HIV Patients Suffer From Related Emotions, Anxiety and Depression

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Requirement

Does evidence suggest that HIV patients suffer from related emotions, anxiety and depression?

Solution

Abstract

HIV infection has developed as one of the real difficulties of the current world. Regardless of, awareness and education about this disease, a HIV patient is still thought to be a social outcaste and is dealt with intensely by the group on the loose. HIV/AIDS has picked up conspicuousness over the world as a developing general wellbeing issue. There is a complex yet huge connection between psychological wellness and HIV/AIDS. HIV influences psychological wellness by its direct neurobiological activity, the effect of having the ailment, by its treatment including that for opportunistic infections and by its effect on the family. In addition, the presence of multiple diseases due to suppression of immunity is an additional variable that add to the unpredictability of evaluation, differential analysis and disease management. The dissertation describes the search for literature, review of the literature and its critique. The literature from diverse sources was collected, reviewed and the essentials of the literature were collated. The outcome based on evidence was discussed for the effect of HIV-mediated anxiety, depression, or emotion on medication/therapy was discussed. The effect of socioeconomic conditions on anxiety in HIV infected patients was elaborated along with the possible factors that influence the lifespan of HIV victims.

The disease has incurred significant injury on communities, bringing about high dismalness and mortality. The casualties of HIV convey the burden of being caretakers for individual who infected with HIV while also stressing over their own particular wellbeing; be that as it may, little is thought about how HIV/AIDS influences mental illness among patients. The patients who reported more worry over being infected with HIV and more greater HIV-related stigma were critically more inclined to report more prominent symptoms of anxiety and depression. These discoveries propose that mediations that decrease HIV-related stigma are probably going to upgrade psychological function among the patients, which thus will enhance the patient's personal satisfaction and prosperity. Diverse factors that contribute for mental illnesses include gender, socioeconomic status, society and culture. In conclusion, studies have reported depression, anxiety and emotional distress are being the most common psychiatric morbidities among the afflicted individuals separately. No study dealt with the combination of mental illnesses in HIV victims.

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It appears that no article describes the underlying mechanisms of mental illness in HIV victims. In addition, there is a more requirement for psychosocial support for HIV-influenced families inside the setting of growing HIV-related services in healthcare system. The psychosocial mediations among HIV-influenced families also upgrade the viability for the alleviation of disease manifestations and in order to decrease the side effects of emotional sickness. A holistic approach to deal with HIV anticipation and care (coordinated administrations that are family-engaged) that addresses the family's needs (supporting guardians/parental figures, advancing family working, tending to physical and in addition emotional well-being requirements, and offering money related support when required) and additionally the wide scope of requirements for children (access to class, physical wellbeing needs, advancement of psychological well-being), might be important to decrease the burden the HIV infection and minimize the negative consequences of HIV infection for present and future eras.  Future research should focus the investigations to identifying the underlying causes and mechanisms.

CHAPTER-1

1.1 Literature review

During past few decades, researchers have shown great interest in the phenomena of social support, particularly in the context of health. According to reports (Maija & Bert, 2008), the high quality or quantity of social networks have a decreased risk of mortality in comparison to those who have low quantity or quality of social relationships.  Especially the support is needed for certain diseases like human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS).  HIV/AIDS is confined neither to any one class, community, religion, age, gender, and group nor to a profession. Therefore, it is the major concern of health psychologists to fight with AIDS because it is a major health problem of this century (Lefton, 1997). The AIDS is one of the most dreaded diseases that mainly impair body’s immune system to fight bacteria, viruses, cancer, etc, (Lahey, 1997). Following exposure to HIV, the person is vulnerable to germs that a normal immune system could destroy. HIV can be transmitted through sexual/contact or from mother to child through the placenta or by transfer of whole blood or blood product. However, it is important to note that social support in case of AIDS is operationalized in several different ways. Most broadly, support can be conceptualized in terms of the structural components (e.g. social integration). Despite of marginal support from society, individual with HIV/AIDS experience the threat of major negative life events and medical conditions. According to reports, the HIV/AIDS patients could show diverse effects on individual health and wealth including, premature death, physical disability and pain, loss of employment, social isolation, coasts of medical treatment, anxiety for future of family members (Alpana & Ila, 2010). Early reports of psychological responses of HIV infection revealed pervasive feelings of anxiety and depression (Fleishman & Fugal, 1994). Depression is either mood of clinical syndrome, such as emotional, motivational, cognitive, somatic or behavioral (Sarason & Sarason, 2000). The feeling associated with a depressed mood includes disappointment, helplessness and hopelessness (Comer, 1995).  It indicates that patients with HIV can undergo for diverse complications in terms of alterations in health condition due to the development of negative thoughts. Therefore, it is desired to investigate the possible factors that contribute for such emotional distress.  This section describes the search strategy in brief and reviews of available literature.

1.2. Search strategy

The available and popular sources were used to search for the evidences. The sources, diverse online electronic resources including BNI (British Nursing Index), CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE (the Excerpta Medica database), Pubmed, The DARE (Database of Abstracts of Reviews of Effects), HTA (Health Technology Assessment Database) and NHS (Economic Evaluation Database). The search was made for past 30 years to collect the relevant sources and link the evidences to the current context. In addition, the available textbooks (pharmacology, nursing, health education) from the library were also searched for the evidences. Satisfactory safety measures were made to channel the quest for the pertinent sources. The keywords utilized for the pursuit incorporate "HIV/AIDS effect on emotion, negative life occasions, premature death, physical disability, loss of employment, social isolation, anxiety and depression etc. The outcome of the search for the relevant sources has been depicted in subsequent sections.

