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Mental Disorder in People Living with HIV/Aids in South Africa

Melvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar and Kevin Kelly South African Journal of Psychology 2008 38: 489 DOI: 10.1177/008124630803800304 The online version of this article can be found at: http://sap.sagepub.com/content/38/3/489

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Mental disorder in people living with HIV/Aids in South Africa

Melvyn Freeman Human Sciences Research Council, 30 Urania Street, Observatory, Johannesburg, 2198, South Africa mfreeman@telkomsa.net Nkululeko Nkomo Human Sciences Research Council Zuhayr Kafaar SAAVI Socio-behavioural Group, Department of Psychology, University of Stellenbosch Kevin Kelly CADRE, Institute for Social and Economic Research, Rhodes University We investigate the prevalence of mental disorder in people living with HIV/AIDS in a developing country context and examine the relationship between the presence of mental disorder and various independent variables. Nine-hundred HIV positive people were interviewed in 18 recruitment sites across five provinces in South Africa, using a cross-culturally validated diagnostic instrument and a structured socio-demographic and health information questionnaire. Prevalence of mental disorder was established using the Composite International Diagnostic Interview (CIDI). Chi-square, Fischer exact test, and binary logistic regression examined the relationship between mental health disorders and demographic characteristics, disease stage, CD4 count, and whether the person was on antiretroviral treatment. A number of respondents (43.7%) were found to have a diagnosable mental disorder. Depression was the most common disorder (11.1% major and 29.9% mild depression), followed by alcohol abuse disorder (12.4%). The presence of mental disorder was significantly associated with gender, employment status, having children, and the clinical stage of the disease. Gender and the stage of disease were the best predictors of mental disorder. Rates of mental disorder were substantially higher in people living with HIV/AIDS than generally found in populations in developing countries and similar to HIV positive groupings in developed countries. Viral impacts on the brain, psychological reactions, and social conditions all contributed to the higher prevalence rates. Mental health interventions need to become a central part of comprehensive HIV/AIDS sup port, care, and treatment programmes. Keywords: CIDI; developing countries; HIV/AIDS; mental disorder prevalence; South Africa Mental health interventions have not been systematically integrated into HIV/AIDS care and treat ment programmes in most developing countries, including South Africa (Baingana, Thomas & Comblain, 2005; Freeman, Patel, Collins & Bertolote, 2005; WHO, 2005). Important reasons for this include a lack of resources for effective interventions, poor identification of mental disorders, stigma, and a low prioritisation of mental health in health services generally. Critically, planners of HIV/AIDS programmes in developing countries appear unaware of HIV/AIDS/mental health comorbidity and of the possibilities of improving physical and mental health through mental health interventions. Most mental health prevalence studies with people living with HIV/AIDS (PLH A) have been conducted in developed countries with low level or concentrated epidemics and caution is needed when extrapolating findings to developing countries with generalised epidemics (Freeman, 2004; Freeman & Thorn, 2006). For example, co-morbidity of mental disorder and HIV infection can be expected to be inflated in countries where a relatively large number of infections are through intra venous drug use, since there is already co-morbidity of substance abuse and mental disorder. On the

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South African Journal of Psychology, 38(3), pp. 489-500

