), with significantly more anxiety symptoms (Morrison, 2002). The HCSUS study (N=2,864) found that HIV-positive individuals with probable mood disorders had significantly lower scores on health-related quality of life measures (Sherbourne, 2000). Among a sample of 234 African American men who have sex with men (159 HIV+) and 135 African American women (100 HIV+), there was a high prevalence of anxiety spectrum disorders (38%) and mood disorders (23%) in both groups, and significant rates of PTSD (50%) among the women (Myers, 1999).

A meta-analysis of 10 published studies found that the frequency of major depressive disorder was nearly two times higher among HIV-positive individuals than HIV-negative controls (Ciesla, 2001).

Depressive symptoms may result from a myriad of depressive disorders, including bereavement, adjustment issues/disorders, post-traumatic stress disorders, borderline personality disorders, major depressive disorder or bipolar depression, and can present with numerous comorbid conditions, such as substance use disorders that can cause secondary organic mood disorders. From a clinical perspective, depressive symptoms require careful differential diagnostic assessment because of different treatment requirements (See Tables 9-4 and 9-5).

Isolating and characterizing the extent to which some depressive symptoms may derive from an organic mood disorder directly related to HIV infection of the central nervous system is a difficult task. A specific role for an HIV-related central nervous system effect on psychiatric symptoms, however, is implied in the HCSUS study, which found that patients who initiated or maintained ARV therapy had fewer psychiatric symptoms 8 months later, and this was significantly related to higher CD4 cell counts, fewer opportunistic infections, and fewer HIV-related symptoms (Chan, 2003). Similarly, in a Canadian study of 234 HIV-positive participants who were depressed at baseline (52% of the total), an analysis of change in the CES-D before and after initiating protease inhibitor–containing HAART regimens found a significant improvement in depressive symptoms, after controlling for CD4 count, employment status, income, and age (Low-Beer, 2000).

B. IMPACT OF DEPRESSION AND MENTAL HEALTH SERVICES ON ANTIRETROVIRAL THERAPY, ADHERENCE, OUTCOME, AND COST

According to a number of recent studies, women with HIV who do not have access to mental health services and/or whose depressive symptoms and disorders are not treated are less likely to be on antiretroviral medication, less likely to be adherent to antiretroviral medication, and more likely to have a poor medical outcome at more cost.

Access To Mental Health Services:

In the HERS study, 38% of HIV-positive women and 35% of high risk HIV-negative women reported needing mental health services in the prior six months and, of those, only 67% of HIV-positive and 65% of HIV-negative women actually received services (Schuman, 2001). In the WIHS cohort, 50% of HIV-positive women reported contact with a counselor or other mental health professional at one or more study visits, but at baseline, there was less likelihood of use of mental health services among women with no college education and who were African American (Cook, 2002). An estimated 27.2% of HIV-positive men and women in the HCSUS took psychotropic medications, including antidepressants (20.9%), anxiolytics (16.7%), antipsychotics (4.7%), and psychostimulants (3.0%). Of patients with major depression or dysthymia, 43.2% reported receiving antidepressants and 34.3% reported receiving anxiolytics (Vitiello, 2003). In the HCSUS study, 61.4% of adults in HIV care used mental health or substance abuse services. Although the HIV population sampled had high mental health utilization compared to the general population, socioeconomic factors associated with poorer access to health services predicted lower likelihood of using mental health outpatient services, raising concerns that these are the same subpopulations with limited rates of antiretroviral usage (Burnam, 2001).

Access To And Adherence With Antiretroviral Therapy:

Women have significantly lower rates of HAART utilization than men (Shapiro, 1999). Among 273 HIV-positive women in the HERS study, 80 women had CD4 counts below 200/mm³, and of these only 23% were on HAART (Gardner, 2002). In the WIHS study, women with significant depressive symptoms were much less likely to be on HAART regimens, as were women with poor mental health quality of life. However, if women had recently received mental health services, they were significantly more likely to be on HAART (Cook, 2002). In an analysis of merged Medicaid and surveillance data from New Jersey for HIV-positive women and men, patients with depression who received antidepressant treatment were more likely to receive antiretroviral treatment than those with untreated depression (Sambamoorthi, 2000). HIV-positive women who were depressed and were treated with antidepressants were almost twice as likely to be on ARV therapy compared to those who were depressed and not yet treated with antidepressant medication (Turner, 2001).