1.3. Effect of HIV mediated anxiety on medication/therapy

Blank et al (2011) investigated the effect of the interventions from the community-based advanced practice nurse (APN) to promote adherence to HIV and psychiatric treatment regimens. The investigators conducted a randomized clinical trial utilizing 238 AIDS patients with mental illnesses. The APNs who were involved in intervention for the patients are assessed for the mental status and AIDS for 12 months. The intervention group showed a significant decrease in viral burden. The authors demonstrated that nursing interventions are showing positive impact in disease reduction. However, there are no details pertaining to the type of mental illness in detail. Most aspects are related to assessment of severity of AIDS. The focus towards the etiology behind the HIV for the mental disorders is missing. It was also evident from other reports (Vitiello et al., 2003) that the about 20.3% of HIV-infected patients who receiving medical care are associated with anxiety and other psychotic disorders (panic disorder, 12.3%; post-traumatic stress disorder, 10.4%; generalized anxiety disorder, 2.8%). Among the patients most patients are consuming psychotropics however, half of the patients did not receive medication for depressive disorders. Kuo et al., (2014) reported the data from a cross-sectional survey of families in HIV-endemic South Africa. The researchers studied the relationship between HIV impacts and caregiver anxiety. The patients included in the study comprises of either  not caring of children orphaned by AIDS;  caring for a child orphaned by AIDS but not living with HIV or dual HIV effects. The outcome of the study (Kuo et al., 2014) suggests that it was not caring for a child orphaned by AIDS per se that increased risk for anxiety. In addition, female patients appear to be of high risk of anxiety due to negative actions towards coping responses to stress (Rudolph, 2002) and etiological differences. Equally age can also increase the risk for anxiety due to an increase in chronic health conditions (Schoevers et al., 2005) and neurological changes. Due to associated thinking, the patients with positive HIV can develop psychological distress leading to development of anxiety for instance. The symptoms of anxiety have to be relieved in order to promote and sustain the health of infected person. In another study, it was quoted that the South African children and adolescents living in HIV/AIDS-affected families are at elevated risk of both symptoms of anxiety and depressive symptoms (Boyes & Cluver, 2015). The investigators opined that the poverty and HIV/AIDS-related stigma are as additional risk factors towards negative mental health outcomes.  The study contains youths from high HIV-pervasive groups in South Africa were met and caught up one year later. Familial HIV/AIDS at pattern appraisal was not specifically connected with psychological wellness results 1 year later. However, the researchers opined that the usage and thorough assessment of intense programs in South African people group may enhance emotional wellness results for HIV/AIDS-influenced youngsters and youths.  In addition, the support from family appears to show some influence towards the mitigation of infection. Some reports recommend supporting by family (Mohanan & Kamath, 2009) so that the infected person can reduce the symptoms. Mohanan & Kamath (2009) assessed the effect of family support on morbidity, mortality, quality of life, and economics in families with at least one HIV-infected member, in developing countries. The authors utilized numerous databases including CENTRAL, the Cochrane Database of Systematic Reviews, MEDLINE, AIDSLINE and CINAHL etc. No trials found pertaining to the inclusion of family members for the support in the studies. It indicates that there is an insufficient evidence to bring out the effect of family support in reducing the morbidity and mortality of HIV-infected persons in developing countries. 

1.4. Effect of HIV mediated depression on medication/therapy

Pence et al., (2015) investigated the impact of antidepressant efficacy in HIV care for the improvement of adherence of antiretroviral therapy and depression morbidity. The pseudo-cluster randomized trial was conducted in HIV-infected adults with major depressive disorder based on US infectious diseases clinics. The depression care managers used systematic metrics to give HIV primary-care clinicians standardized antidepressant treatment recommendations during 2010-2013. About 149 participants were randomized to intervention and 155 to usual care. Diverse patients belonging to majorly men, Black, non-Hispanic, unemployed, and virally suppressed with high baseline self-reported antiretroviral adherence and depressive severity were included. The outcome reveals that there was significant improvement in depression.  Mitzel et al., (2015) tested the role of depressive symptoms on adherence of anti HIV-medication adherence. The study was conducted in 66 HIV-infected men who have sex with men from an outpatient infectious disease clinic. The outcome reveals that the stigma-related experiences were positively associated with depressive symptoms and negatively associated with adherence. These results highlight the importance of treating depressive symptoms in interventions aiming to improve medication adherence among HIV-infected patients. Turan et al., (1999) tried to fill the gap of the research by conducting the study in women in association between internalized stigma and ART adherence.  The multicenter cohort study was based on questionnaires in 1168 women who were taking ART. Among the women, the minority woman showed significant suboptimal ART due to development of depressive symptoms. The authors explained the probable causes of depression in minority community in general and female in particular contrasted with other racial/ethnic gatherings. Another cross-sectional study (Medha et al., 2011) depicted the connections between social bolster, HIV exposure, and melancholy among 340 country African American ladies with HIV ailment living in the southeastern United States. Three parts of social backing (saw accessibility of bolster, wellsprings of accessible backing, and fulfillment with accessible backing) were measured alongside HIV exposure and sadness. Seen accessibility of backing and fulfillment with backing intervened the relationship between HIV divulgence and sorrow. On the off chance that affirmed in longitudinal studies, these discoveries have suggestions for planning and executing mediations supporting African American ladies with HIV ailment in revealing their HIV status fittingly, especially to their youngsters.

