ORIGINAL ARTICLES

Vulnerability of HIV/AIDS in patients with mental disorders: an integrative review

Iraci dos Santos¹, Leandro Andrade da Silva¹

¹Rio de Janeiro State University

Descriptors: Psychiatric Nursing; Acquired Immunodeficiency Syndrome; Mental Health.

INTRODUCTION

The process of Brazilian Psychiatric Reform (RPB, in Portuguese) was understood to be a movement that extrapolated the strict field of mental health assistance to become one of the most expressive social processes in the contemporary national scenario. It aimed to qualify the health care service provided to the individual diagnosed with a mental disorder, it built new social spaces that did not consider these disorders to be general madness questioning and changing the practices of traditional psychiatry and other relevant institutions in Brazilian society^(1-2).

Such reform, through its political, epistemological, sociocultural and technical-assisting dimensions, permitted a deep review of the legislation regarding mental health and helped articulated actions with different social actors and health care institutions⁽³⁾.

This reform was understood as a heterogeneous social movement, in a vast and complex field. Above all, it was a process that showed the scars from the 1970s and was inserted into a wider movement called Sanitary Reform. This last reform tried to politicice the mental health care challenge, especially the struggle against psychiatric institutions when producing critical and strategic reflections about caring, which are counter-hegemonic if compared to traditional psychiatry which would encourage segregation between the subject and social life⁽⁴⁾.

This whole process was articulated alongside other social movements, allied in the struggle for the process of the redemocratization of Brazil in the 1970s. Nowadays, it is impossible to deny that in many aspects the health care service offered to people diagnosed with mental disorders has developed, especially through substitute devices, against the use of hospital-centered model, expressed mainly by the implementation and use of the Psychosocial Attention Centers (CAPS, in Portuguese), which permits a profound transformation in the process of dealing with mental illness⁽⁴⁾.

Another contributing factor was the approval of Bill 10,216⁽⁵⁾, which describes psychiatric reform in Brazil. This law was processed over twelve years in the Brazilian Senate, and the final text was far from what was necessary, as many articles were vetted. The Bill passed in 1989, when it became clear that its original text clearly proposed the progressive extinction of mental asylums and the substitution of these by other services⁽⁶⁾.

The Bill 10,216⁽⁵⁾ was transformed in a timid document, keeping the existing hospital structure and regulating psychiatric hospitalizations. There was a substitution of the health care service model used, suggesting that this service should preferentially be offered in mental health community service structures⁽⁴⁾.

In the year 2010, the 4th Brazilian National Conference in Intersetorial Mental Health (CNSMI, in Portuguese) occurred in Brasilia, where CAPS was declared to be the fundamental device of a psychosocial care model, rather than the psychiatric hospital, highlighting CAPS’ strategic uses in setting the service network and the necessity of promoting intersetorial partnerships and intensifying the communication between CAPS, the mental health network and the health general network, contemplating the intra- and intersetorial dimensions⁽⁷⁾.

The 4th CNSMI confirmed the relevance of safeguarding the principles of integrality, accessibility, intersetoriality and respect for cultural identity, as well as the right to an universal access to mental health care⁽⁷⁾. In this context, the discussion about people with mental disorders also living with the Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) was inserted into the Conference, as well as the situation of other mental health care service users at an especially vulnerable stage. The Brazilian Psychiatric Reform barely mentions this topic, despite its ethical and contemporary relevance. Therefore, the aim of this study was established as: analysing the vulnerability of people with mental disorders who have been diagnosed with Acquired Immunodeficiency Syndrome.

In regards to this little-explored topic, this study demonstrates the relevance of subsidizing the assistance of individuals with mental disorders. Adding to that, an understanding of the terminology of vulnerability, which overcomes the classical idea of risk, is presented as a view that enables transformations in health care practice because, at its core, it makes it urgent to rethink health care within its social and historical spectrums. This rethinking demands the society work from within its different spheres and permit transdisciplinarity as an imperative phenomenon. This idea of vulnerability justifies the importance of this study, as it can be organised by the elements that trigger it, such as the previously-lived experiences of the clients and the unpreparedness of mental health professionals while working⁽⁷⁾.

