Inequities, HIV/AIDS and mental illness

Across countries and societies, mental illness has been associated with poverty, inequalities and social vulnerability. [1] Its burdens can be particularly high when it interacts with vulnerabilities to physical illness.

Risk of acquiring HIV/AIDS is more clearly associated with gender and economic inequities than absolute poverty, although the 'downstream' impacts of having HIV are far greater in poorer populations [2]. South Africa is the most developed nation in sub-Saharan Africa but it remains a divided society with large social and economic inequalities. complicated by the legacy of arpatheid.[3] Around 11% of the population in South Africa has HIV, making it the country with the largest HIV positive population (c.5.7 million people).

To complete a triangle of circumstances, studies have shown that persons with a mental illness are at a greater risk of contracting HIV [4] The lifetime prevalence of depression in patients infected with HIV has been estimated at 22-45%. [5] Additionally, by impairing immune function or influencing behaviour, [5] chronic depression, stressful events, and trauma have been found to negatively affect HIV disease progression, with greater risk of clinical decline and mortality [6]

Soweto:

 

The convergence of inequities, HIV/AIDS and mental illness creates challenges for Luthando clinic in serving the population of Soweto.

A former black township in Johannesburg with an estimated population of , Soweto was the focal point for uprisings that catalysed the ending of apartheid. It remains a deprived area of Johannesburg with very low household incomes [7]

Gender and socio-ecomoic inequities in Soweto create conditions for high-rates of HIV and mental illness. Poor uptake of HIV testing has been noted in men, particularly those from the most deprived backgrounds.[8] Meanwhile, a recent study found that 21% of women attending antenatal care reported having had sex in exchange for material gain, increasing risk of acquiring HIV by 50%.[9] Risk factors for 'transactional sex' included social-disadvantage, exposure to gender-based violence and substance misuse. Similarly, partner violence, deprivation and maternal stress have been shown to have adverse effects on child behavioural problems in Soweto. [10]

Many highlight that social conditions in Soweto are in part a legacy of apartheid. Its pernicious effects on social relations and the brutality of the apartheid-era regimen have left their own mental health burdens. Managing these impacts requires an understanding of the need for healing at a societal level including the role of justice and reconciliation and tackling remaining inequalities.

Minds for Health Support:

We believe that simple human contact and friendship is a powerful way to offer support at some of the worst times of a person's life. The use of ‘therapeutic letter writing’ within psychiatric settings has been growing and letter writing has begun to be explored more extensively with positive findings.[8] Like HIV, the experience of mental illness can be isolating and lonely. Previous Minds for Health volunteers at Antara Psychiatric Hospital have noted how valued the letter exchange programme is. Patients say that writing provides a means to voice what they otherwise feel unable to express. Participants at both sides seem to enjoy the opportunity to have a personal insight into a different culture and place and to follow the events of each others’ lives.

References

^[1] Patel, V. & Kleinman, A. (2003) Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81, 609-615.

^[2] Gillespie, S., Kadiyala, S. & Greener, R. (2007). Is poverty or wealth driving HIV transmission? AIDS, 21, 5-16.

^[3] RSA (2010) Country Progress Report on the Declaration of Commitment on HIV/AIDS. Republic of South Africa, March 2010.

^[4] Rosenberg, S. D., Goodman, L. A., Osher, F. C. Swartz, M. S., Essock, S. M., Butterfield, M. I., Constantine, N. T., Wolford, G. L. & Salyers, M. P. (2001). Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. American Journal of Public Health, 91(1), 31-37.

^[5] Penzak, S. R., Reddy, Y. S. & Grimsley, S. R. (2000). Depression in patients with HIV infection. American Journal of Health-System Pharmacy, 57(4), 376-386.

^[6] Leserman, J. (2008). Role of Depression, Stress, and Trauma in HIV Disease Progression. Psychosomatic Medicine, 70, 539-543.

^[7] Crankshaw, O., Gilbert, A. & Morris, A. (2000). Backyard Soweto. International Journal of Urban and Regional Research, 24(4), 841-857.

[8] Venkatesh KK et al (2010): Who gets tested for HIV in a South African urban township? Implications for test and treat and gender-based prevention interventions. J Acquir Immune Defic Syndr, online edition, 2010.

[9] Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD (2004) Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection. Soc Sci Med; 59(8):1581-92

[10] Ramchandani PG, Richter LM, Norris SA, Stein A (2010) Maternal prenatal stress and later child behavioral problems in an urban South African setting. J Am Acad Child Adolesc Psychiatry; 49(3):239-47.

^[11] Pyle, N. R. (2006). Therapeutic Letters in Counselling Practice: Client and Counsellor Experiences. Canadian Journal of Counselling, 40(1), 17-31.