1.5 Effect of HIV/AIDS on emotion

Without treatment, a large proportion of HIV-positive people live for a decade or more before the virus begins to take a noticeable toll. In addition, there is a small proportion of people with HIV who have immune systems that can naturally resist replication of the virus for an indefinite period of time (Okulicz et al., 2009). Some people may have outdated concepts of the harm caused by HIV because earlier antiretroviral drugs and combinations did not treat HIV effectively. However, the discovery of new classes of antiretroviral in the late 1990s resulted in dramatic reductions in HIV-related illnesses and deaths in high-income countries. For example, the age-adjusted HIV-related death rate in the United States dropped from 17 per 100,000 people in 1995 to about five per 100,000 people by the end of the decade (Mocroft et al., 2002). Once the patient is diagnosed for the positive HIV, can cause lot of emotional distress. Moneyham et al., (1997) investigated the impact of psychological mediators of HIV-related stressors on emotional distress in 264 HIV positive women. It appears that the effect of HIV-related stressors on emotional distress was indirect through cognitive appraisal. The findings indicate that how HIV+ women think about HIV-related stressors is an important factor that may account for individual variability in the ability to maintain a sense of subjective well-being in the face of a devastating fatal disease. Numerous reports are not available to link the emotional distress and their mechanisms. However on report (Wei et al., 2016) describes the relation between stigma (discriminatory behaviors), stereotyped attitudes and emotional behavior. The researchers utilized data from 790 children (age, 6-17 years) affected by HIV for the analysis and mediation of the model. They found that a significant interaction between perceived stigma and age suggested that negative emotions increase with age among those who perceived a higher level of stigmatization. Asikhia & Mohangi (2015) reported the outcome of a qualitative study utilizing 11 orphaned adolescent (5 boys and 6 girls aged between 15-18 years) patients with AIDS. All the participants show that a high prevalence of psychological, behavioral and emotional problems and lack of adequate support from the teachers. From the evidences it appear that most patients are associated with a lack of support to get rid of the symptoms making the patients to be emotional and psychological distress. Therefore there is need of adequate support from the government in the disease management.

1.6. Effect of socioeconomic conditions on anxiety in HIV infected patients

Robinson et al., (2015) evaluated the effect of interventions aimed at sustaining and improving employment in HIV+ persons utilizing a comprehensive search from 1981 until December 2014. The evaluation has been done from randomized controlled trials or controlled before-after studies. All the participants appear that they have undergone for vocational training and antiretroviral therapy. No studies dealt with psychological interventions. Among the studies, two studies compared employment outcomes of HIV+ persons on ART therapy to healthy controls. Three other studies compared HIV+ persons on ART to HIV+ persons not yet on ART. Two studies indicated an increase in the likelihood of employment over time due to the impact of ART for HIV+ persons compared to HIV+ person’s pre-ART. It indicates that there are no investigations associated with the assessment of mental illnesses in HIV infected patients. Despite of low quality of interventions it was expected to improve ART interventions outcomes of employment for the positive HIV persons. Due to lack of high quality interventions, it is preferable to have adequate randomized studies to assess the effectiveness of interventions for HIV+ persons.

1.7 Discussion

Numerous articles found from the PubMed search in comparison to other sources. However few reports can be found in both the searches for instance PubMed and Cochrane. The psychological disorders and alterations in mood are often comorbid with chronic illnesses such as HIV leading to an increase the associated morbidity and mortality rates (Frasure-Smith and Lesperance, 2005). The review was also extended towards available guidelines. It was apparent from the guidelines that the guidance is recommending to diagnose the HIV positive individuals for anxiety and depression using validated tools (Duncan et al., 2015). Despite of describing the role of HIV on mental illnesses, the guidance (Duncan et al., 2015) describes separately the aspects of strategies for individual diseases such as HIV, Kidney diseases, mental illness and cardiovascular diseases. In addition, the reports (Bernard et al., 2014) describe the diagnosis of HIV infection utilizing an algorithm (Fig-1) and are based on testing of serum or plasma specimens. WHO (2016) even describing the general features of disease including, signs and symptoms, transmission of disease; risk factors associated; diagnosis and disease management. It appears that none of the source is describing the underlying mechanisms involved in the development of emotional distress, anxiety and depression in HIV infected patients. However, it was apartment from some of the sources the personnel who were positive towards the HIV are associated with psychological distress. 

1.8. Development of Recommendations

After summarizing the state of the literature, we next identified gaps in the available evidence, critical unanswered questions, and promising strategies to address the effects of HIV on psychological distress. From the evidences it was apparent that there is a need of involving family members, government, and society to educate the patients. The individual’s health beliefs are in general influenced by health literacy, and these beliefs are also contributors to non-adherence. There is a clear need for rigorous studies of the clinical effects of family support on people with HIV in developing countries. Hence it is aimed to investigate the effect of HIV associated emotions, anxiety and depression and provide possible recommendations to reduce such behavior so that the life span of the patients can be increased.