Based on what was demonstrated here, this study aimed to identify, through an integrative review, the Brazilian and international journals that dealt with the vulnerability of individuals with mental disorders and HIV/AIDS who are supported by the services provided specifically in terms of mental health care.

METHOD

We used the Literature Integrative Review (RIL, in Portuguese), as this method enables decision-making and an evaluation of the quality of clinical practice, considering the synthesis of the results of several studies on a specific topic in a systematized and orderly way, thus contributing to a further deepening of the understanding of the investigated topic⁽⁸⁾. The following steps, demonstrated in Image 1, were developed for use in this study.

The first stage was based on choosing the guiding question: Which are the relevant registers in scientific journals about the vulnerability of patients with mental disorders who have been diagnosed with HIV/AIDS? The second stage was a search in two electronic databases: the National Library of Medicine (Medline) and the Latin-American Literature of Health Sciences (Lilacs, in Portuguese), during the period from January to February 2012. We used the search words and expressions “AIDS in patients with mental disorders”; “HIV in mental health”; and “HIV in psychiatry” as it was observed that there are no standardized terminologies in the workbook Descriptors in Health Sciences (DeCS, in Portuguese) that matched the aims of this study.

During the third stage, studies were selected according to the following inclusion criteria: that they were published between the period 1995 and 2011; written in Portuguese, English or Spanish; and that abstracts and full texts existed and were available online on the above-mentioned databases. The criteria of exclusion were: articles whose descriptions did not fit into the goals of this study. Fifteen studies were identified and six were selected. The fourth stage focused on methodological accuracy through the elaboration of a form composed by the variables related to the identification of each article⁽⁹⁾: title; name of the journal; year of research and publication; place of study development; keywords; identification of the authors (title and affiliation) and; identification of the research (subjects, method, aims, synthesis of the results, conclusions).

During the fifth stage, a critical analysis of the selected studies was performed⁽⁸⁾, comparing the theoretical knowledge, the identification of conclusions and the resulting implications from the integrative review, allowing the identification of the situations that permit infection by HIV/AIDS among patients with mental disorders, including a possible vulnerability in this group.

In the selected studies, the following level of evidence was established, as described here: level 1 – evidences resulting from a meta-analysis of multiple controlled and randomized studies; level 2 – evidences from individual studies with experimental design; level 3 – evidences from quasi-experimental studies, temporal series or control-cases; level 4 – evidences from descriptive studies (non-experimental or qualitative approach); level 5 – evidences from case or experience reports; level 6 – evidences based on the opinion of committees of specialists, including the interpretation of information not based on research or regulative or legal opinions⁽⁹⁾.

Finally, at the sixth stage, we proceeded with the review/synthesis of the knowledge produced, in which we included the information that enabled us to evaluate the relevance of the proceedings used in the elaboration of the review and the attribution of the evidence level (from 1 to 6) for the article analyzed, considering the method of research used. During this stage, the data were submitted to an analysis of the content, generating two thematic categories; a profile of scientific production on the topic and the results regarding the vulnerability of clients diagnosed with mental disorders to infection with HIV/AIDS.

RESULTS

Profile of the scientific production on the topic
An analysis of Chart 1 (below) shows that, of the six selected articles, two were published in foreign journals and written in English^(10-11) and four in Brazilian journals^{(12-13-14-15)}. All research used the quantitative and descriptive methods, of which three were multicentered^(12-13-15). (See Chart 1).

Analyzing the temporal cut, we observed that the international journals are less recent, as the last update was in 2005, while Brazilian journals started to publish about this topic in 2007.