The presence of depression or other mood disorders may also affect adherence to antiretroviral therapy, when this is prescribed. Patients in the HCSUS with depression (Odds Ratio, OR=1.7), generalized anxiety disorder (OR=2.4), or panic disorder (OR=2.0) were more likely to be nonadherent than those without a psychiatric disorder (Tucker, 2003).

Medical Outcome:

After controlling for potential confounding variables, women with chronic depressive symptoms also had a more rapid decline in CD4 counts compared with women with limited or no depressive symptoms (Ickovics, 2001). Depressed women with HIV were found to have increased mortality. Participants in the HERS study with depressive symptoms were nearly twice as likely to die as those without, after controlling for clinical evidence of declining health over time. Among respondents with no reported HIV-related symptoms at baseline, those with chronic depressive symptoms were 3.6 times more likely to die than those with limited or no depressive symptoms, although unmeasured mediators of this effect could include adherence, healthcare utilization, and psychiatric treatment. For women whose CD4 count was less than 200, HIV-related mortality for those with chronic or intermittent depressive symptoms was 54% and 48% compared with 21% for those with limited or no depressive symptoms. Evans et al. suggest that depression may decrease natural killer cell activity and lead to an increase in viral load (Evans, 2002).

Cost:

After controlling for socioeconomic and clinical characteristics, HIV-positive New Jersey Medicaid recipients diagnosed with depression and treated with antidepressant medications had a 24% reduction in total monthly health care costs compared to those with depression who remained untreated (Sambamoorthi, 2000).

C. NEUROPSYCHIATRIC DISORDERS

HIV-associated dementia (HAD) is characterized by significant changes in cognitive, motor, and behavioral function consistent with a subcortical dementia. HIV-associated minor cognitive-motor disorder (MCMD), seen at earlier stages of illness, is associated with at least two of the following: impaired attention or concentration, mental slowing, impaired memory, slowed movements, lack of coordination, personality change, and acquired cognitive-motor abnormality on neurological or neuropsychological testing.

Antiretroviral therapy has had a dramatic effect on the neuropsychiatric disorders associated with HIV/AIDS. Median survival following the diagnosis of AIDS dementia complex (HAD) increased to a greater extent than that for all other AIDS illnesses, from 11.9 months in 1993-1995 to 48.2 in 1996-2000, in a study in Australia (Dore, 2003). A study based on the semiannual administration of a neuropsychological battery to women in the HERS study with CD4 counts less than 100 /mm³ demonstrated that antiretroviral therapy, particularly when taken for more than 18 months, had a significant impact on neurocognitive function compared to those women not treated with HAART, with improved verbal fluency, psychomotor, and executive functions (Cohen, 2001).

However, there have been reports of increased incidence of HIV encephalopathy over time with increasing antiretroviral use and increased prevalence of HIV encephalopathy at the time of death. This may indicate that, although there is longer survival after initial HIV infection in the HAART era and effective combination therapy decreases overall prevalence of central nervous system opportunistic infections, these therapies may be less active in preventing direct HIV-1 effects on the brain (Neuenburg, 2002).

It is important to remember that symptoms of neuropsychiatric disorders can be confused with depression. If a patient has a low CD4 count without prior antiretroviral therapy, it may be appropriate to assess the response of these symptoms to a standard antiretroviral regimen before initiating antidepressant medication (See Chapter IV). Finally, both psychotropic and antiretroviral medication can cause neuropsychiatric symptoms as side effects. See Treisman (2002) for a thorough discussion of these issues.

V. Diagnosis Of Major Depressive Disorder  TOP

Major depressive disorders are frequently undiagnosed (Asch, 2003) and once diagnosed, are often under-treated. Care providers may project their own feelings and think “I’d be depressed too, under the circumstances,” and not think about intervening with medication. Substance disorders are sometimes missed as contributors to the depression, and bipolar disorder is often not recognized when depression is the presenting symptom.

Normal grief or sadness does not require treatment with medication. The central feature of a major depressive disorder is the loss of pleasure in all activities or “anhedonia,” rather than sadness alone. Waves of grief are usually accompanied by lighter moments or even laughter as the most acute grief subsides. Sadness for other reasons, such as a major disappointment, is also responsive to environmental change such as an enjoyable activity, and the mood will be quickly reversed if the source of the disappointment changes.