CHAPTER-2: CRITIQUE OF LITERATURE

2.1. Literature review

The HIV infected victims fail to resist towards the attack of pathogenic and non-pathogenic diseases. The complications of the patient are going to be increased. Therefore, the life span is going to be reduced significantly if untreated. In view of the patient condition, by looking to other patients, most HIV infected patients develop a kind of psychological distress. Most researchers contributed for the identification of possible factors and their control towards management of disease. However, there exist certain gaps in the literature. The gaps have been identified and depicted in below sections. Late diagnosis and thus more severe illness at the time of diagnosis can propel the older individuals and makes them to confuse towards for the development of symptoms of HIV.  The review of literature made utilizing diverse sources as depicted in preceding chapter. A literature critique is an analysis of a piece of literature. The scope of a critique is to examine each aspect of the work and involves breaking the literary piece apart into its separate components and evaluating how they fit together to accomplish the piece's purpose. The outcome of the literature along with positive and negative aspects is shown in this chapter. The critique would help in developing the objectives and planning the research further.

2.2. Effect of AIDS on Psychological disorders

2.2.1. Effect of HIV mediated anxiety on medication/therapy
The methods employed by Blank et al (2011) are based on randomized clinical trial in numerous AIDS patients with mental illnesses. The intervention comprises for the assessment of mental status and AIDS for a period of 12 months. The entire study duration is relatively good and is based on clinical trials and showed a significant influence on the results. Despite of positive influence, it appears that there exist certain limitations in the study. A generalized term of ‘mental illness’ is provided however no details are captured on the type of mental illness in detail. An emphasis towards focus for the assessment of AIDS induced mental illness should have been covered. The causes behind in the mental illness are missing. The investigators even did not put additional efforts for the identification of mental illness in the patients with AIDS. Certain reports describe the use of antipsychotic medication in HIV infected patients. Among, the investigation performed by Vitiello et al., (2003) focused mainly on the effectiveness of psychotropic medication on recovery of AIDS. The medical intervention showed a decrease of disease intensity. However, the authors did not describe the underlying reasons, why the psychotic symptoms are developed in those individuals. The outcome of the study reported by Kuo et al., (2014) have covered a broad range of victims with anxiety as one of the effect in AIDS patients from South African context. The report gave an insight of how the caregivers are influencing psychologically. However, the researchers are not addressed the impact of AIDS on patient’s perspective. Similar to other reports, the investigators are not covered the factors contributing for anxiety and other psychological disorders. The focus of other reports (Mohanan & Kamath, 2009) is based on recommendations but not on the mechanism involved for the psychological distress in AIDS patients.
2.2.2. Effect of HIV mediated depression on medication/therapy
According to the literature it appears that, AIDS patients and their caregivers can undergo depression. Therefore, most physicians prescribe antipsychotic medication a part from the AIDS medication. Antidepressant efficacy in HIV care have been evaluated by Pence et al., (2015), did not bring a significant improvement in HIV outcome despite of following adequate assessment and statistics. The investigators evaluated the adherence of antiretroviral therapy and depression morbidity. Except depression, no other psychological diseases such as anxiety have been covered in the investigation. The study was also pseudo cluster randomization, a design most suits for in smaller number of study participants (Melis et al., 2011). The sample size included is reasonably good however, the investigators employed pseudo cluster randomization. A systematic investigation comprising of a structured statistical design has to be used for the study.  Mitzel et al., (2015) tested the role of depressive symptoms on adherence of anti HIV-medication adherence.
The study was based on homosexual patients (66 HIV-infected men who have sex with men) in an outpatient infectious disease clinic.  The investigation did not reveal about the types of design employed however the outcome showed a significant impact in terms of stigma-related experiences. It was positive with depressive symptoms and negative towards adherence. Similar to preceding outcomes and methods, the investigators did not covered other psychological disorders. Turan et al., (2015) attempted to fill the gap of the research between internalized stigma and anti retroviral therapy.  The investigation was carried in more than 1000 women patients. The researchers used an old method for the assessment of depression and are on grading. Novel methods such as Preguntas con Cartas (Caplan, 2016) should have been used to avoid the bias of the old method. The study was based on multicenter however inter comparisons of the study was missing. In addition, the aspects of emotion and anxiety are not covered.  A cross-sectional study (Medha et al., 2011) based on southeastern United States covered the relationship between social bolster, HIV exposure, and melancholy.  A part from the dermatographic data, the investigators (Medha et al., 2011) investigated the effect of independent variables (nine-item scale with a 3-point Likert-type) on dependent variables, depression. The relationship between independent and dependent variables is missing. However, the outcome reveals that the rural women from southeastern United States are often under-diagnosed and inadequately treated for depression. The details pertaining to other disorders such as emotion and other psychological disorders are missing.

