**Triple Challenges of Psychosocial Factors, Substance Abuse, and HIV/AIDS Risky Behaviors in People Living with HIV/AIDS**

Gemechu B. Gerbi, Tsegaye Habtemariam, Berhanu Tameru, David Nganwa, Vinaida Robnett, and Sibyl K. Bowie *Center for Computational Epidemiology, Bioinformatics and Risk Analysis (CCEBRA), College of Veterinary Medicine, Nursing and Allied Health (CVMNAH), Tuskegee University, Tuskegee, Alabama, U.S.A* 

#### **1. Introduction**

134 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

Yahaya, L. A.; Jimoh, A. A. G & Balogun, O. R. (2010). Factors hindering acceptance of

state, Nigeria. *African Journal of Reproductive Health, 14* (3) 159-164.

HIV/AIDS Voluntary Counselling and Testing (VCT) among youth in Kwara

 http://en.wikipedia.org/wiki/Maslow%27s\_hierarchy\_of\_needs World Health Organization (WHO; 2011). *Psychosocial support.* Retrieved http://www.who.int/hiv/topics/psychosocial/support/en

> Thirty years ago, the first cases of Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) garnered the world's attention. Since then, the lives of people living with HIV/AIDS (PLWHA), their families, communities, and the society as a whole are all affected by the HIV/AIDS pandemic. Not only does HIV/AIDS elicit detrimental physical manifestations but psychosocial health is affected negatively as well in PLWHA. Since the discovery of the Highly Active Antiretroviral Therapy (HAART) in the mid-nineties, PLWHA have overcome the fear of what previously was a certain death sentence. Their life expectancy, as a result of HAART, is now approaching that of the general population (The Antiretroviral Therapy Cohort Collaboration, 2008). However, many PLWHA confront a broad range of challenges that are multiple and chronic in nature. These challenges may yield adverse psychosocial consequences that can lead, eventually, to substance abuse and other HIV/AIDS-risky behaviors.

> The discovery that one is infected with the HIV is associated with reduced psychosocial health in China, the United States (U.S), and South Africa (Freeman et al., 2007; Sun, 2007; Vanable, 2006). Studies show that PLWHA have complicated histories including substance abuse, mental illness, mood disorders, and social stigma (Stoskopf, 2004; Pence, 2007a; Whetten, 2006). These negative experiences have been seen across a wide range of populations including adult men and women (Kelly, 1993), men who have sex with men (MSM) (Martin, 1998, Strathdee, 1998), HIV-positive adults (Kelly, 1993), minority women (Champion, 2002), substance users (Camacho, 1996), gay and bisexual men (Rogers, 2003), adolescents, and young adults (Ramrakha, 2000). Furthermore, these negative experiences have been associated with psychosocial disorders which in turn can contribute to increased substance abuse and HIV/AIDS-risky behaviors among PLWHA (Pence, 2007b; Leserman, 2003; Tucker, 2003). Similarly, substance abuse can contribute to numerous problems for PLWHA. For example, alcohol abuse can modify liver drug metabolism, thus complicating treatment for patients with HIV/AIDS hepatitis C virus co-infection as alcohol may

Triple Challenges of Psychosocial Factors, Substance Abuse,

risky behaviors that are commonly seen in PLWHA.

services were not receiving them (Taylor et al., 2004).

others in the community.

PLWHA had depression (Lesser, 2008).

**behaviors** 

in turn would be associated with HIV/AIDS-risky behaviors.

and HIV/AIDS Risky Behaviors in People Living with HIV/AIDS 137

hypothesized that psychosocial variables would be associated with substance abuse which

This chapter presents the findings of our original research with respect to triple factors that influence HIV/AIDS transmission among PLWHA. The research methodology and findings are presented under their respective sections. In addition, recommendations for a multidisciplinary approach to research and interventions are provided to address the triple challenges and interrelationships of psychological factors, substance abuse, and HIV/AIDS

A substantial amount of literature indicates depression is one of the most commonly occurring mental disorders identified among PLWHA. HIV/AIDS, its related infections, and the anti-viral drugs used to treat these illnesses can cause depression along with number of other psychiatric disorders (Desquilbet et al., 2002). Psychosocial problems have been associated also with HIV/AIDS-risky behaviors, non-adherence to medications, and shortened survival (Farinpour et al., 2003; Cook et al., 2004). Despite the prevalence of psychosocial distress experienced by PLWHA, the available body of evidence indicates that depression is frequently undiagnosed and goes untreated on a large scale. For example, in a large cohort of patients undergoing care for HIV/AIDS in the U.S., nearly half of those who met the criteria for major depression had no mention of such a diagnosis in their medical records (Asch et al., 2003); and one-third of PLWHA who needed psychosocial health