These studies started as research performed in different assistential scenarios. The international studies were performed in three hospitals and one psychiatric clinic in Chicago, USA^(10-11). In Brazil, the study published in a nursing journal used two clinics and two psychiatric hospitals distributted in two Brazilian states, Minas Gerais and Rio de Janeiro, as a research environment⁽¹²⁾. The articles published in medical journals present, as their study scenarios, eleven psychiatric hospitals and fifteen psychosocial care centers in many different parts of Brazil^(13-14-15). In one of the studies⁽¹³⁾, different health institutions were chosen randomly throughout Brazilian territory. Only one study⁽¹⁴⁾ did not have a scenario as it was a literature review study.

The descriptors used to characterize the studies included 30 terms, of which the most-often mentioned were: sexually transmitted diseases, psychiatry, mental disorder and AIDS. The majority of the authors came from the medical field (see Chart 1, above).

In regards to the methodology, one of the foreign studies⁽¹⁰⁾ used a group of teenagers with mental disabilities and, as an instrument of data collection, a psychological test known as information–motivation–behavioral (IMB), which aimed to check the information and/or understandings that the teenagers may have had concerding the transmission of and preventive methods pertaining to HIV/AIDS.

Synthesis and evidence of the selected articles
From Chart 2 (below), it is possible to check how the researchers analysed the data found regarding the topic, in terms of attitudes, beliefs and behaviorial abilities, in order to identify through the discourse of a group of patients with mental disorders the situations that make them vulnerable, with the objective of classifying these patients as youngsters with high-risk sexual behavior. As a continuation, the following chart was produced, classifying the level of evidence according to the order mentioned above in the methods section⁽⁹⁾. (See Chart 2).

Another study⁽¹¹⁾ focused on youth, its transformations, and especially the situation of being an adolescent with a mental disorder and being a user of psychatric services. This group of studied younsters represented, according to the authors, a population with a high risk of exposure to the HIV virus, plus an aggravating factor: risky sexual behavior is poorly understood by these younsters, because of the changes in judgement caused by their psychopathology.

This same study⁽¹¹⁾ presented results regarding the risk factors linked to gender, especially within a family context, in order to have a complete picture of the mechanisms associated with HIV and risk behavior, which could be different for female and male youngsters. This study also tried to verify whether the parental relationships could place these youngsters in a situation of vulnerability because of parental permissiveness. Another objective of this same study was to check whether there was a higher vulnerability related to ethnicity, which could not be proved.

Of the studies performed in Brazil, three were multicentered^(12-13-15), among which one⁽¹³⁾ aimed to find evidence that could indicate which patients with mental disorders could have an elevated vulnerability to sexually transmitted diseases and another study tried to determine the prevalence of different sexually transmitted infections (STIs), such as HIV, hepatitis C and B and syphilis, among this clientele in Brazil.

Of the 2,475 patients interviewed, 2,238 had blood tests. The majority, 88.8%, had been sexually active throughout their lives, and 61.4% of them had had some sort of sexual contact in the past six months. The females attracted special attention as they represented 51.9% of the infected subjects, of whom 66.6% were single, with less than five years of education and a monthly average wage of below US$ 210.00. The study also showed that the use of preventative measures during life was low, only 8%. Regarding the use of preventative measures in the last six months, only 16% of the subjects had used them. The general seroprevalences were 1.12%, 0.80%, 1.64%, 14.7% and 2.63% for syphilis, HIV, HBsAg, anti-HBc and anti-HCV respectively⁽¹³⁾.

In the case of studies that considered geographical as pects, it is necessary to draw a parallel with national Brazilian data, which registered 492,581 cases of HIV/AIDS nofitied through the Information System of Diseases Notification (SINAN, in Portuguese), during the period from 1980 to June 2010. The methodology of linking databanks generated an increase of 37% in the cases notified via SINAN, resulting in 592,914 cases being identified during this period. This increase, when divided by the region, shows that the HIV/AIDS databank of SINAN lacks 54% of registries country-wide; regionally, this lack is North 47%; Northeast 35%; Southeast 33%; South 32% and Middle-West for the same period⁽¹⁶⁾.