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2.2.3. Effect of HIV/AIDS on emotion
Most people across the globe are aware of the curable and non-curable diseases. The diseases that are not curable can in general pose risk towards the development of emotion in patients. In absence of adequate preventive measures before diagnosing the HIV infection, the individuals can survive for the couple of years. Once the disease is diagnosed for the AIDS, individuals can undergo emotional distress leading to significant reduction of life span. Few reports are available for the investigation of AIDS and its influence on HIV infected victims and their family members. The relevant literature was analyzed critically and the outcome is described in subsequent sections.
Okulicz et al., (2009) reported the role of viral load on the reduction of victim immunity however, why and how the individual is undergoing for emotional distress is not explained. The link between the ‘suppression of immunity’ and its repercussions on emotions is missing. However, it can be understood that certain biological modulators are releasing in the body due to stress that in turn are contributing for the development of emotional distress. Such changes in biological system could decrease the life span significantly. To prolong life, investigators (Mocroft et al., 2002) recommended using either single or multiple regimens from novel source for the mitigation of diseases. The study was conducted in about numerous patients and found that the ‘dropping’ rate was comedown with the treatment. They talk about the use of drugs in the treatment but no details been covered pertaining to the emotional distress. The drug use could decrease viral load therefore the life span of patients can increase. The physiological mediators contribute for emotional distress it appears. Moneyham et al., (1997) investigated the impact of HIV-related stressors on emotional distress in HIV positive women. The findings indicate that how HIV positive women think about HIV-related stressors is an important factor that may account for individual variability in the ability to maintain a sense of subjective well-being in the face of a devastating fatal disease.
The possible modes by which the reduction of emotional distress are missing in the report. However, it is possible to from the insight of the outcome (Moneyham et al., 1997) to reduce the emotional distress to the intensity of the disease. Numerous reports are not available to link the emotional distress and the underlying mechanisms. However, the available report (Wei et al., 2016) covers the relation between stigma, stereotyped attitudes and emotional behavior. The researchers (Wei et al., 2016) utilized data from young children (age, 6-17 years) affected by HIV for the analysis and mediation of the model. Compared to young children, the thinking capacity and thus emotional distress in adults and geriatrics could differ. Therefore, the focus was missed in the adults and elderly patients pertaining to emotional distress. The environment and society also contributes for the emotional distress due to lack of adequate moral support from peers, neighbors and surrounding environment. Especially for children who are in schooling stage, adequate support from teachers is needed to reduce the emotional distress. Experts of psycho-education can also help in the reduction of emotional distress in children. However most schools do contain neither experts nor teachers for the intervention. In addition, some schools keep the victims a way and in isolation from other children i.e., non-HIV children. These activities can force the infected victims to discrimination of the infected students. It further potentiates them for the development of emotional distress. Few reports are available in this direction. Among, the relevant one is based on the findings from the article (Asikhia & Mohangi, 2015). The researchers conducted a study in small group of adolescents with HIV infection. The depth analysis is missing from the study with respect to mechanisms, statistical assessment between infected and normal population. From the literature it can be understood that, pieces of research outcome is available however a link between the research aspects is missing a part from the emotional distress.
2.2.4. Effect of socioeconomic conditions on anxiety in HIV infected patients
The education background, employment status, culture and society can certainly influence the medical interventions on the disease management. The literates with adequate employment status can take precautions in the disease management and vice versa for patients with low education background. Few articles found for the investigation of socioeconomic conditions on anxiety in HIV infected patients. Most relevant articles were analyzed and the summary is depicted in this section. The outcome of Robinson et al., (2015) from a randomized controlled trial indicates that the patients with below poverty are more victims and the lifespan of those patients is low compared to the individuals with sound economic status. This could be due to lack of adequate awareness of the disease symptoms and its risk for the patients with low poverty. However, no study dealt with psychological interventions. Few studies are based on comparative evaluations for HIV positive persons on anti retroviral therapy (ART) to healthy controls. It indicates that neither cited report nor available sources dealt with the assessment of mental illnesses in HIV infected patients. 

2.3. Discussion

Among the sources, it appears that few articles are dealt with the role of HIV infection on depression and emotional distress. However, no article is covering the aspects of HIV induced anxiety and emotion in detail. Even the mechanism of depression and psychological change due to AIDS is not covered. Most articles are speaking about the role of medication on the suppression of AIDS. However, certain validated tools (Duncan et al., 2015) are available for the diagnosis and treatment of AIDS. In fact, no article refers the use of validated tools. The validated tools should have been used to rely on the data. The reliability of the data from the published literature appears to be limited as no investigator had used validated tools for the research. Well-developed algorithms are available (Fig-1) for the treatment but no clue about the impact of AIDS on emotion and anxiety (Bernard et al., 2014). WHO (2016) even describing the general features of disease including, signs and symptoms, transmission of disease; risk factors associated; diagnosis and disease management. It appears that none of the source is describing the underlying mechanisms involved in the development of emotional distress, anxiety and depression in HIV infected patients. The reported studies utilize a large population from specific country to study the impact drugs on HIV and/or a specific mental illness. The investigations can contribute to better understanding of connection between diverse population and HIV. The overall impression on available data is that the careful examination of data that influence the mental illness in HIV patients. From the evidences, it can be understood that the personnel who were positive towards the HIV are associated with psychological distress. 

CHAPTER-3: DISCUSSION AND FINDINGS

3.1.    Introduction

The chapter discusses the findings based on the literature in order to develop a concrete plan for the possible solutions and design the research. The psychological distress due to diverse causes in HIV infected patient’s needs to be addressed in terms of possible solutions. This is to reduce the mortality and morbidity of the victims. Hence, the present chapter aims in discussing the findings of the literature for the development of possible solutions.

