Shock and disbelief may be followed by depression, anxiety, and fear in adjusting to having contracted a serious and still potentially deadly illness. In many nonindustrialized countries AIDS remains a rapidly terminal condition. Untreated depression and hopelessness may be associated with continuing risk behavior, even suicidal ideation (Liberman et al. 1986). Like serious mental illness, HIV and AIDS can be highly stigmatizing, possibly resulting in rejection, abandonment, and further social isolation.

If a worsening of psychiatric symptoms follows the initial HIV diagnosis, the most effective intervention is individual counseling and supportive therapy geared to both the current mental status of the patient and his or her knowledge and understanding of HIV infection (Broder et al. 1994). Legal regulations or guidelines for confidentiality and the disclosure of HIV- or AIDS-related information are in place in many countries and can set the stage for upholding humane and responsible individual and public health standards.

Contact notification by physicians may not be required, but legal statutes may allow doctors or public health officers to notify the contact themselves if they determine that a patient will not inform a contact who is at significant risk. Laws that are applicable to the locality should be consulted in making decisions that involve confidentiality and contact notification. Testing for HCV can occur at any point and does not require a special consent. Nonetheless, it remains important to explain the test result to patients found to be HCV positive and to refer such patients for further evaluation and, as appropriate, hepatitis A and B virus immunization. For HIV-infected psychiatric patients who are asymptomatic, supportive groups may encourage behavioral change and promote ways to preserve physical health in the community and within the psychiatric setting.

This kind of group intervention can prevent worsening of psychiatric symptoms and provide a sense of community that can decrease social isolation, reinforce safer peer norms, and encourage altruism, which appeals to ego strengths and gives patients a sense of worth and accomplishment. Although most outpatient agencies in New York City, an early epicenter, distribute HIV educational material, half or fewer of these service settings provide risk reduction interventions, conduct risk assessments, offer pre- and posttest counseling, or hold support groups for HIV-positive patients.

The reason for this may be unmet needs for training, reported by 84% of agencies that serve between 1 and 10 persons with HIV infection annually and have staff members already trained in providing at least one HIV-related service. Services may be directed at patients on the basis of their suspected or presumed risks rather than on the basis of a thorough risk assessment (McKinnon et al. 1999, 2001).

These findings are echoed in other United States regions (e.g., Brunette et al. 2000) and may suggest how to improve service delivery systems in other AIDS-endemic areas where resources allow for comprehensive care. Clinicians may be in the best position to help their patients access HIV testing, treatment, and prevention opportunities. They can employ many strategies to help their patients determine their risk of acquiring or transmitting the AIDS virus; to prevent new infections, to promote healthier behaviors; and to reduce the impact of HIV-related illness on this vulnerable population. They also are uniquely qualified to help their patients manage the many medications required to maintain their psychiatric and physical health.

Milton L. Wainberg, M.D.
Francine Cournos, M.D.
Karen McKinnon, M.A.
Alan Berkman, M.D.

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