Approximately one-quarter of an estimated 1.2 million people currently living with HIV (PLWH) in the United States are women.1,2 Mental health conditions affect women living with HIV (WLWH) at substantially higher rates compared with men living with HIV (MLWH) and HIV-negative women.2 However, treatment regimens and research literature related to mental health do not reflect the proportion of affected WLWH.
In a narrative review published online in the January 2021 issue of the Journal of the International Association of Providers of AIDS Care, Elizabeth M. Waldron, MS, a doctoral student in the clinical psychology program at Northwestern University Feinberg School of Medicine in Chicago, and colleagues described various mental health interventions, and their feasibility and outcomes for WLWH.2
They found that routine screenings, cognitive behavioral therapy (CBT), CBT approaches, and psychopharmacologic therapies, with varying degrees, could all be tools in diagnosing and treating mental health conditions that affect WLWH.
Women in the general US population have a greater risk than men of being diagnosed with depression, post-traumatic stress (PTSD), and anxiety disorders. “For women living with HIV, there are even higher rates of depression, PTSD, and other trauma-related conditions, due in part to several intersectional stressors like HIV-related stigma, psychological stress from disease management, exposure to trauma, and – for women of color living with HIV – racism,” Waldron told us in a recent interview.
In a study of 832 WLWH from 94 countries, 82% of survey respondents indicated that they had experienced symptoms of depression, and participants reported that their mental health issues increased 3.5-fold following a HIV diagnosis.3 Researchers have found that prevalence rates of major depressive disorders in WLWH are 4 times higher compared to HIV-negative women and up to 2 times as high as rates in MLWH, with greater symptom severity in WLWH.2 As depressive disorders are often underdiagnosed in PLWH, especially women, it is likely that these rates are even higher than reported.
PTSD: WLWH have demonstrated elevated rates of exposure to traumatic events and symptoms of PTSD globally, and US studies “have found a strong association between history of childhood trauma, intimate partner violence, and depression among WLWH,” as stated in the review.2 Results of a meta-analysis involving WLWH in the US and numerous other countries revealed a recent history of PTSD in 30% of participants – more than 5 times the rate observed in women in the general population – and a history of abuse in 70% of participants.2
Anxiety: Research findings suggest that anxiety disorders may be more prevalent in WLWH compared to HIV-negative women and MLWH, and symptoms may be more severe in WLWH.2 In a Canadian study of 361 WLWH of reproductive age, 37% of participants had high levels of anxiety as reflected by a score of at least 11 on the Hospital Anxiety and Depression Scale (HADS-A).4 High anxiety was associated with HIV stigma, the use of antiretroviral therapy (ART), and concerns related to reproductive health, while low anxiety was linked to older age, undetectable viral load, and being in a romantic or sexual relationship.4
Mental health issues are often compounded in pregnant and postpartum WLWH due to a range of factors, such as perceived stigma from healthcare providers and worries related to perinatal HIV transmission, as well as the elevated mental health risk associated with pregnancy and the postpartum period in general.2
Roughly 80% of WLWH in the US belong to racial and ethnic minority groups, and findings suggest that these women experience a higher burden of perceived stress, mental health risk factors, and HIV stigma in addition to racial- and gender-based discrimination and other intersectional systemic issues. Rates of trauma exposure (56%) and depressive symptoms (44%) are especially high among transgender women.2
Along with the direct burden of psychiatric illness, such disorders may influence HIV outcomes and health-related quality of life via lower rates of ART adherence and medical appointment attendance.2,5 Conversely, mental health treatment has been linked to increased ART use and lower mortality.2 “That is why treating these conditions in women living with HIV is so important – not only can it enhance well-being and psychosocial functioning, but effective mental health treatment has the potential to improve HIV management and outcomes for overall improved health,” Waldron explained.
Mental health treatments for WLWH
There are still significant gaps in the realm of evidence-based interventions for mental health conditions in this population. One study found, for example, that less than 50% of WLWH and depression received adequate treatment in the US,and this may be partly attributable to the dearth of research focused on mental health treatments for WLWH who have psychiatric diagnoses.2,6 It is also unclear how co-occurring stigma related to both HIV and mental health should be addressed to increase engagement in mental health services.