3.2. Effect of AIDS on Psychological disorders

3.2.1. Effect of HIV mediated anxiety on medication/therapy
The randomized clinical trial based investigations performed by Blank et al (2011) reveal that the longitudinal models for a period of 12 months and so gave a significant outcome in term of viral load. The intervention group exhibited a significantly greater reduction in log viral load (p<0.001) compared to control group indicating that the studies on long-term basis are needed for the investigations and to elucidate the impact of HIV on mental status of the victims. It indicates that long-term investigations are needed to avoid the bias from statistical perceptive. In addition to the viral load in the proposed studies, other parameters such as a detailed type of mental health are to be incorporated. The aspects of assessing the mental status such as anxiety were considered in the patients suffering from other diseases (Baqutayan, 2012). Despite of non-availability of such practices, the methods used in other cases (Baqutayan, 2012) can be applied for the investigation of HIV victims. Therefore, such practices can be implemented for HIV infected patients. The outcome of the investigation (Vitiello et al., 2003) revealed that antidepressants are the most commonly prescribed medicines (20.9%) followed by anxiolytic (16.7%), antipsychotics (4.7%), and psycho stimulants (3.0%).  It indicates that the HIV-positive victims undergo for frequent depression in the population tested and similar phenomenon can be anticipated across the globe.  Therefore, an emphasis can be given for the investigation towards depression, why the HIV positive patients undergo for frequent depression. What factors contributing for the development of symptoms and mental illness. What are the underlying physiological mechanisms?  The presence of HIV positive in the victims not only influences the victim’s mental health, also influences the caregiver’s health status. Therefore it is expected that the caregiver’s even suffer from mental illness. In an attempt, Kuo et al., (2014) evaluated the South African based caregivers for the assessment of psychological status utilizing multivariate hierarchical logistic regressions. The authors found that the caregivers who are associated with HIV positive patients can develop anxiety (p<0.001) who were living with the patients. This further increases the risk of development of psychological symptoms for the patients. From these evidences it can be understood that there is lack of adequate support from psychologically, socially, medically and behavior perceptive. Therefore the patients require a mechanical and moral support to come out from the ‘continuous’ thinking on the HIV and its symptoms. A periodic counseling from experts from psychology can aid in minimizing the disease symptoms. An insight can be devised from the available sources that no source is describing the factors and causes contributing for the assessment of mental status in HIV positive patients. Hence, it would be desired to focus an investigation to study the underlying mechanisms utilizing randomized clinical trials on long term basis. In addition, the aspects of counseling with experts can be incorporated to study the impact of counseling on the reduction of symptoms of mental illness.
3.2.2. Effect of HIV mediated depression on medication/therapy
The inclusion of patients from diverse study groups can avoid the bias and help in understanding how the depression does affect the medication in HIV patients. The inclusion of patients from diverse cultural background could minimize the variability and increase the abilities to understand the severity of disease. The patients with intervention for 6 months showed a lower extent of depression  (mean difference -3.7) and a lower tendency of suicidal behavior (-18%)  (Pence et al., 2015).  It indicates that the patients are associated with certain anxiety and depression. Therefore, the symptoms have significantly reduced with the pharmacological interventions in the studied groups. It gave an insight for conduct of studies for long time.  The investigation (Mitzel et al., 2015) revealed that there exist an association between HIV-related stigma and adherence. The symptoms of depression are strongly related  to the HIV adherence while the stigma did not. The outcome gave an insight for the importance of treating depressive symptoms in interventions aiming to improve medication adherence among HIV-infected patients.  The investigation did not reveal about the types of design employed however the outcome showed a significant impact in terms of stigma-related experiences. It was positive with depressive symptoms and negative towards adherence. Similar to preceding outcomes and methods, the investigators did not cover other psychological disorders.
The proposed study should cover other types of mental illnesses a part from depression. Turan et al., (2015) proved the relation between internalized stigma and self-reported suboptimal anti retroviral therapy. It was based on the relation between the depressive symptoms and low extent of social support, the investigators concluded that there exist an association between internalized stigma and suboptimal adherence. From the available results, it can be understood that the studies were utilizes depression and the investigators are trying to establish correlation between stigma and depressive symptoms. Most of the evidences are based on a single center so it is desirable to have the findings from multicenter studies. In addition, other aspects of mental status have not been captured. Therefore, the proposed study should focus on anxiety and other mental illness.
3.2.3. Effect of HIV/AIDS on emotion
From emotional aspects perceptive, Okulicz et al., (2009) investigated the role of viral load on the reduction of victim immunity utilizing elite and viremic controllers. The outcome reveals that the elite controllers had favorable time for the development of AIDS (P=0.048) in comparison to viremic controllers. The researchers have not addressed the emotional aspects of the patients. The authors mentioned that the use of multiple drug regimens can increase the life span of victims and possibly reduce the emotional distress of the patients (Mocroft et al., 2002), but how they improve the health is not described. The aspects of counseling with medication and without medication could equally considered as the variables to address the efficacy of single and combination approaches on the disease mitigation. The use of combination therapy rather than single drug use could certainly increase the efficacy thus the lifespan of patient can increase. In an attempt, the researchers (Mocroft et al., 2002) proved as the ‘dropping’ rate was decreased (P<0.001) with the use of drugs but no details pertaining to psycho education. A part from pharmacological interventions, the counseling with psychiatrist can minimize the symptoms of mental illness. Moneyham et al., (1997), explain the possible mechanisms involved in emotional distress. The investigators opined that the physiological mediators influence the HIV-related stress on emotional distress. No insight is provided in terms of possible approaches for reduction of emotion by physiological and pharmacological interventions. Another cause for emotional behavior could be stigma related effects and was correlated with age (Wei et al., 2016). The stigma and age interaction term was significant for negative emotions for the total sample, with higher age associated with greater experience of negative emotions. This suggests that the effect of perceived stigma on negative emotions is moderated by age in HIV-affected individuals.
The multiple linear regressions suggest that there exist an emotional regulation partially mediated the relationship between negative emotions and both types of stigma, including enacted stigma and perceived stigma (Wei et al., 2016). One source (Asikhia & Mohangi, 2015) is describing about the interventions to reduce the emotional distress in schoolchildren. There was a high prevalence of psychological, behavioral and emotional problems and that the school support provided to them (teachers' support, the general school environment and the degree of discrimination, labeling and bullying that exists in the school) was not sufficient (Asikhia & Mohangi, 2015). The available sources neither discussing the etiology of emotional aspects in HIV victims nor proposing the strategies of intervention. Therefore, focus can be given to find out the factors and establish a link between the emotional distress and HIV utilizing randomized trials. The considerations for the incorporation of adequate sample size should be included in the study to achieve adequate power and minimize the variability.
3.2.4. Effect of socioeconomic conditions on anxiety in HIV infected patients
The education level, status and position of employment and status of individual in society can certainly influence the medical interventions and on the disease management. Robinson et al., (2015) revealed that no investigation dealt with psychological interventions. However, the researchers evaluated the performance of vocational training and pharmacological interventions. Among the studies, the vocational intervention could not infer a significant outcome due to lack of adequate data. The pharmacological interventions showed diverse outcome due to differences in the studies. In addition, the use of diverse drugs could show varying influence on the patient. The aspects of physiological variability should have been considered. The individuals with positive HIV and employment showed a significant improvement in terms of mitigation compared to those without adequate socioeconomic condition. This could be due to the availability of adequate resources in terms of financial status and awareness of HIV infection. Always the education and above poverty status could minimize the disease symptoms. The victims with adequate work at job do not get time to think and undergo for psychological distress.
Another report from Peltzer & Pengpid (2013) reveals that the income, level of education, and employment/occupational status was significantly and positively associated with the level of adherence of treatment. About 73.2% of studies showed a positive outcome in terms of adherence of therapy. Despite of positive outcome it appears that the available evidence does not provide conclusive support for the existence of a clear association between socio-economic status and adherence to anti retroviral therapy in adult patients infected with HIV (Peltzer & Pengpid, 2013). Another report describes the relationship between socioeconomic status and HIV infection (Ogunmola et al., 2014) utilizing an analytical case-control study and logistic regression model. The outcome reveals that HIV positive patients with secondary school levels of education and all categories of monthly income showed statistically significant relationships with HIV infection (P=0.018 and P<0.05, respectively). It indicates that there exists a relationship between socioeconomic status and HIV infection However, no report precisely dealt with the assessment of mental illnesses in HIV infected patients. 