Under this same analysis – by regions – it is demonstrated that 344,150 cases of HIV/AIDS were identified in the Southeast region (58% of the cases in Brazil), 115,598 of the cases were in the South (19.5%), 74,364 resulted from sexual intercourse, 73.8% of the cases in males and 94% in females in that year⁽¹⁶⁾.

The bibliographical study⁽¹⁴⁾ focused on subjects with chronical mental disorders in Brazil and abroad and tried to find evidence in the scientific literature that suggested an increased vulnerability amongst this clientele to the risk of infection by HIV, syphilis, and hepatitis B and C in chronic mental disorder patients in Brazil and abroad. However, the study revealed that a heightened prevalence of these infections among patients with chronic mental disorders is not yet established. It was observed that the majority of the studies on this topic were conducted in developed countries, with samples that were relatively narrow, thus they do not universally represent the clientele.

As a whole, the prevalence of HIV, hepatitis B, hepatitis C and syphilis varied from 0% to 29%, 3% to 66%, 0.4% to 38% and 3.3 to 7.6% respectively. Many risk factors were identified and discussed, however, in today’s literature, according to the authors, no meaningful findings were produced by the representative studies. Such a review highlighted the lack of informtion about the prevalence of sexually transmitted infections and their associated factors among patients with chronic mental diseases and allowed the identification of blanks regarding the production of understanding about the topic in developed, as well as developing countries⁽¹⁴⁾.

In the studies found above, one article⁽¹³⁾ is to be emphasised, as it aimed to evaluate the indicators of structure and the process of the observation of STDs/AIDS in care services and the users of mental health care services .As a method, it used a study with a multicentered transversal cut through a meaningful, nationwide sample. In this study, the users and professionals of mental health care services were listened to. Eleven psychiatric hospitals and fifteen centres of psychosocial care from many parts of the country were chosen randomly. A questionnaire was used to evaluate the mental health care services through a local research supervisor. The focus of the instrument was to descriptively evaluate the selected indicators of the structure and the assistential process of mental health.

The results showed, through an in loco evaluation, that in both assistential devices, there were prevailling difficulties for health professionals in dealing with providing clinical care for patients infected by the illnesses focused on in the study. Only 19.2% of the services considered that the reference and counterreference systems were completely structured, demonstrating a poor interconnection between the mental health care service and managers. Furthermore, a fragility in human and material resources was observed in CAPS, as well as a lack in the availability and resources for the disposal of medication used in clinical emergency situations. According to the researchers, there were some rare service situations that had programs of sexual orientation or the distribution of preventatives, besides which they knew of the existance of patients infected by the HIV virus⁽¹³⁾.

The only article found in a Brazilian nursing journal⁽¹²⁾ dealt the question of sexual health promotion among women with severe and persistant mental disorders, including those with a diagnosis of chronicity in psychiatry. The authors called attention to the highly elevated rates of STIs among this population in the country. The “sexual routines” lived by these women were analysed, with an aim to understand the influence of sexual culture on the women’s ways of thinking and living sexuality, as well as the reflexes in terms of vulnerability to sexually transmitted diseases of these subjects in psychic suffering. The method of data collection used was a deep interview, in a sample of 17 women. The data went through a narrative analysis structure, from which it was possible to better understand the experience of the sexuality of these patients, through which it was observed that the situations of vulnerability came mainly from the roles historically related to the female gender.

In respect of the diagnoses, it was found  patients with schizophrenia, bipolar disorder, delirious disorder, depression, organic disorders that included intoxication, dementia and mental retardation. It is important to mention that the authors of this study only cited the clinical diagnoses and did not aim to correlate infection with HIV to those above-mentioned psychiatric disorders, considering that, independently from the specificity of the disorder, all were vulnerable to sexually transmitted diseases and need caring information in order to be guided in their sexual health. We highlight that none of the patients reported  having received any information regarding STDs and HIV/AIDS from mental health care services. The reports of the clientele are an illustration of the vicious cycle of vulnerabilities formed by poverty, abandonment, sexual violence, prostitution and the use of illicit drugs⁽¹²⁾.

