Journal of Infectious Diseases & Therapy
Open Access

HIV-affected individuals have more psychiatric manifestations compared to other individuals with sexually transmitted diseases [1]. People living with HIV/AIDS and comorbid psychiatric conditions have many challenges to overcome. Studies have pointed out that the common factors for bidirectional link of HIV and mental illness are homelessness, incarceration, poverty and substance misuse [2]. Mental health professionals have to address their needs and ensure quality of life of persons affected with HIV and mental health problems as well as their families. The authors have briefed a case of a woman with HIV and comorbid psychiatric condition who had significant psychosocial stressors.

Ms.X, is a 24 years old married lady, who studied up to 2nd standard, is unemployed and belongs to a lower socio economic status presented with three months’ history of authoritative behaviour, over talkativeness, restlessness, talking to self, smiling to self, elevated selfesteem, grandiose ideas, decreased sleep, poor compliance to anti-retro viral treatment (ART) and increased use of tobacco in the form of chewing. Premorbidly, she has emotionally unstable personality traits, personal history of being diagnosed as immuno – compromised state at age of 13 years and started Antiretroviral Therapy (ART) for 3 years with poor compliance to ART. She has a past history of one episode (post-partum onset) of mania with psychotic symptoms, and two episodes of depression along with suicidal attempt. Mental status examination revealed that the patient came to the interview room with bright coloured clothes, and presented to be overactive, restless, with inappropriate smiling, difficulty in establishing rapport, excessive motor activity, increased tone and volume, pressured speech, flight of ideas, elated mood, with delusion of grandiosity and impaired judgment and insight. She was started on antipsychotics and mood stabilisers by which there was significant improvement. Psychosocial assessment and interventions were carried out by a Psychiatric Social Worker (PSW) revealed untold stories of her life.

Her family of origin consisted of father, mother, a younger sister and a younger brother. She was born out of a non-consanguineous union, from a rural background. Her mother was a coolie and reportedly engaged in sex work who was the functional and nominal leader of the family. Father was engaged in coolie work but who spent most of his money on alcohol. When she was six-year-old, her mother had an unnatural death. After the death of her mother, she discontinued her studies to take care of her siblings. Due to some legal issues, her father was arrested and imprisoned. Then she started to sell bangles on the streets for her livelihood. During those times, her uncle used to sexually abuse her and threatened not to report it to anyone. Once a police officer found her on the road and took her to his house to make her to work as a maid and she faced severe torture from there. After a month she was able to leave the place. Later, she was trapped at a brothel in Mumbai Red Street by some women known to her. After 6 months of torture in the brothel she somehow escaped and came back to her native place. Though she made a suicide attempt after coming back, she was saved by neighbours. Her father was back from prison by this time and he soon forced her to marry a person with a criminal background and addiction to drug.

After the marriage, she had great difficulty to live with him as he was abusing her physically after getting drunk. She became pregnant at the age of 16 and gave birth to a male child in a hospital where she was diagnosed as Retro Positive. During the period she was highly talkative and had disorganized behaviour, delusion of persecution, delusion of reference and decreased sleep. After the first delivery she was admitted at NIMHANS, Bangalore to treat Postpartum Psychosis. Knowing the illness, her husband divorced her, and she spent the rest of the time in her own home as her father was not keeping well. The child was taken by the husband and went for legal divorce.

Her father died when she was 19 years old due to alcohol related health issues. Then she was completely taken care by a Christian religious institution. She got a job as a field worker for people living with HIV/AIDS and she was regularly compliant to ART till the age of 23 years. With the help of the institution and colleagues, she married a person who was also diagnosed with HIV. Initially, both of them had difficulty in adjusting with each other but later were able to adjust and move on.

