As more HIV-positive people access treatment and live longer, the number of people suffering from HIV-related mental disorders is growing, but mental health remains an ethical, legal and clinical minefield, where many doctors and nurses fear to tread – and fear to test.
"We're moving away from seeing patients on their death beds towards patients who are living longer, and are being affected by mental disorders that have real impacts on their life and work," said Dr Greg Jonsson, a psychiatrist at the Luthando Psychiatric HIV Clinic at the Chris Hani Baragwanath Hospital, in Johannesburg.
Various studies have shown a higher than average prevalence of mental illness among people living with HIV. A 2005 study by South Africa's Human Sciences Research Council found that about 44 percent of the 900 HIV-positive individuals surveyed suffered from a mental disorder.
The links between HIV and mental illness are complex, but factors include the effects of the virus on the central nervous system, as well as difficulties in dealing with HIV-related stigma and discrimination.
South Africa has the world's largest ARV programme to counter an HIV prevalence rate of about 18 percent, according to UNAIDS, and about 920,000 people are on ARV treatment.
No easy choices
Doctors and nurses in clinics often find it daunting to test mental health patients for HIV. "People who are not trained in psychiatric disorders are scared of getting consent from patients with mental disorders," Jonsson told IRIN/PlusNews. "People should not assume that mentally ill or even psychotic patients are incapable of understanding [testing] and consenting."
But Jonsson added that there would be times where doctors would need to make tough calls about testing severely mentally ill patients who could not consent to HIV testing and whose families may not be approachable to consent on their behalf.
|Psych is hard because the 'three ticks equal this' approach doesn't really work, and that's why people are so scared of it.|
"If you can't obtain informed consent, you need to weigh up the potential harm and benefit to the patient - ask yourself whether this test is going to change your diagnoses or your treatment," he suggested to health workers at an annual symposium held by the Aurum Institute, a non-profit medical research organization.
"I think if the answer is 'yes' to either, then go for it. It is really the right of the patient to be offered effective HIV treatment," said Jonsson, who pointed out that doctors should be aware of possible interactions between mental health medications and antiretroviral (ARV) drugs.
He advised doctors to document the process and counsel patients throughout, especially about how to reduce risk, given the prevalence of substance abuse among mental health as well as HIV patients.
"Psych is hard because the 'three ticks equal this' approach doesn't really work, and that's why people are so scared of it," Jonsson told IRIN/PlusNews.
No right answers
Once a mental health patient started taking ARVs, healthcare providers would have to evaluate whether mandating a "treatment supporter" – a friend or family member to help the patient adhere to treatment - would be appropriate. Again, there may not be a right answer.
"We need to draw up protocols and put them in primary healthcare, but the problem with protocol-based system is that people don't think outside the box - with mental health patients it really is on a case-by-case basis," Jonsson told the symposium audience.
"I tell most of my patients, 'If you can get treatment support, go for it', but I don't insist on it - disclosing to a patient's family is difficult and ... at my clinic, our patients on treatment are already so stigmatized and victimized."
The Luthando Psychiatric HIV Clinic has a treatment default rate – patients who discontinue ARVs – that is the same as institutions in Johannesburg that mandate treatment supporters, Jonsson added.