Position statements

Position Statement on HIV in Psychiatry by the South African Society of Psychiatrists

HIV infection and mental health/disorders are intimately connected in a number of ways.

1. The neuro-psychiatric manifestations of infection with HIV. These range from minor cognitive motor disorder to HIV dementia and new onset psychosis and mania.
   1. a. Where patients with HIV infection present with psychiatric manifestations, it is critical that practitioners accurately stage the infection and determine the need for anti-retroviral treatment. HIV Dementia and new onset psychosis and mania usually indicate late stage-3 or stage-4 disease and indicate the need for antiretroviral treatment even if the CD4 count is above 200/ml.
      1. Such patients should not be denied treatment on the basis of their mental state, nor should any patient by denied optimal psychiatric care because of his/her HIV status.
      2. Interventions to ensure adherence must be put into place in situations where it is difficult for the patient him/herself to adhere.


2. The issue of diagnosis of HIV-status is complicated in people with severe psychiatric disorders because of the issues around informed consent for voluntary counselling and testing. In addition, dealing with a diagnosis of HIV in an individual who may already be compromised in terms of their psychological functioning, can be very difficult. This requires sensitivity on the part of practitioners and knowledge of guidelines for testing for HIV-status in such individuals.
   1. Generally, testing should be done with full informed consent and adequate pre- and post-test counselling. Guidelines exist for situations where informed consent is not possible and testing is necessary.
   2. With the availability of Anti-Retroviral Treatment, it is particularly important to ensure that the diagnosis of HIV infection is made where there is clinical suspicion as it is ethically unacceptable to deprive someone of the opportunity to access appropriate treatment for this life-threatening infection.


3. It is also important to actively look for and treat opportunistic infections, particularly in in-patient settings where overcrowding may be an issue, and infections such as Tuberculosis can so easily spread.



4. The psychosocial implications of a diagnosis of HIV for an infected individual and their loved ones clearly fall within the ambit of mental health. This is seen in the increasing number of infected and affected individuals who are seen in mental health services with depression, suicidal behaviour, and other mental disorders. It is a concern that there are many other people (particularly children and adolescents) who suffer mentally as a result of HIV without ever receiving any treatment.



5. The impact of the epidemic on children and adolescents: An increased incidence of anxiety and mood disorders as well as disruptive behavioural disorders may be expected in children, and reduced access to education and other resources may exacerbate their distress and impairment. Caregivers may need help to guide children through the many challenges they face, such as fear of the loss of parents and home, rejection by peers, exploitation, own medical stressors or early death, due to lack of understanding of normal child and family development and emotional needs, or caregivers' own psychological 'blindness', or lack of parenting skills as well as to identify or resolve early signs of maladaptive emotional development or behaviour in child or family.
   1. The psychosocial vulnerability of children who are orphaned or otherwise negatively affected by HIV/AIDS must be taken into account when planning and delivering child and adolescent mental health services.
   2. Information regarding available treatment services for children as well as information regarding abnormal development and functioning must be made widely known, especially to caregivers of children infected and affected by HIV/AIDS.
   3. Services should as far as possible be available in a non-stigmatising way (both in terms of HIV and mental illness).


6. People with severe psychiatric disorders may be at increased risk of contracting HIV as a result of high-risk behaviours, and other mental health issues such as gender violence and substance abuse put people, particularly women and children, at risk of contracting HIV. This makes it imperative that psychiatrists play an active role in prevention efforts in these vulnerable groups.

It is our responsibility as psychiatrists working in South Africa to address the epidemic at all levels, in particular with regard to the psychiatric consequences of the HIV epidemic and to ensure that the patients that we care for (including children and adolescents) receive the appropriate treatment (for both their medical and psychiatric conditions).

The psychosocial implications of HIV infection make it imperative that medical and mental health/psychiatric services work together actively to provide holistic care for people infected with or affected by HIV. Psychiatrists are encouraged to develop working partnerships with HIV physicians and primary care practitioners in their area of practice in order to provide a better service to our people.

Prepared by Rita Thom
Convenor of HIV Special Interest Group
On behalf of the South African Society of Psychiatrists
April 2006