This is not the case in a major depressive episode, where the world has no joy regardless of the activity or turn of events, and where the outlook is gloom and doom regardless of the likelihood of a positive change. There may be obsessive rumination on past wrongs, or preoccupation with guilt or regrets that are impossible to balance with any feelings of accomplishment or hope. In addition to depressed mood, anhedonia, and hopelessness, major depressive disorders are usually accompanied by vegetative or biologic symptoms: low energy and psychomotor retardation; sleep disturbance (hypersomnia or insomnia), early morning awakening (around 2:00 AM to 4:00 AM); appetite disturbance (hyperphagia or hypophagia); decreased libido and, constipation. Finally, there may be cognitive changes such as decreased attention and concentration, social withdrawal and tendency toward isolative behavior, diminished range of affect, uncharacteristic irritability, and increased use of drugs or alcohol. In the most severe cases, psychotic symptoms such as delusions and hallucinations may be present.

The mood of a major depressive disorder is often worse in the morning, whereas the sadness of adjusting to difficult events tends to worsen over the course of the day, followed by a new day which is filled with more hope. A family history of mood disorders is often present. The constellation of depressive symptoms develop together over a course of weeks or months and can help to differentiate major depressive disorders from similar disturbances related to medical illnesses. Hopelessness indicates severe depression and is the most consistent predictor of completed suicides. The suicidal ideation associated with bipolar depression can be particularly dangerous. A combination of psychotherapy and antidepressant medication has been shown to be therapeutic for HIV-positive patients with major depressive disorders (Markowitz, 1998).

Some of the clinical misperceptions that get in the way of evaluating major depression and other psychiatric disorders are listed in Table 9-4 (page 359), along with reminders for complete assessment. For the complete diagnostic criteria of each disorder, see the DSM-IV-TR of the American Psychiatric Association (2000).

VI. Psychopharmacology For The HIV Positive Woman:
General Guidelines  TOP

Numerous studies have indicated that psychotropic medications are safe and effective for HIV-positive individuals and do not adversely affect the immune system (Ferrando, 1999; Rabkin 1999; Repetto, 2003; Robinson, 2002). Standard antidepressant medications are generally well tolerated. While specific medications and common clinical dosing ranges are listed in Table 9-6 and are discussed below, the following general guidelines should be kept in mind when approaching psychotropic medications with the woman with HIV:

• Start low, go slow: There is evidence that for antipsychotic medication, women in general require lower doses than men. Use slow upward titration as with geriatric patients. (ADA, 2004; Seeman, 2004).
• Expect the unexpected: HIV-positive patients often experience unusual side effects, or common side effects at low doses, or complicated drug-drug interactions.
• Dynamic monitoring: Changes in weight, metabolism, other medications, or medical illness episodes require frequent updating and reevaluation of dosing or choice of medications; this is particularly important with increased weight or abdominal girth, new onset of hyperlipidemia, or hyperglycemia. (see below and chapter XIV Pharmacology).
• Interdisciplinary coordination: Psychiatrists and primary health care providers should be in regular communication with each other about clinical updates, dosing changes, and major medical events.
• Suspect substances: Depression may be complicated by alcohol, anxiety by withdrawal syndromes, mania by psychostimulants; patients often forget that when their consumption has decreased, their CNS sensitivity to the effects of these substances increases over time.
• Address medication adherence: Use medication boxes, simple regimens, written instructions, coordination with antiretroviral therapies, and patient education. Non-adherence or discontinuation may diminish the overall treatment effect if not specifically targeted (Ferrando, 1999).
• Potential drug-drug interactions are a concern in prescribing psychotropic and antiretroviral medications. The primary cytochrome P450 systems at issue for psychiatric medications are CyP2D6 and CyP3A4: The major CYP450 drug-drug interactions to keep in mind are included in Table 9-7.