3.3. Discussion

From the outcome of the sources, it can be understood that no single report is available to address the issues pertaining to the impact of HIV mediated mental illness in patients with positive HIV. Many of the articles are based on randomized controlled trials. Few articles dealt with depression and emotional distress. As no articles are available to cover the diverse mental illness in HIV victims and even adequate diagnosis of the disease. It indicates that, there is a scope to investigate the mental status of patients with HIV. The proposed research should address the trend of mental illnesses and elucidate the possible underlying mechanisms. Despite of availability of advanced tools (Duncan et al., 2015) no study utilizes the validated tools. The proposed study may be conducted by incorporating statistical methods in the study design to avoid bias and find out the significance in comparison to control groups. Certain statistical concepts are incorporated in HIV dynamics in AIDS research (Wu, 2005) however, the objectives are different. Such concepts may be incorporated in proposed research. In addition, the variables such as counseling with experts for patients and caregivers, periodic interactions with teachers in case of schooling children, patient education and its extent, use of pharmacological interventions in patients can be included in the proposed investigations. The proposed studies can be conducted in the same population with large number and for long duration. It is also important to consider the implications of validated tools versus creating new active control groups for the investigation. One major issue that influences the control trials is the reliability of outcome as the trails are not validated. Same question could be arisen from the reported literature as the investigations are neither used a validated tool. The problem of adherence in HIV prevention trials can have a major effect on scientific viability. For instance, a low adherence in a trial makes it impossible to measure effectiveness, and can lead to widely divergent results across studies. Therefore, a focus can be given to increase the adherence towards study so that the outcome can be trustable. 

