The finding:
This study examined a subset of women with HIV (WWH) participating in a larger study of WWH and alcohol use in a large urban HIV ambulatory care setting. Using a standardized psychiatric interview, the prevalence of psychiatric disorders and substance use disorders in African-American (AA) WWH with heavy alcohol use (HD) and AA WWH with moderate or no alcohol use (ND) was compared to AA women in the general population. Significant findings were as follows: 1) When compared to AA general population women, both HD WWH and ND WWH were significantly more likely to have a current and lifetime psychiatric disorder with the exception of no difference in prevalence of current bipolar disorder between ND WWH and AA general population women. Of striking significance, HD and ND subgroups were significantly more likely to have a current diagnosis of PTSD compared to AA general population women, with ORs elevated 16-18 fold among WWH. 2) There were no significant differences in number of lifetime psychiatric disorders between the HD and ND subgroups. AA WWH in both the HD and ND groups were twice as likely as AA general population women to have at least one current psychiatric diagnosis. Additionally, among participants with 2 lifetime psychiatric disorders, comorbid PTSD was significantly more likely to be a second diagnosis in HD and ND WWH when compared to AA general population women. 3) HD WWH were more likely to use marijuana, cocaine and heroin compared to ND WWH. Similarly, marijuana and cocaine use were significantly greater among ND WWH compared to AA general population women. Compared to AA general population women, HD WWH and ND WWH were significantly more likely to have a history of drug treatment.   

Strength and weaknesses:
The study used the Structured Clinical Interview for DSM-IV (SCID) administered by trained interviewers to diagnosis psychiatric disorders. While this standardized measure facilitates diagnostic accuracy, it does not account for the changes in criteria for PTSD in the DSM-5. The SCID may lead to greater prevalence of PTSD, compared to prevalence of PTSD using DSM-V criteria, which are more narrowly defined. The sample size of 315 AA WWH was large. Both study participants as well as women in the comparison group, who were drawn from the National Comorbidity Survey-Replication (NCS-R), comprised self-identified AA women. The NCS-R defined current psychiatric disorders as occurring in the past 12 months, whereas the SCID uses the past month to define a current episode of illness. Thus findings in this study may have underestimated psychiatric prevalence. In contrast, oversampling of WWH with alcohol misuse may have led to higher prevalence rates given the common co-occurrence of alcohol misuse and psychiatric disorders. The clinical sample was drawn from AA WWH receiving care in a high HIV prevalence setting, thus findings may more closely approximate patients who present in a “real-world” setting. Study findings may not be generalizable to the general population of WWH or to women out of care because the study sample was largely low-income, AA WWH in active treatment.   

Relevance:
Elevated rates of psychiatric and non-IVDU substance use disorders among clinical samples of people living with HIV are well-documented. There is also a growing body of research describing the contribution of these disorders to HIV transmission and poorer health outcomes, especially among men who have sex with men. Psychiatric comorbidity among women with HIV (WWH) is less well-studied, even though WWH account for roughly 20% of new infections. More specifically, African-American women, compared to other racial and ethnic groups, comprise the majority of new HIV infections in WWH. This study expands our limited understanding of factors mediating HIV transmission among AA women and may inform development of interventions to enhance both HIV prevention efforts as well as treatment outcomes. The finding of similar, elevated rates of PTSD across all levels of alcohol use, despite varying degrees of drug use suggests that drug use was not the major contributor to PTSD. Interventions that address trauma will also be required to reduce risk of HIV transmission and occurrence of anxiety, depressive and substance use disorders. Similar prevalence of psychiatric disorders among AA WWH who were heavy drinkers and those with moderate or no alcohol use was a surprising finding. This suggests the importance of other factors, such as educational and income levels and neighbourhood quality of life in determining risk of psychiatric morbidity. This study heightens the recognition that HIV prevention and treatment programs must account for the unique social and structural challenges faced by AA women at risk for and living with HIV.

Type of study:
This was a case-control study comparing prevalence of psychiatric disorders in a clinical sample of AA WWH with AA women in the NCS-R.