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Melvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar, Kevin Kelly other hand correlations have been found between poverty and mental health and this could be in fluential in inflating mental disorder prevalence in developing countries. Although some research on the prevalence of mental disorder in people infected with HIV in developing countries has been conducted, this is limited. Collins and colleagues summarised 30 studies concerned with the mental health consequences of HIV in developing countries and the result shows clearly the dearth of reliable and recent mental health epidemiology data (Collins, Holman, Freeman & Patel, 2006). The mental health status of people infected with HIV has consistently been found to be higher than in community or clinic samples, ranging from relatively mild distress to full-blown mental disorder (Catalan, 1999; Ferrando in Cournos & Forstein, 2000; Green & Smith, 2004; Maj et al, 1994a; Maj et al., 1994b; Tostes, Chalub & Botega, 2004). Reasons for this have been found to include pre-morbid mental conditions, the effects of the virus on the central nervous system, the psychological impacts of living with HIV/AIDS, side-effects of medication, and results of social stigma and discrimination ( Freeman et al., 2005). Mood disorder has been found to be the most frequent psychiatric complication associated with people with HIV/AIDS (Collins et /.2006; McDaniel & Blalock, 2000;). A meta-analysis of USA studies found that the prevalence of depression amongst HIV positive people was twice that of the general population (Ciesla & Roberts, 2001). Previous prevalence studies in South Africa, though using relatively small sample sizes, have found rates of depression of up to 60% (Els et al., 1999; Olley et al., 2004). Anxiety disorders in studies in the USA range from negligible to around 40% (McDaniel & Blalock, 2000). Anxiety has been linked to certain 'milestones' such as initial diagnosis, first opportunistic infection, declining CD4 count and the onset or progression of AIDS defining illness. Antiretroviral therapy (ART) is reported as having had a significant impact on mental health where it has been.available although there are as yet no published studies in developing countries based on objective assessment of mental health. Importantly, with ART the progressive neuropsychiatric pro gression of HIV is diminished. Cross-sectional as well as longitudinal studies have shown decreased depression for people on ART (Low-Beer, Yip, O 'Shaunessy, Hogg & Montaner, 2000; Alciati et al., 2001; Judd et al., 2000; Rabkin, Ferrando, Lon, Sewell & McElhiney, 2000; Kalichman, Graham, Luke & Austin, 2002). However a diagnosis of HIV remains "profoundly distressing" for most people (Green & Smith, 2004). People tend to have "new" problems and anxieties around forming relationships, disclosure and demoralisation around side-effects of medication. The influence of factors such as age, gender, marital status, education, socio-economic status, CD4 count, stage of disease, whether the person has children, how the person was infected on mental health have received some attention in previous studies but have never been integrated and systematically documented in a developing country context. In the present study we report the findings of a mental health prevalence study of 900 HIV positive people in five provinces in South Africa and examine characteristics of co-morbidity, with a view to understanding the need to address mental health needs in HIV care, support and treatment interventions. METHODS Context of study At the time of study, HIV prevalence in South Africa was estimated to be 16.2% in the 15 to 49 years age group (Shisana et al., 2005).While some people were receiving anti-retroviral therapy (ART), widespread roll-out of treatment was not in place. Measures The World Mental Health Survey version of the World Health Organization Composite International Diagnostic Interview (CIDI) was utilised. The CIDI is a comprehensive, fully structured diagnostic

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Mental disorder in people with HIV/AIDS interview for the assessment of mental disorder. It has been designed to be used by trained nonclinicians and (in its full form) diagnoses 22 mental disorders amongst adults from different cultures (Kessler & stn, 2004). As part of the WHO world mental health survey the CIDI was adapted and used in 28 countries including South Africa. The South African adaptation which was translated into six local languages for the WMH study, was utilised here. Five language versions were used i.e., English, Zulu, Xhosa, Sotho and Afrikaans. For the purposes of this study 14 diagnostic categories with potential bearing on HIV/AIDS as well as screens for psychosis and personality disorder and suicidality were measured. The DSM diagnostic system of categorisation of mental disorders was utilised. In addition a socio-demographic questionnaire was designed and administered and where information was available and with the permission of the interviewee, relevant data (CD4 count and disease stage) was extracted from patient files. Procedure Ethical clearance for the study was obtained from the Human Sciences Research Council (South Africa) Ethics Committee. Interviewers previously trained in interview techniques received a further four-day training, including administration of the CIDI, by an instructor accredited in its use. Participants were recruited either at public clinics, HIV 'wellness' centres run by government or through non-government organisations of people living with HIV. There were 18 recruitment sites across five provinces in South Africa and a quota of 900 HIV positive people aged 18 years or older was targeted. The sampling procedure was purposive and designed to cover rural, semi-urban, and urban peo ple who at the time of the interview were using or who would normally use the public health system. Subjects were stratified into four categories of length of time since HIV status was discovered. Consecutive attendees presenting at facilities were approached to participate. Those that agreed to be interviewed (less than 1% refused) were given opportunity to ask any further questions about the study before their signed informed consent was obtained. Interviews were conducted in the home languages of participants and took between one and three hours depending on the number of'skip' questions in individual interviews and the ability of partici pants to readily respond to questions. RESULTS Socio-demographics of participants Table 1 summarises key socio-demographic characteristics of respondents. The higher proportion of women found in this sample is in part accounted for by the higher rates of women infected with HIV in the South African population 20.2% of women compared with 11.7% of men in the 1 5 - 4 9 year age group (Shisana et al., 2005) and by the fact that more women are diagnosed because they are tested at ante-natal services and referred for HIV interventions. Eighteen percent of participants (N= 160) were enrolled in anti-retroviral treatment programmes. Knowledge of HIV positive status Eleven percent of respondents (N = 100) had found out that they were HIV positive within the 4 months prior to the interview. Thirty-one percent (N = 270) had known between 4 months and 1 year, 3 1 % (N= 271) between 1 and 3 years and 27% (N= 237) had been diagnosed positive for longer than 3 years. The majority of respondents believed that they had been infected by their regular partner (62%), while 2 1 % said it had been through sex with a casual partner, 2% (13 respondents) had been raped and 12% did not know how they had been infected. Three percent believed they had been infected through other means such as blood transfusions or drug use. The majority of respondents found out their status after falling ill (52%, N = 350), following