Two studies, which collected data according to geographical distribution, were produced by medical doctors^(13-15) in and studied many parts of  Brazil. The study performed by nurses⁽¹²⁾ collcted data in two states of Brazil. In comparison with the data available at the Brazilian Ministry of Health, it is possible from these studies to observe the distribution of HIV/AIDS cases according to region. In 2009, 38.2% of the cases were in the Southeast, followed by the Northeast (21.9%), South (21.1%), North (11.1%) and Middle-West (7.7%). Despite the fact that the Southeast region presents the majority of the cases, the South region was the one that presented the highest detection rate during that period, with 12.6% infected for every 100,000 inhabitants. The highest proportion of cases of AIDS among youngsters were found in those between the ages of 13 and 24, in both sexes⁽¹⁶⁾.

DISCUSSION

The Brazilian Ministry of Health presented, in the year 2010, the following rates of HIV infection in Brazil: 0.6% of the population between 15 and 49 (0.4% in women and 0.8% in men); 0.12% of male youngsters between the ages of 17 and 20; and 0.28% of young women between the ages of 15 and 24⁽¹⁶⁾. It is worth mentioning that, according to the Brazilian Ministry of Health, in the country the number of deaths of youngsters infected with HIV between the years of 1998 and 2009 was 7,443, 58% of whom were males and 42% females. In the last ten years, the country has registered an average rate of 589 deaths per year among youngsters, representing a reduction of 31.6% in the death coefficient of 1999 (1.9 deaths per 100,000 inhabitants) to 2009 (1.4/100,000 inhabitants)⁽¹⁶⁾.

These data match the publications produced in the United States of America^(10-11), in which patients with mental disorders fit into the population group most vulnerable to infection by HIV. According to the journals^(10-11), those findings can be justified by the influence of parents/guardians on the sexual behavior of teenagers with a mental disorder. Among them, the male young patients have a higher level of permission for sexual activity and the multiplicity of their partners ended up placing them in a more vulnerable position.

The situation is different regarding female teenagers with mental disorders, who often have their sexuality controlled by their parents. However, the research^(10-11) demonstrated a curious trait: female adolescents are less inclined to use preventative measures because their families find it difficult to dialogue about sexuality as a whole, and when they are having sexual relationships, they usually prefer men older than themselves, who are usually against the use of preventative measures, justified by the old cultural wisdom that women must be unilaterally loyal⁽¹⁰⁾.

These findings can be linked to a reduction in critical thinking skills generated by the psychopathology that the adolescents have. To judge is to produce a judgement, and is essentially a human ability by nature, from which it is possible to establish a relationship between the world and the person and enable a distinguishing of truth from error, ensuring the existance or not of a noticeable object. It thereby becomes possible to evaluate situations, a process called ‘value judgement’. Every judgement implies a subjective, individual part, and a social, historically-built part, both working in consonance with sociocultural determinants⁽¹⁷⁾.

Yet, in regards to the discussion of gender, the study developed by nursing professionals focused on 17 women with mental disorders who were infected with the HIV virus, with ages varying from 18 to 68 years old. The highest number of participants were between 31 and 40 years old. These women presented lifestyle components that placed them in a higher vulnerability bracket, such as low education and low income; many of them were in a situation of extreme poverty.

Linked to these factors were the cases of domestic physical violence, especially from partners, who had extramarital relationships and neglected any participation in family care. The obligation to have sexual intercourse with their partners, combined with the lack of stimulus, was justified by the fact that the partners were financially responsible for the whole family, besides the fear of new aggressive episodes. It is worth mentioning that the extramarital relationships of the partners were responsible for the STD. Facing chaotic routines, these women claimed they used alcohol and illicit drugs as a strategy to alleviate anxiety, sadness and the blemishes of life⁽¹²⁾.