However, health care service providers and associated facilities may be unaware of the depressive experiences of their HIV/AIDS patients and the effects these experiences can have on both behaviors and health outcomes. As a result, prevention and treatment of depression and provision of psychosocial support are often neglected in PLWHA, despite the fact that they are critical components of their health care. So, to support and promote mental health throughout the lifespan of the illness a number of interventions, including psychosocial support and basic counseling for depression, are required. As the medical community adapts to managing HIV/AIDS as a chronic disease, understanding the conjoint influence of depression and substance abuse on HIV/AIDS risky behaviors is very important. Failure to recognize these variables may endanger both HIV/AIDS patients and

Studies of patients who seek HIV/AIDS treatment or preventive health services have reported a fairly high prevalence of psychosocial problems including depression, anxiety, and hostility (Kalichman, 2000; Cohen et al., 2002). Other research shows that psychosocial variables, such as depression and other mental health problems, drug or alcohol addictions, or any combination of these are most commonly prevalent among PLWHA (Moore et al., 2008; Wyatt et al., 2002; Whetten et al., 2006). It is estimated that up to 50% of PLWHA suffer from a mental illness, such as depression, and 13% have both mental illness and substance abuse issues (Bing et al., 2001). The same study indicates also that one-half of adults living with HIV/AIDS had symptoms of a psychiatric disorder; 19% had signs of substance abuse; 13% had co-occurring substance abuse and mental illness (Bing et al., 2001); and one-half of

**2. The relationship between psychosocial factors and HIV/AIDS-risky** 

compromise pegylated interferon therapy and exacerbate the progression of liver disease (Kresina, 2002).

Since the first cases of HIV/AIDS emerged in the early 1980s HIV/AIDS-related stigma and its resulting discrimination continue to traverse across countries, religious groups, communities, and individuals. According to United Nations Secretary-General Ban Ki Moon, "Stigma remains the single most important barrier to public action. It is the main reason why too many people are afraid to see a doctor to determine whether they have the disease, or to seek treatment if so. It helps make AIDS the silent killer, because people fear the social disgrace of speaking about it, or taking easily available precautions. The stigma associated with it is a chief reason why the AIDS pandemic continues to devastate societies around the world" (Ban Ki-Moon, 2008). For example, if they feel a need to conceal their HIV-positive status within their social network, PLWHA may refuse to use protection during sex for fear that their partners may interpret condom use as a sign of being they are HIV positive (Klitzman, 2004). Stigmatization has been linked to higher risk behaviors in France, South Africa, and China (Mahajan, 2007).

The impact of HIV/AIDS is not only biological but psychosocial in nature. Increasingly it has become evident that psychosocial factors, substance abuse, and HIV/AIDS- risky behaviors co-exit together and therefore contribute to ongoing HIV/AIDS transmission pathways in many regions of the world. Importantly, as newer and more effective treatment therapies continue to evolve psychosocial factors, substance abuse problems, and other cooccurring risky behaviors in PLWHA must be addressed to develop more effective treatment protocols and to formulate highly-effective public health policies and prevention and control strategies to address the HIV/AIDS pandemic. Further, the high prevalence of comorbid medical and psychosocial conditions highlights the urgent need to co-locate varied health services and specialists who understand HIV/AIDS-related psychosocial factors in relation to HIV-risky behaviors so they can provide comprehensive care for the special needs of and overlapping medical and psychological conditions for PLWHA. Sweat and colleagues (2004) suggest a multidisciplinary, integrated approach to HIV/AIDS prevention be adopted to cater to the needs of PLWHA.

With this in mind, a study to address the triple challenges of psychosocial, substance abuse, and HIV/AIDS-risky behaviors among PLWHA has been conducted at the Center for Computational Epidemiology, Bioinformatics and Risk Analysis (CCEBRA), a research center located in the College of Veterinary Medicine, Nursing and Allied Health at Tuskegee University, Tuskegee, Alabama, USA. The specific objective of this study was to determine if significant differences exist in the prevalence of psychosocial factors and HIV/AIDS-risky behaviors before and after establishing HIV infection status among PLWHA.