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Melvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar, Kevin Kelly Table 1. Socio-demographic characteristics of respondents Variable Gender Age Category Male Female 18-25 26-35 36-45 Over 45 Single Married/living with partner Widowed Other Never been to school Some schooling but did not complete Completed schooling Post-school qualification Employed (full time) Employed (part time) Unemployed Not enough money for basic things such as food and clothes Money for these basics but have no resources beyond seeing to basic needs Have most things but no luxury goods or money for holidays Have children Do not have children n (%) 235 (26) 662 (74) 144 (16) 452(51) 229 (26) 68(6) 651 (73) 181 (20) 37(4) 27(3) 28(3) 668 (74) 161(18) 43(5) 75(9) 125 (14) 685 (77) 608 (68) 264 (30) 14.(2) 690 (78) 195 (22)

Marital status

Schooling

Employment status

Socio-economic status

Children

routine antenatal testing (19%, N= 128) or after disclosure of a positive status by a partner or child (12%, N = 87). Few respondents (11%) found out that they were positive simply because they were concerned and went for testing. The staging of the disease and the CD4 count was obtained from patient records and was available for 80% and 40% of people, respectively. Of these 30% (N = 213) were in stage 1 (asymptomatic-normal activity), 37% (N = 235) in stage 2 (symptomatic-normal activity), 22% (JV= 140) in stage 3 (bedridden <50% during last month) and 17% (N = 74) in stage 4 (bedridden >50% during last month). Fifty-five percent of people where CD4 count was available (180) had counts above 200 while 45% (146) had counts below 200. Prevalence of mental disorder The prevalence of mental disorders found are given from Table 2. Given the dearth of theory regar ding the prevalence of mental disorders in PLHAs, the research team chose to initially test associa tions with Chi-square and Fischer exact test analysis (for bivariate factors). These were conducted with regard to the presence of: (1) any diagnosis of mental disorder; and, as the two disorders with the substantially highest prevalence rates; (2) depression (major and minor combined); and (3)alcohol abuse (dependent variables), in relation to the following variables: gender, age, marital status, educa tion, employment, household situation, province, provider type, whether the person had children, ages of children, period since knowledge of positive status, how infected, how status discovered, disease stage, CD4 count and whether the person was on antiretroviral treatment. Of the 14 variables measured, significant associations (p < 0.05) were found only with respect to the six variables included in Table 3. As is evident in Table 3, strong associations were apparent between the presence of any disorder and both employment status and stage of disease as well as

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Mental disorder in people with HIV/AIDS Table 2. Prevalence of mental disorder Mental disorder Major depressive disorder Mild depressive disorder Alcohol dependence Alcohol abuse disorder Drug dependence Drug abuse General anxiety disorder Post Traumatic Stress Disorder Post Traumatic Stress Disorder (Event HIV) Panic disorder Social Phobia Intermittent Explosive Disorder Agoraphobia Presence of any mental disorder Male n (%) 24(10.2) 66(28.1) 13 (5.5) 54 (23) 3(1.3) 12(5.1) 2 (0.9) 0 12(5.1) 0 2 (0.9) 9 (3.8) 0 116(49.4) Female n (%) 76(11.5) 202 (30.5) 13(2) 58 (8.8) 0 5 (0.8) 2 (0.3) 6 (0.9) 26 (3.9 1 (0.2) 6 (0.9) 26 (3.9) 0 273 (41.2) Total (%) (CI) 11.1(9.05-13.8) 29.9(26.91-32.89) 2.9(1.8-4.0) 12.4(10.25-14.55) 0.3 (-0.06 - 0.66) 1.9(1.01-2.79) 0.4 (-0.01-0.81) 0.7(0.16-1.24) 4.2(2.89-5.51) 0.1 (-0.11-0.31) 0.9(0.28-1.52) 3.9(2.72-5.28 0 43.7(40.46-46.94)

