1. Mental Health Aspects in HIV/AIDS:
An Indian Perspective
Kasi Sekar*
Sudeep Jacob Joseph
Arthur Julian Joseph
*Professor of PSW
National Institute of Mental Health and Neuro Sciences
Bangalore 560 029, India
+91 98452 14397 sekarkasi@gmail.com

2. HIV in India: An Overview
– India profile
– NIMHANS at a glance
– HIV profile
– Essentials of Mental Health
– Contributory factors
– HIV in the brain
– Psychiatric manifestations
– Psychiatric emergencies
– Psychosocial factors
– Special groups
– Interventions
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3. India Profile
Area: 3.2 m sq.kms.
States: 30
Union Territories: 7
Population: 1.2 billion
(2011)
Urban population:25.7%
Growth Rate:21.34%
Sex Ratio: 933 /1000
Literacy rate :65.38%
Coastline :> 8000 Kms

4. India Profile
• Multi climatic
• Multi agro
• Multi lingual
• Multi ethnic
• Multi religious
• 6 Religions
• 6 Ethnic groups
• 29 Major festivals
• 618 Languages
• 6400 Castes
YET one proud country!!! India
No the continent by itself

5. NIMHANS HIV/AIDS a glance
• Nearly three decades of
• service,
• capacity building
• research
in the area of HIV AIDS
• Neurology, Virology
• Psychiatry
• Clinical Psychology
• Psychiatric Social Work
• Psychiatric Nursing
• Mental Health Education
• Epidemiology

6. NIMHANS at a glance

7. NIMHANS at a glance

8. NIMHANS at a glance

9. HIV/AIDS in India: An Overview
• India is a country with low HIV
prevalence (0.31%)
• However, third largest population of
PLHIV (2.39 million in 2008 – 2009)
– 57.5% male
– 39% female
– 3.5% children
Source: National AIDS Control Organisation. (2011). Annual Report 2010 –
2011. Ministry of Health and Family Welfare, Govt. Of India. New Delhi.
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10. • The estimates
highlight an
overall reduction
in adult HIV
prevalence, HIV
incidence as well
as AIDS related
mortality in India
• Decline by more
than 50% percent
during the last
decade in new
annual HIV
Infections
Source: NACO, 2011
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11. “Mental health issues are an
essential for both prevention
and care in HIV”
Several psycho-social factors impinge
upon HIV progression:
•Emotional Well-being
•Types and Levels of Stressors
•Coping Skills
•Psychosocial Support
Source: Ramakrishnan, J and Chandra P.S (2010). Mental Health
and HIV/AIDS in South Asia. NIMHANS Journal. Bangalore

12. Why Address Mental Health
Issues in HIV?
• Decreased access to health care
• May increase high risk behavior
• Decrease treatment adherence
• May affect nutrition and impaired
Quality of Life
Sources:
Ramakrishnan, J. and Chandra P., S. 2010. Mental Health and HIV/AIDS
in South Asia. NIMHANS Journal. Bangalore
Chandra, P., S. 2011. Psychiatric Aspects of HIV/AIDS. in Kasi, S. 2011
Manual for Training of Trainers on Mental Health Aspects of HIV/AIDS.
NIMHANS, Saksham. Bangalore
World Health Organisation. 2003. Investing in Mental Health. Geneva
accessed from www.who.int/mental_health on 10th August 2011
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13. Contributory Factors
• Impact of HIV infection
– “psychosocial factors like chronic depression and
stressful life events affect clinical and
immunological progression of HIV/AIDS”
• Effects of virus
– “brain pathology arises early in the infection as a
consequence of viral damage of central nervous
system”
• HIV drug treatment
– ART drugs known to cause psychological
problems as side effects
Sources:
Ramakrishnan, J. and Chandra P., S. 2010. Mental Health and HIV/AIDS
in South Asia. NIMHANS Journal. Bangalore
Kasi, S. et al. (eds.) 2011 Manual for Training of Trainers on Mental
Health Aspects of HIV/AIDS. NIMHANS, Saksham. Bangalore
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14. Contributory Factors
• Alcohol and drug use
– Contribution in aetiology and outcome of
psychiatric problems among PLHIV
• Poor social support
– Associated with faster disease
progression and several mental health
problems
Sources:
Ramakrishnan, J. and Chandra P., S. 2010. Mental Health and HIV/AIDS
in South Asia. NIMHANS Journal. Bangalore
Kasi, S. et al. (eds.) 2011 Manual for Training of Trainers on Mental
Health Aspects of HIV/AIDS. NIMHANS, Saksham. Bangalore
14

