If you test positive for HIV at the Los Angeles LGBT Center, you immediately get sent upstairs to the mental health department.
HIV is still a jarring enough diagnosis to plunge a patient into depression. With a chronic condition like HIV, depression can fuel additional problems, such as failure to take life-saving antiretroviral medications.
In a day and age when the disease is manageable, it pains mental health professionals to see HIV-positive patients in the depths of depression. When depression is paired with HIV, the two diseases can feed off of one another.
A 2001 meta-analysis of studies on HIV and depression underscored the severity of the problem. It showed that people with HIV run twice the risk of depression as those who are at-risk for HIV but remain uninfected.
Jeffrey Newman is a New York City man with HIV who runs a website called Positively Jeffrey. The site encourages all people, not only those with HIV, to live life positively. He has seen the impact of HIV and depression and maintains his site and Facebook pages to do his part to beat it back.
Newman remembers learning about his own HIV status. “I chose to embrace it and I refuse to allow it to control my destiny, my happiness, or who I was or would be,” he told Healthline. “Gratitude is such a simple concept, and yet it’s one of the most powerful, inspiring, life-affirming, and mentally healthy things we can do to make our lives better. Dwelling on the negative accomplishes nothing.”
Depression Casts a Wide Net
In Los Angeles, depression and HIV make life hard for young and old alike. On the one hand are young people ravaged by substance abuse who turn up positive. On the other are older adults who have lived longer with HIV than they ever expected to. They have also been sick for many years and may have been unable to save enough money for retirement.
HIV-positive women are the most likely of all to suffer from depression, according to research presented at the 2nd International Workshop on HIV & Women in 2012 in Bethesda, Maryland.
There are other HIV-positive groups facing problems with depression too, Newman pointed out.
“The new group of the population who are testing positive, who don’t live in places like New York City or Los Angeles or San Francisco. They live in rural America and places that aren’t as progressive or accepting and don’t have access to information, and feel that HIV is still a death sentence," he said. "They get diagnosed and slip into a great depression, and start drinking or using substances to ease the pain.”
Shame, Guilt Over Testing Positive
Some people become overwhelmed with shame when they learn they are HIV-positive, said Mike Rizzo, manager of crystal methamphetamine addiction and recovery services at the Los Angeles LGBT Center. “Especially nowadays when we know how to prevent [HIV] and people still are getting infected," he said. "There is shame, guilt, and remorse."
Keeping your status a secret isn’t an option for sexually active people because of disclosure laws that vary by state. So learning to come to grips with disclosure is another stress trigger for an HIV-positive person. “I’m also diabetic, but I don’t have to disclose to anyone that I’m diabetic,” said Rizzo. “I’m about to engage in a behavior where I’ve got to tell somebody that I’m HIV-positive, and the rejection that may follow that.”
In Los Angeles, Rizzo sees rampant crystal meth use in the homeless community, as well as among those newly infected with HIV.
“In regards to homeless youth, it really is a survival drug,” Rizzo said of crystal meth. “It helps them stay awake all night so they are safer on the streets. It staves off hunger and thirst.”
Some of these young men also get by on so-called “survival sex,” Rizzo explained. The meth helps them stay in a world of denial. “If I’m walking the boulevard I’m not actually living on the boulevard," he said. "If I don’t curl up under a bush or am not sleeping under an overpass, I’m not actually homeless.”
Combine Testing, Counseling to Get Patients Help
In Los Angeles, the LGBT Center provides extensive mental health services for people suffering from depression. In the past year, it has served about 2,000 people, 43 percent of them for substance abuse problems.
The Center’s Jeffrey Goodman Special Care Clinic offers a network of care for both the mental and physical effects of HIV. Those newly diagnosed with HIV go through six crisis counseling sessions. “It’s not just here’s your diagnosis, see you later,” Rizzo said.
He believes tending to the mental health issues related to the diagnosis is even more important than treating the illness itself, at first. “There’s partner notification and all that goes along with that,” Rizzo said of stress triggers that come along with learning you have HIV.
When it comes to substance abuse, doctors at the Center first try to determine whether there is a compounding mental health problem. People suffering from depression or mania may turn to substances as a way to self-medicate.
When Taking Medication Doesn't Seem to Matter
Paradoxically, a second major problem with depression and HIV is that those who are depressed may stop taking their antiretroviral medication to keep HIV under control, according to a 2011 study. This not only affects their personal health but also allows the virus to replicate and be transmitted more easily to others.
In Los Angeles, some drug and alcohol-addicted young men sell their prescription pills for Truvada to prevent HIV infection on the street. Sometimes it’s just medication fatigue, plain and simple, explained Rizzo.
“Being HIV-positive is not a fun lifestyle,” he said. “The simple process of taking the meds on a daily basis becomes a constant reminder of what you’re dealing with. I think without appropriate support that can be very hard on an individual.”
Medicating HIV and Depression Together
The solution may be to treat both conditions at once.
Most medications for depression do not interact with antiretrovirals, though the American Psychological Association says people with HIV also being treated for depression need to be closely monitored for drug interactions.
Rizzo said Center medical professionals have seen success in treating people with crystal meth addictions with the drug bupropion hydrochloride (Wellbutrin) for depression. The drug lessens the urges for meth, he said.
Some HIV drugs themselves have been known to cause psychological side effects, particularly efavirenz (Sustiva). Efavirenz these days is more commonly included in the combination medication Atripla along with two other HIV drugs.
A study published in the July issue of the Annals of Internal Medicine shows that people who take efavirenz are twice as likely to develop suicidal thoughts or to commit suicide than other HIV patients.
People who have taken efavirenz for long periods have also complained that the drug gives them nightmares.
Women Impacted by Violence, Trauma
Women with HIV often face poor health outcomes, usually due to stigma, depression, and post-traumatic stress disorder, according to the Positive Women’s Network-USA (PWN-USA). A landmark study by researchers at the University of California, San Francisco (UCSF), released in July, showed that even women being treated for HIV often face violence and other trauma.
“Over 90 percent of our patients are on effective antiretroviral therapy — far higher than the national rates — but far too many are dying from suicide, addiction, and violence,” Dr. Edward Machtinger said in a statement. Machtinger heads the women’s HIV program at UCSF.
Advocates for women with HIV have long said that helping them get past life traumas is essential for boosting health outcomes. “Depression, addiction, and especially trauma are very common and often devastating for women living with HIV, but are not effectively being addressed by most clinics.”
PWN-USA applauded the research in a news release. “An expressive therapy originally developed by San Francisco’s Medea Project for incarcerated women has shown highly promising effects on the health and well-being of women living with HIV,” Machtinger said.
Aging Not Easy for Anyone
Lastly, aging plays a role in how severe depression can become for someone living with HIV. Whether you’re gay or straight, female or male, getting older causes a lot of people to become depressed.
Older gay men in Los Angeles are in a place where being young and pretty is celebrated. Youth and beauty is, after all, the image Hollywood markets to America.
“You never see yourself on TV or the movies,” said Glenn Lindsey, a clinical program manager in mental health services at the Los Angeles LGBT Center.
Older patients sometimes become bitter seeing young people frolicking carelessly. “There’s a feeling of ‘We fought so hard for this and people don’t care,’” Lindsey, 71, told Healthline of the mentality among older men.
This pervasive sense of hopelessness is hard to fight, but with community support and the right medications, it is possible. HIV patients don't need to live in the shadow of depression — it is time for them to step into the light and prioritize their mental wellbeing.