Table 3. Variables associated with mental disorder Presence of any disorder Variable df Employment status Clinical stage of the disease Gender Whether have children How infected How status discovered /><.05; 885 724 897 885 5 3 1 1 20.37** n 862 df 1 3 5.34* 19.95*** 897 1 32.08*** 862 df 1 4.34* Depression Alcohol abuse

28.29*** 724 4.31* 4.71" 884

15.85*

884 893

22.87* 20.81"

**

p < .01;

p<.001

between alcohol abuse and both how the person was infected and how they discovered their status (p < .01). Very strong associations were evident between stage of disease and depression as well as gender and alcohol abuse (p < .001). Three binary logistic regressions were then conducted with respect to the presence of (1) any mental disorder; (2) depression; and (3) alcohol abuse. As reported in Table 4, stage of disease [p < 0.0001, OR 3.203, CI 1.784 - 5.752, stage 1 less likely than stage 4] and gender [p < 0.05, OR 1.599, CI 1.088 - 2.349, women less likely than men] were found to be the only significant predictors of overall prevalence of mental disorder. Stage of disease [p < 0.0001, OR 2.783, CI 1.574-4.920, stage 1 less likely than stage 4] was the only significantly predictor of depression, whilst gender [p < 0.001, OR 2.932, CI 1.782 - 4.825, men more than women] and employment status [p < 0.05, OR 1.976, CI 1.020 - 3.830, unemployed more than employed] were the only significant predictors of alcohol abuse.

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Melvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar, Kevin Kelly Table 4. Associations with mental disorder from logistic regression analyses Dependent variable Presence of any mental disorder Depression Alcohol abuse disorder Predictor Stage of disease Gender Stage of disease Gender Employment status Significance p< 0.0001 p < 0.05 p< 0.0001 p< 0.001 p < 0.05 Odds Ratio (CI) 3.203 (1.784-5.752) 1.599 (1.088-2.349) 2.783 (1.574-4.920) 2.932 (1.782-4.825) 1.976 (1.020-3.830)

The following trends are evident in the Chi-square and logistic regression analyses: Males were more likely than females to experience a mental disorder. This is a reflection of higher levels of alcohol abuse, as in all other categories of mental disorder there was no signi ficant gender difference. Unemployed people were more likely to experience any mental disorder and have particular susceptibility to depression and alcohol abuse compared to their employed counterparts. Those with children were more likely to experience a mental disorder, but having children is not related to the presence of any particular disorder. Origin of infection is associated with both depression and alcohol use. Respondents who did not know how they were infected were more likely to suffer from depression than those who knew no matter how they were infected. On the other hand a diagnosis of alcohol abuse was asso ciated with having been infected by a casual partner. Way of learning about status was related to alcohol abuse only. Respondents who fell ill and went for care were more likely to have alcohol abuse disorder than those who found out from other means. There was a strong relationship between stage of illness and presence of any disorder, and with depression. Depression increased with stage of illness. Gender (more men than women) and stage of disease (later stage) were the only significant pre dictors of the presence of any mental disorder in the regression analysis. DISCUSSION The prevalence rate of 43.7% of mental disorder amongst PLHAs confirms findings from extensive studies in developed countries and more limited data from developing countries that there is a high prevalence of mental disorder in people with HIV/AIDS. Results of the first 14 countries of the World Mental Health Survey (WMHS), which used the same instrument as this study to measure the prevalence of mental disorder (although each country had adaptations) and which included six lessdeveloped countries, found prevalence rates of mental disorder in the general population (12 month prevalence) ranging from 4.3% to 26.4% (WHO, 2004). In the South African version of the World Mental Health Survey that used the same version of the Composite International Diagnostic Interview as this study (with the exception of the version of the instrument used for measuring Post-Traumatic Stress Disorder) an overall prevalence of mental disorder of 16.5% was found (Williams et al, 2008). While it is spurious to attribute the differences found in these two studies directly to the presence of HIV, as socio-demographic variables were not controlled for and it is unknown how many people living with HIV were also part of the general population survey, the differences in the findings of these studies suggest that PLHA are at least two and a half times more likely to suffer from mental disorder as members of the general population. Previous studies on the prevalence of mental disorder in South Africa using similar samples in terms of socio-economic status and rural/urban mix (though 494