Common potential side effects of all of the antidepressant medications include agitation, irritability, sedation, sexual dysfunction, weight gain, headache, gastrointestinal distress, dry mouth, and activation of mania. There may be discontinuation syndromes with paroxetine and venlafaxine so these drugs should be tapered when increasing or decreasing the dose. Venlafaxine may also cause hypertension. “Second generation antipsychotics”, as listed in Table 9-6, are routinely recommended over traditional antipsychotic medications such as haloperidol, except for acute or short-term use, because of potential improvement of “negative” (affect, social interaction) as well as “positive” (hallucinations, delusions) psychotic symptoms, and lower associated incidence of extrapyramidal side effects such as dystonia, akathisia and the long-term risk of dyskinesia. However, recent concern about the association of olanzapine, clozapine (not recommended for first-line use) and, to some extent, quetiapine and risperidone, with weight gain and possible increased risk for diabetes and dyslipidemias, necessitates extreme caution in using these agents in conjunction with antiretroviral medications which may also be associated with hyperlipidemia and lipodystrophy, hyperglycemia and weight gain. Hyperprolactinemia may occur with quetiapine or olanzapine, with associated sexual side effects or galactorrhea.

Tolerance, dependence and withdrawal syndromes, including rebound anxiety, can complicate the use of benzodiazepines, especially alprazolam, and patients should be warned about sedation, cognitive effects and slowed reflexes, especially with regard to driving when using these agents.

Adverse effects with mood stabilizing drugs include potential significant weight gain with both valproic acid and lithium, still considered first line agents for mood stabilization. Depression may increase with valproic acid when some patients experience more “antimanic” than true mood stabilizing effect. Valproic acid may also be associated with more serious adverse effects, including hepatic dysfunction, thrombocytopenia or pancreatitis. Lithium may be superior for patients with clinical history dominated by clear cycles of mania. Because lithium is excreted through the kidneys, patients are at risk of toxic lithium levels if they become dehydrated due to vomiting or diarrhea, excess sweating or use of diuretics. Carbamazepine and oxcarbazepine are related compounds which may be helpful in primary or adjunctive mood stabilization, although both may be sedating. Oxcarbazepine may be associated with hyponatremia, but has the advantage of fewer drug-drug interactions and does not require monitoring with blood levels. Carbamazepine has been associated with rare instances of severe hematologic and dermatologic complications, but has been safely used in the setting of HIV infection with careful clinical monitoring. Lamotrigine interacts with both valproic acid, which doubles lamotrigine levels, and with carbamazepine, which cuts lamotrigine levels in half; lamotrigine has also been associated with severe rash upon occasion.

Finally, patients who experience severe or unusual side effects, have multiple diagnoses or require multiple medications, or are not responding at routine doses with initial medications should be referred for psychiatric consultation.

VII. Evaluation Of Suicide Risk  TOP

Women are significantly more likely to attempt suicide than men, but men are significantly more likely to complete the suicide (male:female ratio of at least 4:1). Caucasians commit suicide at twice the rate of African Americans and Hispanics. It is estimated that 90% of individuals have a psychiatric disorder at the time of suicide and 45–79% of those have major depression. Fifteen percent of individuals with a mood disorder commit suicide (Buzan, 1996).

Women more commonly attempt suicide by overdose, whereas men use more violent means, such as firearms or hanging. Women who have few social supports, have been widowed or divorced, or who have a history of sexual abuse are at increased risk for suicide. Women with children attempt suicide less frequently. Any risk factor is increased by the presence of alcohol, psychosis, or an organic mental syndrome.

It is likely that suicide rates are decreasing among individuals with HIV (Marzuk, 1997). This may be due to a global or specific treatment effect of antiretroviral therapies (Chan, 2003), which can improve organic mood disorders and cognitive function (Ferrando, 1998), in addition to increasing longevity and hope.

To assess suicide risk, the clinician must inquire about it (see Table 9-8). Knowing that this does not increase the likelihood an individual will attempt suicide. The clinician should practice a standard way of asking, such as “Have you ever had thoughts of hurting yourself?” or “. . . of ending your life?” or “Do you ever feel that life is not worth living?”

VIII. Care Provider Issues  TOP

One of the most important relationships the woman living with HIV has is the relationship with her health care provider. The dynamics of this relationship can have significant impact on the experience of the HIV-positive woman, and she will be affected not only by what the clinician communicates about HIV disease and treatment, but by how the information is communicated and how the provider relates to her. The practitioner who is able to establish a trusting relationship with the patient may find that the strength of their relationship can motivate the HIV-positive woman as much as lectures about viral load. Care providers, in turn, may experience, and should be aware of, a variety of potential reactions to their patients.