Waldron and other experts believe that screening for depressive and trauma-related symptoms should become a routine part of HIV and primary care, followed by referrals for mental health treatment when warranted.5 “Having a trusted provider link the patient to mental health care can curb the stigma associated with mental illness and treatment,” she noted. “Like in other behavioral medicine areas, this mental health treatment facilitation is even more powerful if services are integrated within or affiliated with the HIV care facility that a woman living with HIV already knows and trusts.”
Among the limited available data related to the topic, studies have shown that CBT improved quality of life and cognitive functioning, and decreased health-related distress, sense of loneliness, and subsequent depression symptom severity in WLWH.2 Women with active depression or other psychiatric disorders were not included in the studies, however, thus limiting generalizability to these populations.
Findings from a study published in the January 2021 issue of AIDS and Behavior supported the feasibility of a group-based intervention to “enhance positive affect and gender empowerment and decrease depressive symptoms for Black WLWH.”7
Small studies investigating CBT approaches to address PTSD showed reduced symptoms and improved psychological well-being in WLWH.2 Other results point to the potential value of supportive, peer-facilitated interventions to improve psychosocial and mental health in WLWH, although substantial research needs remain to elucidate these approaches.2
While evidence is limited regarding psychopharmacologic therapies in WLWH, several studies have demonstrated that these medications were associated with reduced depression symptoms and increased ART adherence (by 83% in a meta-analysis).8,9
There is a clear need for extensive research to explore potential mental health treatment approaches for women with co-occurring HIV and psychiatric disorders. “Future research should assess which interventions are the most effective and whether standard evidence-based treatments should be adapted to improve acceptability and outcomes,” said Waldron. “We also need research on how these interventions perform among transgender women living with HIV and women in vulnerable reproductive stages like pregnancy and menopause.”
- Basic Statistics. Centers for Disease Control and Prevention. Updated January 27, 2021. Accessed February 24, 2021. https://www.cdc.gov/hiv/basics/statistics.html
- Waldron EM, Burnett-Zeigler I, Wee V, et al. Mental health in women living with HIV: the unique and unmet needs. J Int Assoc Provid AIDS Care. Published online January 21, 2021. doi:10.1177/2325958220985665
- Orza L, Bewley S, Logie CH, et al. How does living with HIV impact on women’s mental health? Voices from a global survey. J Int AIDS Soc. 2015;18(Suppl 5):20289. doi:10.7448/IAS.18.6.20289
- Ivanova EL, Hart TA, Wagner AC, Aljassem K, Loutfy MR. Correlates of anxiety in women living with HIV of reproductive age. AIDS Behav. 2012;16(8):2181-2191. doi:10.1007/s10461-011-0133-6
- Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, Mellins CA. Mental health and HIV/AIDS: the need for an integrated response. AIDS. 2019;33(9):1411-1420. doi:10.1097/QAD.0000000000002227
- Cook JA, Burke-Miller JK, Grey DD, et al. Do HIV-positive women receive depression treatment that meets best practice guidelines? AIDS Behav. 2014;18(6):1094-1102. doi:10.1007/s10461-013-0679-6
- Bassett SM, Brody LR, Jack DC, et al. Feasibility and acceptability of a program to promote positive affect, well-being and gender empowerment in black women living with HIV. AIDS Behav. Published online January 2, 2021. doi:10.1007/s10461-020-03103-w
- Cruess DG, Kalichman SC, Amaral C, Swetzes C, Cherry C, Kalichman MO. Benefits of adherence to psychotropic medications on depressive symptoms and antiretroviral medication adherence among men and women living with HIV/AIDS. Ann Behav Med. 2012;43(2):189-197. doi:10.1007/s12160-011-9322-9
- Sin NL, DiMatteo MR. Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis. Ann Behav Med. 2014;47(3):259-269. doi:10.1007/s12160-013-9559-6