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Mental disorder in people with HIV/AIDS using different instruments) have found rates of mental disorder ranging from 10% - 25% (Parry, 1996; Parry & Swartz,1997; Thorn, Zwi & Reinach, 1993). Disease stage, time since diagnosis and CD4 count There is conflicting evidence internationally of the association between HIV disease progression and mental disorder. Ickovics and colleagues concluded that depressive symptoms are associated with lower CD4 count and disease progression but Evans and colleagues found no such relationship (Ickovics et al., 2001; Evans et al., 2002). In a South African study Moosa and colleagues found no significant differences in the CD4 counts between depressed and non-depressed groups of HIV infected individuals (Moosa, Jeenah & Vorster, 2005). In the present study no significant associations were found between CD4 count and the presence of a mental disorder. However, a very strong association was found between depression and disease stage (p < 0.000). While in stages one and two mental disorder differences were minimal (39.8% and 37.2%, respectively), at stage three 49.7% of respondents had identifiable psychiatric diagnoses and at stage four 68.8% of respondents were diagnosed with mental disorder. No associations were found between length of time since hearing the diagnosis and mental disorder. Reasons why the CD4 count did not correlate with the stage of disease as may have been antici pated and why correlations were found between mental disorder and the stage of disease but not CD4 count are not clear. It is possible that because CD4 counts are not tangible and visible, people with lower levels did not have negative psychological responses whereas their deteriorating condition associated with disease stage was experienced as highly distressing. Further research is needed. Gender There is little evidence of gender differences in population prevalence of mental disorder in general populations (WHO, 2001). However it has been consistently found that more women experience depression and anxiety disorders than men with ratios varying from 1.5:1 to 2:1 whilst men experience more alcohol use disorders (WHO, 2001). In this study men indeed had significantly more alcohol related problems than women. However levels of depression and anxiety were not signifi cantly different. A number of authors have pointed to the significant additional Stressors, and resultant depression, that women living with HIV/AIDS experience, given their family and career roles (Morri son et al., 2002; Hackl, Somlai, Kelly & Kalichman, 1997). So it is somewhat surprising to find that men and women do not differ in the rate of mood disorders. It is of interest to note that Olley and colleagues made similar findings (Olley et al., 2004). It may be the case that HIV has physiological effects leading directly to depression in which case men and women may be expected to be affected equally. Alternatively men living with HIV may find it more difficult to cope with deteriorating physical health leading to heightened susceptibility to depression. More research is needed to explain this uncharacteristic finding. Socio-economic status The relationship between socio-economic status and mental disorder could not be tested as there were too few participants who were not impoverished to use as a basis of comparison. It is important to note however that poverty and HIV prevalence are related in South Africa and poverty and mental health disorder are also related (Hargreaves, 2002; Shisana et al., 2005; Patel & Kleinman, 2003). It may be the case that elevated mental disorder in HIV positive people is a consequence of poverty rather than HIV specifically. However given that previous mental health prevalence studies have found much lower rates than this study, it is likely that poverty and HIV/AIDS exacerbate each other and in combination impact on mental health, leading to levels of mental disorder higher than are expected for other very poor people or those who have HIV but are not poor. This vicious circle may

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Melvyn Freeman, Nkululeko Nkomo, Zuhayr Kafaar, Kevin Kelly be further exacerbated by the possibility that poor mental health can be both a risk factor for poverty and HIV/AIDS as well as a consequence of both of them. High unemployment, HIV/AIDS and mental health are likely intertwined in a complex cycle of mutual causality. Employment status Mental disorder was significantly correlated with unemployment status. However it was not possible to ascertain the extent to which unemployment followed rather than preceded the person's HIV status. However, given the official rate of 26% national unemployment (Statistics South Africa, 2005), and the 77% of unemployed people in this study, it seems likely that highly elevated levels of unemploy ment in the sample, resulted from ill-health related to HIV disease and possibly employment discri mination. Children PLHA who have children were significantly more likely to have a mental disorder than those that did not (p< 0.05). It seems likely that problems associated with caring for children and worries about what will happen to the children with disease progression and possibly death, results in raised mental disorder. Furthermore, financial burden of caring for children and associated stress may lead to higher levels of disorder. How infected People who thought they had become infected through a casual sexual partner were more likely to have an alcohol abuse disorder than people infected through a long term partner or other ways (p < 0.05). It is possible that the alcohol disorder preceded the HIV infection or that these people felt intense regret or self-blame associated with casual relationships. On the other hand people who were unsure how they were affected were more likely to be depressed. It is somewhat surprising that people who were infected by their spouse or long term partner did not experience more mental disorder as it seems likely that for many of this group there may have been a betrayal of partner loyalty by the partner who then 'brought' the HIV into the long-term relationship. It is possible that people in longer term relationships received more support and that this accounted for their experiencing less mental disorder. Factors influencing mental disorder in HIV infected people Pre-existing mental disorders are a risk factor for contracting HIV and are likely to have contributed somewhat to the high levels of mental disorder found. Moreover there is evidence that HIV infection causes direct neuropsychiatric complications (Prince et al., 2007). The extent to which these factors have contributed to the prevalence levels found in this study is impossible to determine from this study. However some important pointers, requiring more directed research, were found. Firstly, despite all indications suggesting that women living with HIV/AIDS should show higher levels of depression than men, this was not found to be the case. This could be because the physiological effects of the virus itself on mental health is gender blind. Secondly, a distinct increase in depression was found in stages 3 and 4 of HIV disease. Of course a deterioration in health in stages 3 and 4 is highly likely to cause severe psychological distress which may well account for the differences found. However if the depression was only reactive, an increase in depression when the person first heard about their condition (due to the shock and demoralisation) may also have been expected, but was not found. Qualitative interviews conducted simultaneous with this research found that after the initial diagnosis of HIV, most people suffered severe shock and either retreated into depression-like states or engaged in 'wild' behaviours such as overdrinking or high sexual activity. However, this may not have reached levels of diagnosable mental disorder (Freeman, Nkomo, Ntlabati & Kleintjes, 2005).