CHAPTER-4: IMPLICATIONS FOR PRACTICE AND PERSONAL REFLECTION

4.1. Summary of the evidences

From the evidences it gives the idea that differing components including poverty, financial status and moral and profound contemplations could impacts the unfriendly impacts of HIV on mental issue. The existence of adolescent spirituality is connected with less nervousness, wretchedness, and versatile adapting to an interminable ailment contrasted with children. To comprehend the likely explanations, the present chapter summarizes the implications to derive views on the management of HIV. 
The outcome of this study supported the speculations that more stress over being HIV-positive and impression of more prominent HIV stigma are associated with more distress in the HIV positive populace. Stressing over contracting HIV was altogether connected with more current emotional trouble. Among the sex, ladies with positive manifestations of HIV gives off an impression of being more inclined for distress and along these lines mental disarranges. Others would be embarrassed about them on the off chance that they got to be HIV positive. Such situation can propel the victims to develop emotional distress beyond the HIV-related worry. In addition, HIV related stigma contributes for a greater psychological distress, including anxiety, depression, and negative affect (Neuman et al., 2013). A few studies have recommended that HIV stigma might be particularly adverse to ladies (Lichtenstein et al., 2002).
Ladies who perceive HIV stigma in their society as high might be hesitant to get tried; this evasion may prompt expanded stress, ensuing enthusiastic misery, and an absence of access to essential care. The existence of stress over contracting HIV and HIV stigma is obscure, yet it can be comprehended from the evidences there exist certain hazard for the improvement of mental issue. This could prompt stress over getting to be HIV-positive, eventually leading to the development of depression and anxiety. The likelihood of more depression and tension could build stress and stigma over HIV, apart from emotional and psychological prosperity of patients. However the physiological mechanisms from the available evidences are not clear why HIV positive patients are developing such symptoms. The evidences and subsequent review gave an insight for the development of socially sensitive HIV education programs that additionally address issues of emotional distress. In considering approaches to address the issues in a particular region that have been unequivocally affected by the HIV epidemic. The major contributing variables that impact the improvement of symptoms include the gender, HIV programming and part of psychological wellness into HIV counteractive action and treatment administrations. Other variables that may influence life traverse of HIV positive patients and distress to be analyzed in future research. Besides, in clinical practice, social insurance suppliers ought to survey the degree of emotional distress in HIV positive patients, as depression and tension may increase with regards to HIV-related care. For instance, it is conceivable that emotional distress and dread of having HIV, as opposed to deception or absence of get to, keeps patients from getting tested or looking for health care services.

The disadvantages of methodologies should be considered when performing new investigations. The constraints could be either identified with little specimen size to encourage a helpful testing methodology. Future research is required with both the sexual orientation of more socially and topographically differing population to look at the relationship of HIV and emotional distress with regards to social convictions. Most studies depended on self-report measures, so future research should also use alternative types of measures, for example, the appraisals and perceptions of health care providers. The cross-sectional study designs did not address the examination of causal connections so such investigation and plans can be avoided. Future studies should also analyze whether HIV stress and stigma prompts expanded emotional distress, or if the inverse is valid. Location of a causal relationship would have various ramifications for health care providers.

It creates the impression that a multidimensional idea is expected to bring awareness in HIV patients. However, from quality of life (QOL) perceptive, the aspects are questionable. HIV/AIDS speaks to a high financial effect from society perspective. The self perception of QOL has been appeared to be a valuable screening item for evaluating worldwide QOL. QOL relates both to ampleness of the material conditions and to individual sentiments about these conditions. As wellbeing is by and large referred to as a standout amongst the most imperative determinants of general QOL, it has been recommended that QOL might be remarkably influenced by particular ailment process, for example, AIDS. There is absence of clarity in characterizing QOL and attendant operational difficulties in it yet at the same time there is earnestness in assessing the QOL in HIV-infected people. Future studies ought to envelop the assessment of more determinants of QOL in HIV/AIDS. The recognizable symptoms of HIV can certainly influence the QOL for individuals living with HIV disease. Adequate and effective management of manifestations is essential for enhancing QOL and possibly to maintain a muddled day by day regimen of antiretroviral medications. As HIV sickness is among the most annihilating of ailments, having numerous and significant impacts upon all parts of life, subsequently the assessment of QOL is essential. In spite of the fact that examination has proposed connections among different psychosocial and spiritual factors, symptomatology, and physical wellbeing, a great deal more research is still expected to archive their potential impacts on invulnerable capacity, and in addition wellbeing status, illness movement, and QOL among people with HIV infection. It is additionally critical to underline the part of counsel contact psychiatry in the analysis and treatment of HIV and AIDS. Stress management interventions for HIV-infected people are a promising way to deal with encourages constructive alteration. Additional studies should focus to center an assessment for the part of routine QOL evaluation in patients who have HIV/AIDS.

The parents (of either one or both) living with HIV and their children, maternal tension/stress had an immediate relationship with child rearing aptitudes. Those parents, who were more on edge about their own wellbeing and working, and more stressed in their parental part, will probably show poorer child rearing aptitudes particularly they connected with kids less much of the time in family schedules, had poorer parent-kid correspondence, and had less steady teach. These discoveries are steady with writing on overall public parent tests, in spite of the fact that this study shows a wide scope of child rearing abilities are influenced by maternal stress. This scope of shortfalls demonstrates a solid requirement for child rearing intercessions for parents living with HIV. Child rearing intercessions need to give guardians data on (i) how their mental distress can influence family working and child outcome; (ii) procedures and support for managing their mental strain; (iii) aptitudes for execution of family schedules, and help with techniques for more established youngsters or other support to keep up family schedules and checking if the parents and (iv) systems for how parents can enhance parent-kid correspondence.
The present study also observed that HIV positive manifestations are connected with greater levels of distress in many patients, well beyond simply stress over contracting HIV. The discoveries highlight the requirement for more research and program improvement to look at option methodologies and mediations for diminishing HIV side effects so that the emotional distress could be diminished. More AIDS training and investigations with preventive action should be conducted in a socially delicate way to address stress and concern with respect to HIV status and defaming dispositions towards HIV infected people. By doing this, projects can ideally start decreasing both social stigma connected to HIV, and also the emotional distress that may come because of perception of such stigma.
 

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