Women who use/abuse drugs or alcohol may provoke strong reactions in care providers, commonly frustration and disapproval, particularly when the woman is pregnant or has children. Providers may feel anger when the woman’s learned helplessness, particularly in sexual situations, results in her submitting repeatedly to unsafe sex, or provide inadequate pain control in response to provocative and insistent behavior on the part of the patient, in order to try to assert control. As is the case with other medical conditions, providers may personalize nonadherence with medications or medical follow-up as an affront to their good intentions or perceive it as a lack of commitment to treatment, rather than adherence to different priorities. Appointments missed to take care of children or because of problems with transportation may be misinterpreted as poor motivation for treatment. Providers who may then convey frustration or disappointment to a patient (e.g., with her nonadherence to medication) may find that she does not return because she has personalized this as a rejection.

On the other hand, providers may also collude with the HIV-positive woman’s feelings of powerlessness and try to take control over things she can actually handle herself with sufficient support. Protective concerns and anger at an abusing partner may tempt the provider to cross professional boundaries and try to rescue the patient. Frank disregard or avoidance of medical treatment may be mistakenly excused without exploring the real meaning of the behaviors. Care providers might assume that a woman is missing visits because she is overwhelmed with the care of her children when she is actually angry at a particular provider, or so frightened about the illness that she avoids treatment. Initiating multiple medications may be the point at which she is forced to break through the denial and confront her illness.

For the female health care provider, the experience of taking care of women with HIV can be both more rewarding and more depleting than general medical care. Personal identification with the patient may work positively to increase empathy, or negatively to increase projection of one’s own values and expectations on the individual. Female providers may also experience amplified grief because of the death of a patient with whom they have developed a genuine connection.

Providers who are either prone to experience patient deaths as their own clinical failures, or who have deep compassion for the suffering of their patients, may be vulnerable to experiencing professional burnout, particularly if subjected to multiple, sequential losses. The practitioner who can cope with these challenges, however, may find personal and professional satisfaction in providing a combination of important services to a subpopulation of women who remain profoundly underserved.

IX. References  TOP

American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus Development Conference on Antipsychotic
Drugs and Obesity and Diabetes. Diabetes Care. 2004; 27:596-601.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 2000.

Asch SM, Kilbourne AM, Gifford AL, et al. Underdiagnosis of depression in HIV: who are we missing? J Gen Intern Med. 2003;18:450–460.

Barkan SE, Melnick SL, Preston-Martin S, et al. The Women’s Interagency HIV Study. The WIHS Collaborative Study Group. Epidemiology. 1998;9:117–125.

Bennett GA, Velleman RD, Barter G, Bradbury C. Gender differences in sharing injecting equipment by drug users in England. AIDS Care. 2000;12:77–87.

Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58:721–728.

Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. N Engl J Med. 1998;339:1897–1904.

Burnam MA, Bing EG, Morton SC, et al. Use of mental health and substance abuse treatment services among adults with HIV in the United States. Arch Gen Psychiatry. 2001;58:729–736.

Buzan R. Assessment and management of the suicidal patient. In: Jacobson JL, Jacobson AM, eds. Psychiatric Secrets. Philadelphia: Hanley & Belfus; 1996.

Chan KS, Orlando M, Joyce G, et al. Combination antiretroviral therapy and improvements in mental health: results from a nationally representative sample of persons undergoing care for HIV in the United States. AIDS. 2003;33:104–111.

Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158:725–730.

Cohen M, Deamant C, Barkan S, et al. Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV. Am J Public Health.
2000;90:560–565.

Cohen RA, Boland R, Paul R, et al. Neurocognitive performance enhanced by highly active antiretroviral therapy in HIV-infected women. AIDS. 2001;15:341–345.

Cook JA, Cohen MH, Burke J, et al. Effects of depressive symptoms and mental health quality of life on use of highly active antiretroviral therapy among HIV-seropositive women. J Acqir Immune Defic Syndr. 2002;30:401–409.

Cunningham WE, Andersen RM, Katz MH, et al. The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States. Medical Care.
1999;37:1270–1281.