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Mental disorder in people with HIV/AIDS A combination of physiological and psychological reasons for the raised prevalence is highly probable. It is important also to bear in mind other reasons for the raised prevalence of mental disorder in PLHAs, besides physiological and psychological causes. Poverty and adverse living conditions as well as poor access to care and support services are themselves risk factors for poor mental health status (Patel & Kleinman, 2003). Limitations of study A direct control group was not available for comparison. Though the results can usefully be contras ted with those from the South African version of the World Mental Health Survey, as the same instruments were used and the trainers who trained the field workers were consistent, sociodemographic variables were not controlled. Moreover given the high prevalence of HIV in South Africa it could also be expected that a number of people assessed as part of the general population survey were also HIV positive. Hence while the prevalence rates found in this study are substantially higher this cannot be directly attributed to HIV/AIDS. Moreover though the study design attempted to determine the 'direction' of whether a mental disorder preceded or followed HIV infection, very few subjects had ever (before or after knowing they were infected with HIV) been diagnosed with a mental disorder and hence determining what came first was not possible. Finally, while the study covered the majority of South Africa's provinces and the recruitment of subjects was done in places where most HIV infected people in South Africa are seen for care and support, this study is not representative of all HIV infected people in South Africa. CONCLUSION This study shows that people living with HIV /AIDS have high rates of mental disorder. Though there were no matched controls in this study the prevalence found is substantially higher than previous general population or clinic-based studies in South Africa (including studies of populations with similar socio-economic status). This finding in a developing country with a generalised epidemic (HIV prevalence amongst 15 - 49 year olds at 16.2% at time of study) replicates the findings of Bing and colleagues in a large scale study in the USA using the same instrument, where HIV prevalence was 1% at the time of study (Bing et al., 2001; Karon et al., 1996; Shisana et al., 2005). In many developed countries mental health care and treatment have been integrated into HIV/ AIDS programmes. It is strongly suggested that sufficient evidence is now available that the same is needed in developing countries. Though the causal relationships between mental health and HIV/ AIDS are complex, mental disorder is as much a direct corollary of the HIV epidemic as a number of the well established physical consequences and requires similar attention. Moreover, adherence to ART is likely to be affected by mental health status (Ammassari et al., 2004; Uldall, Palmer, Whetten & Mellins, 2004). It is crucial that governments, non-governmental organisations and service planners recognise mental health as a significant part of the HIV/AIDS pandemic and that relevant care, support and treatment programmes become part of the HIV/AIDS response. ACKNOWLEDGEMENTS We thank all the members of the HIV/AIDS round table discussion group who recommended that this research be conducted and assisted in the initial conceptualisation. We thank Profs Dan Mkhize and Soraya Seedat for conducting the CIDI training and Sharon Kleintjes for training the interviewers. We also thank the research co-ordinators in the four provinces, the interviewers, and the clinics and non-governmental organizations where interviews were conducted. Finally we thank all those living with HIV/AIDS who allowed themselves to be interviewed especially regarding emotionally sen sitive issues.

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