15. HIV in the Brain
• HIV is neurotropic
• The virus invades and infects the CSF early,
possibly before or at the time of
seroconversion
• CNS conditions over the course of the disease
include
– HIV Encephalopathy
– AIDS Dementia Complex
• Prevalence of AIDS Dementia Complex less
than 20%
• Prevalence among those on HAART 1-2%
Source: Satishchandra, P., Nalini, A., Gourie-Devi, M., Khanna, N., Santosh, V.,
Ravi, V., Desai, A., Chandramuki, A., Jayakumar, P. N., and Shankar, S. K. (2000).
"Profile of neurologic disorders associated with HIV/AIDS from Bangalore, south
India (1989-96)". Indian J. Med. Res. 11: 14–23
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16. Psychiatric Manifestations in
HIV/AIDS
• Depression • Substance Use Disorders
– Prevalence up to 60% – As independent
• Anxiety Disorders diagnosis or part of other
– Found among one- psychiatric syndrome
third of PLHIV
• Delirium • Sleep Disorders
– Prevalence of 40- – As part of psychiatric
60%. syndrome or emotional
• Psychosis reaction to stress
– Found in 4-10% PLHIV
Source: Chandra, P., S. 2011. Psychiatric Aspects of HIV/AIDS. in Kasi, S. et
al. (eds.) 2011 Manual for Training of Trainers on Mental Health Aspects of
HIV/AIDS. NIMHANS, Saksham. Bangalore
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17. Psychiatric Emergencies in
HIV/AIDS
• HIV infection can be • Periods when risk of
associated with suicidal suicide is high
ideas and/or attempts – Following a positive test
• Risk Factors for suicide – Following bereavement,
especially loss of an
– Past history of infected partner
suicidal attempt
– Failure of response to
– Psychiatric illness treatment
– Feeling Hopeless – Severe physical
– Uncontrolled Pain complications
– Alcohol or drug use – During an episode of
– Social Isolation depression
Source: Mehrotra, S. et al.2011. Understanding and Responding to
SuicidalityIn People Living with HIV/AIDS. in Kasi, S. et al. (eds.) 2011
Manual for Training of Trainers on Mental Health Aspects of HIV/AIDS.
NIMHANS, Saksham. Bangalore
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18. Psychosocial Factors
• In families:
– 19% of the PLWHIV were told not to
touch children out of fear of infection
– 18% were not allowed to use /share the
same utensils
– 15% had been thrown out of their homes
– 7 % were threatened with physical abuse
– 6 % were evicted out from landlord
Source: Ramakrishnan, J. et al.2011. Overview of Mental Health Needs of
PLHIV. in Kasi, S. et al. (eds.) 2011 Manual for Training of Trainers on
Mental Health Aspects of HIV/AIDS. NIMHANS, Saksham. Bangalore
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19. Psychosocial Factors
• In health care settings:
– 22% of the HCW refused to touch PLHIV
because of their HIV status
– 22% used gloves for procedures, which did
not warrant wearing gloves like taking
height-weight, temperature
– 6% HCW broke confidentiality of HIV status
without client’s knowledge or consent
– 33 % nurses took extra precaution while
dispensing the medicines
Source: Ramakrishnan, J. et al.2011. Overview of Mental Health Needs of
PLHIV. in Kasi, S. et al. (eds.) 2011 Manual for Training of Trainers on
Mental Health Aspects of HIV/AIDS. NIMHANS, Saksham. Bangalore
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20. Psychosocial Factors
• Punitive attitude of general society is
evident as
– 70% people felt PLHIV had engaged in
‘wrong’ behaviour
– More than half thought that PLHIV are
disgusting
– 48 % felt that PLHIV had brought dishonour
to their families
– 42% believed that PLHIV should feel guilty for
being positive
Source: Ramakrishnan, J. et al.2011. Overview of Mental Health Needs of
PLHIV. in Kasi, S. et al. (eds.) 2011 Manual for Training of Trainers on
Mental Health Aspects of HIV/AIDS. NIMHANS, Saksham. Bangalore
20

21. Psychosocial Factors
• Clinical depression was correlated with
– Higher felt stigma
– Higher internalized stigma
– Avoidance of disclosure
– Less coping
– Higher impact on social relationships
Source: Ramakrishnan, J. et al.2011. Overview of Mental Health Needs of
PLHIV. in Kasi, S. et al. (eds.) 2011 Manual for Training of Trainers on
Mental Health Aspects of HIV/AIDS. NIMHANS, Saksham. Bangalore
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22. Special Groups
• Special groups have special health and
mental health needs
• The key risk groups covered include
– Female Sex Workers
– Men who have Sex with Men and
Transgenders
– Injecting Drug Users
• Though sexual minorities have always
existed in India, their issues have never
seriously been articulated
Sources:
National AIDS Control Organisation. (2011). Annual Report 2010 – 2011.
Ministry of Health and Family Welfare, Govt. Of India. New Delhi.
Parekh, S. 2003. “Homosexuality in India: The light at the end of the tunnel,”
Journal of Gay & Lesbian Psychotherapy, 7 (1/2): 153.
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23. Special Groups
• HIV/AIDS epidemic has added
recognition of male to male sex (MSM)
as a vulnerable group
• Limited literature on the mental health
needs
• Further empirical research in this area
needs to be conducted
Sources:
Parekh, S. 2003. “Homosexuality in India: The light at the end of the tunnel,”
Journal of Gay & Lesbian Psychotherapy, 7 (1/2): 153.
Ranade, K. 2003. “Stigma, stress and coping among gay, lesbian, bisexual
individuals – A qualitative study.” Dissertation submitted in partial fulfillment for
MPhil in Psychiatric Social Work, NIMHANS (Unpublished).
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24. Interventions in Mental Health
• Capacity Building
– Andhra Pradesh
– GFATM R7 training of Master Trainers on Mental
Health Aspects of HIV/AIDS
• Research
– NIMHANS based multi-centric study on stigma and
HIV/AIDS almost unitary study focusing on mental
health
– Ample empirical experience
– Adequate documentation
– More research and publication on mental health
aspects is warranted
Sources:
Kasi, S. et al. (eds.) 2011 Manual for Training of Trainers on Mental Health
Aspects of HIV/AIDS. NIMHANS, Saksham. Bangalore
Ramakrishnan, J and Chandra P., S. 2010. Mental Health and HIV/AIDS in South
Asia. NIMHANS Journal. Bangalore
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25. Interventions in Mental Health
• Services
– Counsellors in VCTC/ICTC
– NGO initiatives
• Drop-in-centres
• Crisis Intervention hotlines and points
– Ministry of Health to ensure presence of
trained counsellors in all VCTCs/ICTCs and
ART centres.
Source: National AIDS Control Organisation. (2011). Annual Report 2010 – 2011.
Ministry of Health and Family Welfare, Govt. Of India. New Delhi.
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26. Thank You