Dore GJ, McDonald A, Li Y, et al. Marked improvement in survival following AIDS dementia complex in the era of highly active antiretroviral therapy. AIDS.
2003;17:1539–1545.

Evans DL, Ten Have TR, Douglas SD, et al. Association of depression with viral load, CD8 T lymphocytes, and natural killer cells in women with HIV infection. Am J Psychiatr. 2002;159:1752–1759.

Farmer P, Connors M, Simmons J, eds. Women, Poverty and AIDS. Monroe, Maine: Common Courage Press; 1996.

Ferrando S, van Gorp W, McElhiney M, et al. Highly active antiretroviral treatment in HIV infection: benefits for neuropsychological function. J AIDS. 1998;12:F65–70.

Ferrando SJ, Rabkin JG, deMoore GM, Rabkin R. Antidepressant treatment of depression in HIV-seropositive women. J Clin Psychiatry. 1999;60:741–746.

Fiore T, Flanigan T, Hogan J, et al. HIV infection in families of HIV-positive and “at-risk” HIV-negative women. AIDS Care. 2001;13:209–214.

Fullilove RE, Fullilove M, Gasch H, Smith M. Violent trauma and HIV risk. Intern Conf AIDS. 1992;8: C287.

Galvan FH, Bing EG, Fleishman JA, et al. The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: results from the HIV Cost and Services Utilization Study. J Stud Alcohol. 2002;63:179–186.

Galvan FH, Burnam MA, Bing EG. Co-occuring psychiatric symptoms and drug dependence or heavy drinking among HIV-positive people. J Psychoactive Drugs.
2003;Suppl 1:153–160.

Gardner LI, Holmberg SD, Moore J, et al. HIV Epidemiology Research Study Group. Use of highly active antiretroviral therapy in HIV-infected women: impact of HIV specialist care. J Acquir Immune Defic Syndr. 2002;29:69–75.

Gilligan C. In a Different Voice: Psychological Theory and Women’s Development. Cambridge: Harvard University Press; 1993.

Gruskin L, Gange SJ, Celentano D, et al. Incidence of violence against HIV-infected and uninfected women: findings from the HIV Epidemiology Research (HER) study. J Urban Health. 2002;79:512–524.

Hoff RA, Beam-Goulet J, Rosenheck RA. Mental disorder as a risk factor for human immunodeficiency virus infection in a sample of veterans. J Nerv Ment Dis.
1997;185:556–560.

Ickovics JR, Druley JA, Morrill AC, et al. “A grief observed”: the experience of HIV-related illness and death among women in a clinic-based sample in New Haven, Connecticut. J Consult Clinic Psychol. 1998;66:958–966.

Ickovics, Hamburger ME, Vlahov D, et al. HIV Epidemiology Research Study Group. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study. JAMA. 2001;285:1466–1474.

Johnson JG, Rabkin JG, Lipsitz JD, et al. Recurrent major depressive disorder among human immunodeficiency virus (HIV)-positive and HIV-negative intravenous drug users: findings of a 3-year longitudinal study. Comp Psychiatr. 1999;40:31–40.

Kalichman SC, Sikkema KJ, DiFonzo K, et al. Emotional adjustment in survivors of sexual assualt living with HIV-AIDS. J Trauma Stress. 2002;15:289–296.

Klein H, Rodriguez-Crane SM, Hoffman JA, et al. HIV risk behavior involvement among low-frequency and high-frequency crack-using women. National Conference on Women with HIV; May 4-7, 1997; Pasadena, CA. 120.

Kobayashi JS, Standridge WL. An integrated program for comprehensive HIV care. In: Cournos F, Forstein M, eds. What mental health practitioners need to know. New Directions for Mental Health Services, No. 87, Fall 2000. San Francisco: Jossey-Bass.

Low-Beer S, Chan K, Yip B, et al. Depressive symptoms decline among persons on HIV protease inhibitors. AIDS. 2000;23:295–301.

Lyketsos CG, Fishman M, Hutton H, et al. The effectiveness of psychiatric treatment for HIV-infected patients. Psychosomatics. 1997;38:423–432.

Markowitz JC, Kocsis JH, Fishman B, et al. Treatment of depressive symptoms in human immunodeficiency virus-positive patients. Arch Gen Psychiatry.
1998;55:452–457.