Besides the incidence of unsatisfactory marital sexual relationships, these women maintained their relationships and sexual practices for many years. Such a fact could be associated with the cultural belief that the female spouse is required to tolerate and fulfill the sexual desires of the partner⁽¹²⁾.

Vulnerability, observed in another selected study⁽¹⁵⁾, was revealed as being linked to the aggravated situation in which this population group was living. The findings from this study show that it is necessary to consider the sociocultural aspects of actions that involve the promotion of sexual health and the prevention of sexually transmitted diseases for this population, which are considered to be contributions to certifying the principle of integrality and the right of all to qualified assistance, based on the Brazilian Federal Constitution and funded by the Brazilian Unified Health System.

In the bibliographical study⁽¹⁴⁾, after the analysis of academic production, it was verfied that in Brazil, as was affirmed previously, the impact of the AIDS epidemic is as yet little known among the mental health clientele, especially among chronic patients. However, in the last few years, mental health services are being filled with a higher number of HIV-contaminated people, either at CAPS or being hospitalised in regular hospitals⁽¹⁴⁾.

It is necessary to have a differentiated view of people who are diagnosed with psychiatric disorders, especially those called chronic psychiatric patients, who demand more complex care due to the peculiarities presented by these subjects. The psychosocial rehabilitation of chronic patients hospitalised for many years goes through interventions that involve many social actors, as well as the reconstruction of territories, encompassing the singularities and the subjectivities of the world to be lived in outside of the hospital environment. Chronic patients have always represented an enormous challenge to all assistential proposals in mental health⁽¹⁸⁾.

Some particular situations of people with serious mental disease can favour an elevation of the risk of exposure to HIV, contributing to the development of risk behavior, such as: difficulty in setting stable relationships; finding themselves at a social and economical disadvantage; being a victm of sexual abuse; coping with damaged critical judgement, especially during psychotic episodes; hypersexuality; impulsivity; and low self-esteem⁽¹⁹⁾. 

These factors, added to hospitalisations during moments of crisis, can lead the users of mental health care services to be even more vulnerable to HIV/AIDS. Rehospitalisations can lead to a possible destruction of the social and affective bonds, making the users more exposed to unknown partners. Some risk situations are not exclusive to people with serious mental problems, but can be lived more frequently by them. Sexual practice with unknown partners, for example, reduces the probability of a person knowing the HIV/AIDS status of their partners⁽¹⁹⁾.

CONCLUSION

Based on the results found, we highlight the necessity of new studies about the vulnerability of people with mental disorders to HIV/AIDS, as this topic has as yet been little explored, either in Brazil or in the world. It was observed from the analysis of the studies, that there is a lack of meaningful actions from mental health teams in order to guide clients and prevent STDs.

HIV infection is recognized as a challenge to science; at the same time it becomes a social tragedy for the people and families infected. It is concluded that, in the specific case of people in a state of psychiatric suffering, the alterations to their critical judgement place them in a situation of higher vulnerability compared with subjects in a perfect mental condition.

Historically, the subjects coping with psychiatric suffering have always been placed in a situation of disadvantage, that is to say, social, family and especially assistential disadvantages. Additional to this is the vulnerability caused by a lack of stable relationships, non-consensual sexual practices, sexual violence and low-value goods in exchange for sex.

To elaborate an assistential proposal for this clientele is a complex task, especially because of the characteristics acquired by these subjects throughout the psychiatric illness process, including a reduction in the ability to make judgements, institutionalization - for some patients - the loss of social and family bonds and advanced age that contribute to the complexity of this object of study.

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Received: 03/04/2012
Approved: 29/10/2012

Note: This study was presented at the 6th Brazilian National Symposium “Care in Health and Nursing” (EnfCuidar, in Portuguese) and won the Online Brazilian Journal of Nursing Prize. EnfCuidar is promoted by the nursing schools of the public Universities in Rio de Janeiro and it was held on April 12th to 14th 2012 at the Nursing School of Rio de Janeiro State University (UERJ, in Portuguese).