The study hypothesis tested was: Multi-factorial and quantitative epidemiologic studies which interrelate multiple health determinants can be developed to extrapolate the quantitative contributions of each of these variables that affect the transmission of HIV/AIDS. Based on the epidemiological assessment of factors believed to influence HIV/AIDS-risky behaviors, three underlying assumptions were formulated: 1) With the exception of HIV/AIDS transmission via infected blood/blood products, tissues, or organs, all other HIV/AIDS transmissions occur only as a result of human behaviors; 2) The effects of psychosocial factors and substance abuse on HIV/AIDS-related risky behaviors are particularly pronounced among PLWHA; and 3) Psychosocial factors and substance abuse help to predict an increase or decrease in HIV/AIDS-related risky behaviors. It was

compromise pegylated interferon therapy and exacerbate the progression of liver disease

Since the first cases of HIV/AIDS emerged in the early 1980s HIV/AIDS-related stigma and its resulting discrimination continue to traverse across countries, religious groups, communities, and individuals. According to United Nations Secretary-General Ban Ki Moon, "Stigma remains the single most important barrier to public action. It is the main reason why too many people are afraid to see a doctor to determine whether they have the disease, or to seek treatment if so. It helps make AIDS the silent killer, because people fear the social disgrace of speaking about it, or taking easily available precautions. The stigma associated with it is a chief reason why the AIDS pandemic continues to devastate societies around the world" (Ban Ki-Moon, 2008). For example, if they feel a need to conceal their HIV-positive status within their social network, PLWHA may refuse to use protection during sex for fear that their partners may interpret condom use as a sign of being they are HIV positive (Klitzman, 2004). Stigmatization has been linked to higher risk behaviors in

The impact of HIV/AIDS is not only biological but psychosocial in nature. Increasingly it has become evident that psychosocial factors, substance abuse, and HIV/AIDS- risky behaviors co-exit together and therefore contribute to ongoing HIV/AIDS transmission pathways in many regions of the world. Importantly, as newer and more effective treatment therapies continue to evolve psychosocial factors, substance abuse problems, and other cooccurring risky behaviors in PLWHA must be addressed to develop more effective treatment protocols and to formulate highly-effective public health policies and prevention and control strategies to address the HIV/AIDS pandemic. Further, the high prevalence of comorbid medical and psychosocial conditions highlights the urgent need to co-locate varied health services and specialists who understand HIV/AIDS-related psychosocial factors in relation to HIV-risky behaviors so they can provide comprehensive care for the special needs of and overlapping medical and psychological conditions for PLWHA. Sweat and colleagues (2004) suggest a multidisciplinary, integrated approach to HIV/AIDS

With this in mind, a study to address the triple challenges of psychosocial, substance abuse, and HIV/AIDS-risky behaviors among PLWHA has been conducted at the Center for Computational Epidemiology, Bioinformatics and Risk Analysis (CCEBRA), a research center located in the College of Veterinary Medicine, Nursing and Allied Health at Tuskegee University, Tuskegee, Alabama, USA. The specific objective of this study was to determine if significant differences exist in the prevalence of psychosocial factors and HIV/AIDS-risky

The study hypothesis tested was: Multi-factorial and quantitative epidemiologic studies which interrelate multiple health determinants can be developed to extrapolate the quantitative contributions of each of these variables that affect the transmission of HIV/AIDS. Based on the epidemiological assessment of factors believed to influence HIV/AIDS-risky behaviors, three underlying assumptions were formulated: 1) With the exception of HIV/AIDS transmission via infected blood/blood products, tissues, or organs, all other HIV/AIDS transmissions occur only as a result of human behaviors; 2) The effects of psychosocial factors and substance abuse on HIV/AIDS-related risky behaviors are particularly pronounced among PLWHA; and 3) Psychosocial factors and substance abuse help to predict an increase or decrease in HIV/AIDS-related risky behaviors. It was

behaviors before and after establishing HIV infection status among PLWHA.

(Kresina, 2002).

France, South Africa, and China (Mahajan, 2007).

prevention be adopted to cater to the needs of PLWHA.

hypothesized that psychosocial variables would be associated with substance abuse which in turn would be associated with HIV/AIDS-risky behaviors.

This chapter presents the findings of our original research with respect to triple factors that influence HIV/AIDS transmission among PLWHA. The research methodology and findings are presented under their respective sections. In addition, recommendations for a multidisciplinary approach to research and interventions are provided to address the triple challenges and interrelationships of psychological factors, substance abuse, and HIV/AIDS risky behaviors that are commonly seen in PLWHA.
