In recent years, remarkable achievements in HIV testing and antiretroviral therapies have improved the detection, management, and care of persons living with HIV (PLWH). In the 1980s and 90s, patients with HIV infection faced a devastating prognosis. But now, with proper medications and support, PLWH can enjoy long and fulfilling lives. Thus, when the topic of suicide among PLWH is raised, many physicians are surprised. They often ask me, “wasn’t suicide an issue of a time before we had access to antiretroviral therapies?”

Lily A. Brown, PhD is an LDI Senior Fellow, Assistant Professor of Psychology in the Department of Psychiatry, and Director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania.

In our recent study in AIDS Care, my colleagues and I found that suicidal thoughts and attempts remain a pressing concern among PLWH, who are significantly more likely to die by suicide compared to the general population. Given that HIV infection can be well-managed with proper care, what accounts for the elevated risk for suicide among PLWH?

In our study, we used the medical records of over 2,000 PLWH to isolate the clinical and demographic factors associated with suicidal thoughts and behaviors. We hypothesized that individuals with a diagnosis of posttraumatic stress disorder (PTSD)—a psychiatric condition that can emerge after exposure to a traumatic event—and substance use disorders would be at especially elevated risk for suicidal thoughts and behaviors. This hypothesis was based on prior research which revealed important interactions between Substance Abuse, Violence, and AIDS, coined the “SAVA Syndemic,” wherein substance abuse and exposure to violence are thought to interact to predict worsened health outcomes among PLWH.

We found that PTSD and a variety of substance use disorders, including alcohol, cocaine, and opioid use disorders, were associated with increased risk for suicidal thoughts or behaviors among PLWH, as were diagnoses of depression and insomnia. Contrary to our predictions, we did not find an interaction between PTSD and substance use on the likelihood of suicidal thoughts or behaviors. 

These findings have important implications for the care of PLWH. To reduce suicide risk in this population, care teams must closely monitor patients for symptoms of PTSD, substance use, insomnia, and major depressive disorder. As we demonstrated in our previous research, psychiatric diagnoses tend to be under-documented among PLWH. To connect PLWH to appropriate mental health care, the first step is to conduct thorough assessment for psychiatric comorbidities (or co-occurring conditions). Fortunately, evidence-based treatments can reduce symptoms of these disorders, which may also reduce suicide risk. As health care providers increase their assessment of psychiatric comorbidities, patients will be more likely to receive appropriate referrals for evidence-based treatments.

More research is needed so that PLWH who are considering suicide can see that their lives are worth living. Now that antiretroviral therapies can promote long-term physical health for PWLH, it’s time to attend to the emotional needs of PLWH as well.

The study, Suicide risk among persons living with HIV, was published online in AIDS Care on August 3, 2020. Authors include Lily A. Brown, Ifrah Majeed, Wenting Mu, Jesse McCann, Stephen Durborow, Song Chen, and Michael B. Blank.