Interventions

She was provided with case work interventions, psychotherapy (a mix of supportive psychotherapy and trauma focused psychotherapy), psychoeducation, adherence counselling, relapse prevention interventions to address her nicotine dependence, insight facilitation, pre-discharge counselling and post discharge supportive interventions. As the family had financial difficulties, an advocacy was done with the hospital authorities for free food, medications, treatment and was facilitated to avail ration card. Considering her family environment, the team made several agency visits and found out a suitable agency where she could stay for a short period as she was not comfortable to go back to her home environment. With her consent she was sent to an agency, but she had difficulty in adjusting to the new environment and was shifted back home. Telephone counselling was provided by PSW whenever required. She improved up to 90 percent. It was found that her husband was very supportive, and she was compliant to medications. Though she had to face discrimination from a hospital where she was admitted for her delivery, timely intervention from the multidisciplinary team helped her and the family to cope up with the same. She delivered a healthy boy child and who was negative for HIV. She was compliant to medication and the follow up revealed 100% improvement.

Her husband also had poor knowledge about the illness which made him critical towards the patient. The husband was expressing burn out as he had difficulty to manage her and he was the only breadwinner. However, the mother-in-law was very supportive to her during this period. Supportive counselling and psychoeducation were provided to her husband as well. Later he was found to be relaxed and was not critical towards his wife.

Some of the studies have looked at the difficulties that can arise as a result of having both HIV infection and severe mental illness and have found out that there is likely a relationship between stress, depression and immune response such that HIV infection may progress more rapidly in individuals with these symptoms [3]. One of the reasons for the Psychiatric disorders common in patients may be due to inadequate care because their psychiatric disorders are itself a barrier to medical care, lack of clarity in communicating with clinicians, and poor compliance to medical advices [4]. The possible negative consequence of the comorbidity between HIV and severe mental illness found that HIV infection can result in neuropsychological impairment [5,6].

This case showed a great amount of sufferings of a woman from disorganised family of origin who underwent significant psychosocial issues within a short span of life. When we see this case in a gender perspective, being a female, she had to face threats instead of opportunities in terms of gender violence from her first husband, sexual abuse in childhood and trafficking to brothel for sexual activity which might have resulted in contracting with HIV. Life events are inevitable in one’s life and its impact always vary from person to person with respect to their coping capacities. A study done to understand the associations between physical, emotional, and sexual abuse in children and a range of mental health, interpersonal, and sexual problems in adult life were examined and found that the history of any form of abuse was associated with increased rates of psychopathology, sexual difficulties, decreased self-esteem, and interpersonal problems [7]. In the area of mental health, studies have been done to understand the negative adult outcomes that have their origins in childhood [8]. Studies have found that trauma survivors have difficulty in regulating emotions such as anger, anxiety, sadness, and shame and the impact is more if the abuse is occurred in young age [9].

Recognizing the effect of traumatic events and how she overcame definitely speaks about her resilience and willpower. A traumainformed social work practice where one can look at this case and ask the client, “What happened to you?” instead of “What is wrong with you?”; so that one can focus on what’s broken, what needs to be changed, and what will work [10]. The strength-based approach of this case focus on strengths, survival skills, abilities, knowledge, resources, desires and potential [11]. One of the key principles of the strengths perspective is that people are recognised as having much strength and having the capacity to continue to learn, grow and change [12]. The lady in this case has undergone significant traumatic events in her life since childhood in the form of physical and sexual abuse, death of family members, domestic violence, physical torture, life-threatening illness etc. The lady in this case had also many strengths to come out of her traumatic situations such as a firm belief about oneself, hope about future, confidence, will power, ability to tolerate, optimistic attitude and more than that, her spiritual belief. Though she underwent all kinds of adversity in her life within a very short span, she was able to cope up and bounced back with her personal strength and support from significant others. Her ability to adapt well in the face of adversity, trauma, and significant sources of stress showed that she was resilient by which it made the authors to call her an ‘iron lady’.

Detailed psychosocial assessment and appropriate psychosocial interventions will definitely help persons with mental illnesses as well as their families. All the cases can be seen in different perspectives in terms of assessment and interventions which may help social workers to provide comprehensive psychosocial care.