Marzuk P, Tardiff K, Leon A, et al. HIV seroprevalence among suicide victims in New York City, 1991–1993. Am J Psychiatry. 1997;154:1720–1725.

Morrison MF, Petitto JM, Ten Have T, et al. Depressive and anxiety disorders in women with HIV infection. Am J Psychiatry. 2002;159:789–796.

Morrow KM, Boland R, Fiore T, et al. Support for HIV-positive women: an assessment of needs and barriers to services. National Conference on Women and HIV; May 4-7, 1997; Pasadena, CA. Abstract P1.43.

Myers HF, Durvasula RS. Psychiatric disorders in African-American men and women living with HIV/AIDS. Cult Diversity Ethnic Minority Psychol. 1999;5:249–262.

Neuenburg JK, Brodt HR, Herndier BG, et al. HIV-related neuropathology, 1985 to 1999: Rising prevalence of HIV encephalopathy in the era of highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2002;31:171–177.

NIMH Multisite HIV Prevention Trial Group. A test of factors mediating the relationship between unwanted sexual activity during childhood and risky sexual practices among women enrolled in the NIMH Multisite HIV Prevention Trial. Women Health.
2001;33:163–180.

Orlando M, Burnam MA, Beckman R, et al. Re-estimating the prevalence of psychiatric disorders in a nationally representative sample of persons receiving care for HIV: results from the HIV Cost and Services Utilization Study. Int J Methods Psychiatr Res. 2002;11:75–82.

Rabkin JG, Wagner GJ, Rabkin R. Fluoxetine treatment for depression in patients with HIV and AIDS: a randomized, placebo-controlled trial. Am J Psychiatry.
1999;156:101–107.

Repetto MJ, Evans DL, Cruess DG, et al. Neuropsychopharmacologic treatment of depression and other neuropsychiatric disorders in HIV-infected individuals. CNS Spectrums. 2003;8:59–63.

Robinson MJ, Qaqish RB. Practical psychopharmacology in HIV-1 andacquired immunodeficiency syndrome. Psychiatr Clin North Am. 2002;25:149–175.

Sambamoorthi U, Walkup J, Olfson M, et al. antidepressant treatment and health services utilization among HIV-infected medicaid patients diagnosed with depression. J Gen Inernt Med. 2000;15:311–320.

Schatzberg AF, Nemeroff CB. Textbook of Psychopharmacology. Washington, DC: American Psychiatric Press; 1998.

Schuman P, Ohmit SE, Moore J, et al. Perceived need for and use of mental health services by women living with or at risk of human immunodeficiency virus infection. J Am Med Womens Assoc. 2001;56:4–8.

Schuster MA, Kanouse DE, Morton SC, et al. HIV-infected parents and their children in the United States. Am J Public Health. 2000;90:1074–1081.

Seeman MV. Gender differences in the prescribing of antipsychoticDrugs. Am J Psychiatry. 2004;161:1324-1333.

Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA. 1999;281:2305–2315.

Sherbourne C, Griffith Forge N, Kung FY, et al. Personal and psychosocial characteristics associated with psychiatric conditions among women with human immunodeficiency virus. Womens Health Issues. 2003;13(3):104–110.

Sherbourne CD, Hays RD, Fleishman JA, et al. Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. Am J Psychiatry.
2000;157:248–254.

Simoni JM, Ng MT. Trauma, coping, depression among women with HIV/AIDS in New York City. AIDS Care. 2000;12:567–580.

Solomon L, Stein M, Flynn C, et al. Health services use by urban women with or at risk for HIV-1 infection: the HIV Epidemiology Research Study (HERS). J Acquir Immune Defic Syndr Hum Retrovirol. 1998;17:253–261.

Stein MD, Crystal S, Cunningham WE, et al. Delays in seeking HIV care due to competing caregiver responsibilities. Am J Public Health. 2000;90:1138–1140.

Surrey JL. The ‘Self-in-Relation’: A Theory of Women’s Development. Wellesley, MA; The Stone Center, Wellesley College; 1982. Work in Progress Series.

Thompson AS, Blankenship KM, Winfrey J, et al. Improving health care utilization and access for drug-using women with or at risk for HIV infection in a correctional facility and at needle exchange sites. HIV Infected Women Conference; February 22-24, 1995; Abstract S19.

Treisman GJ, Kaplin AI. Neurologic and psychiatric complications of antiretroviral agents. AIDS. 2002;16:1201–1215.

Tucker JS, Burnam MA, Sherbourne CD, et al. Substance use and mental health correlates of nonadherence to antiretroviral medications in a sample of patients with immunodeficiency virus. Am J Med. 2003;114:573–580.

Turner BJ, Fleishman JA, Wenger N, et al. Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons. J Gen Intern Med.
2001;16:625–633.

Vitiello B, Burnam MA, Bing EG, et al. Use of psychotropic medications among HIV-infected patients in the United States. Am J Psychiatry. 2003;160:547–554.

Weinhardt LS, Carey MP, Carey KB. HIV-risk behavior and the publichealth context of HIV/AIDS among women living with a severe andpersistent mental illness. J Nerv Ment Dis. 1998;186:276–282.

Weiss EL, Longhurst JG, Mazure CM. Childhood sexual abuse as a risk factor for depression in women: psychosocial and neurobiological correlates. Am J Psychiatry.
1999;156:816–828.

Wise LA, Zierler S, Krieger N, et al. Adult onset of major depressive disorder in relation to early life violent victimisation: a case-control study. Lancet. 2001;358:881–887.

Wong L, Irwin K, Edlin B, et al. Risk factors for rape and prevalence of HIV and syphilis infection among the rape victims in 3 US cities. The Multicenter Crack Cocaine and HIV Study Team. Intl Conf AIDS. 1993;9(2):649.

Wyatt GE, Peters SD. Issues in the definition of child sexual abuse in prevalence research. Child Abuse Negl. 1986;10:231–240.

Zierler S, Feingold L, Laufer D, et al. Adult survivors of childhood sexual abuse and subsequent risk of HIV infection. Am J Public Health. 1991;81:572–575.

Zierler S, Cunningham WE, Andersen R, et al. Violence victimization after HIV infection in a US probability sample of adult patients in primary care. Am J Public Health. 2000;90:208–215.

ADDITIONAL BIBLIOGRAPHY

Brady S, Gallagher D, Berger J, et al. Physical and sexual abuse in the lives of HIV-positive women enrolled in a primary medicine health maintenance organization. AIDS Patient Care STDS. 2002;16:121–125.

Fox-Tierney RA, Ickovics J, Cerreta C, et al. Potential sex differences remain understudied: A case study of the inclusion of women in HIV/AIDS-related neuropsychological research. Rev Gen Psychology. 1999;3:44–54.

Giesen HJ, Hefter H, Jablonowski H, et al. HAART is neuroprophylactic in HIV-1 infection. J AIDS Hum Retrovirol. 2000;23:380–385.

Lechner SC, Antoni MH, Lydston D, et al. Cognitive-behavioral interventions improve quality of life in women with AIDS. J Psychosom Res. 2003;54:253–261.

Lo W, MacGovern T, Bradford J. Association of ancillary services with primary care utilization and retention for patients with HIV/AIDS. AIDS Care. 2002;Suppl 1:S45–57.

Macalino GE, Ko H, Celentano DD, et al. Drug use patterns over time mong HIV-seropositive and HIV-seronegative women: The HER Study experience. J Acquir Immune Defic Syndr. 2003; 33:500–505.

Markowitz JC, Klerman GL, Clougherty KF, et al. Individual psychotherapies for depressed HIV-positive patients. Am J Psychiatry 1995;152:1504–1509.

O’Cleirigh C, Ironson G, Antoni M, et al. Emotional expression and depth processing of trauma and their relation to long-term survival in patients with HIV/AIDS. J Psychosom Res. 2003;54: 225–235.

Stoskopf CH, Kim YK, Glover SH. Dual diagnosis: HIV and mental illness, a population-based study. Comm Mental Health J. 2001;37:469–479.

Turner BJ, Cunningham WE, Duan N, et al. Delayed medical care after diagnosis in a US national probability sample of persons infected with human immunodeficiency virus. Arch Intern Med. 2000;160:2614–2622.

Zablotsky D, Kennedy M. Risk factors and HIV transmission to midlife and older women: knowledge, options, and the initiation of safer sexual practices. J Acquir Immune Defic Syndr. 2003; 33:S122–S130.