Psychosocial Profile of HIV Patients on HAART in Southern India

Background: Mortality of HIV/AIDS patients comes down in India after the National Aids Control Organization started providing free Antiretroviral Therapy (ART) since 2004. Madurai ART Center started providing free ART since 2004. Psychosocial profile of this population explored in this study. Methods: A cross sectional interview conducted during the year 2008 with semi structured questionnaire on HIV positive clients who are on Highly Active Anti-Retroviral Therapy (HAART) for more than 6 months. Convenience sampling done and totally 433 clients were interviewed with informed consent. Results: Three fourth (73.4%) of the clients know about ART centre through Government Hospitals or Primary Health Centre. Most of the Clients (98.6%) on ART feel back to normal life or back to near normal life. Pill burden/Pill fatigue perceived by clients is 4.8%. Discrimination perceived was 8.8% and mostly in their own house or by neighbors, but most of their children (99.2%) were not discriminated as per the clients. Spouse positive rate for the married clients was 61.5% and unmarried in this population was 4.6%. Major or minor psychological problems in this group were 39.7% and attempted suicide was 8.8%. Drug abuse (alcohol and smoking) while started on ART was 40.4% and the current abusers are 7.6%. Conclusion: This study supports effectiveness of free ART program and effective case referral from government institutions. High percentage of major or minor psychological problem warrants further exploratory study and may need psychological interventions in this population.


Background
In India since 2004 with the availability of free HAART in government program [1] through National AIDS Control Organization (NACO), people living with HIV/AIDS keep on increasing.In south India, Madurai ART centre which is having around 2500 clients on ART and regular follow-up, out of these 433 clients on ART are interviewed to find out their demographics, psychological disturbances, and adherence to HAART, etc during the year 2008.

Methodology
With convenience sampling a cross sectional survey was conducted with semi structured questionnaires on HIV/AIDS patients who are all on ART more than 6 months.Clients interviewed are more than 21 years of age.Questionnaire administered includes questions regarding psychological, social, personal and family issues of the clients.Participants should not have any major clinical illness which might discomfort during the interview and their quality of life.

Results
Among the interviewed clients (51.3% males, 48.7% females) 95.8% of them are in 21 to 50 years of age group.Positive clients from rural population is 44.8% and urban/semi urban population is 55.2%.
Totally 75.8% of the clients were education wise illiterate or with in primary school.58.4% of the clients are daily wage laborers (Cooley's) and 19.6% of the clients are unemployed.58.4% of the clients are living with their spouses and 33.7% of them are separated or widowed.Unmarried and divorced are 4.6% & 3.2% respectively.Most (94.7%) of them are getting their economical support by their own, spouses or by their relatives.
Spouses of these clients 61.5% of them are positive.In the positive spouses 35.4% of male spouses and 64.6% of the female spouses are positive.In spouse negative clients 83% of male spouses are negative and 17% of the female spouses are negative (Figure 1).
In the study population 73.4% of the clients were known about ART centre through Government Hospitals (GH) or Primary Health Centre (PHC), 14% through Non Governmental Organization (NGO) and 11% by their own (Figure 2).This shows how they registered into ART program..Among the clients 15.9% of them are traveling more than 100 kilometers to collect their monthly drugs.22.2% of the clients were missed some doses of drug during their regular follow up period, among the total clients 4.6% of them were missed more than 3 days (Figure 3).
As per their own perception 8.8% of these clients were discriminated mainly in their own house or by neighbors (Figure 4).But the children of these positive clients were rarely (0.8%) discriminated.
Major (Suicidal thought) or minor psychological (Sleep disturbances, sad mood, lack of concentration in their work) problems were seen in 39.7% of the clients (Figure 5).
Pill burden/Pill fatigue perceived in this population is 4.8%.Drug abusers (smoking, alcohol, sleeping pills) in this population were 40.4% and the current abusers are 7.6%.In this population 8.8% of them were having the history of attempted suicide.Clients having children were 86%, among them 7.8% of the clients are having positive children and 30.4% of them were not yet tested.Among these clients having children 40% worried about future of their children and 36.6% of them want to send their children to some care takers.99.2% of their children were not discriminated as per the clients.Qualitatively, 98.6% of clients on ART are perceived that they are "back to normal life" or "back to near normal life" (Figure 6).

Discussion
The active, productive and reproductive age group (21 to 50 years) is the majority on HAART, which is the target group (15 to 49) in prevention strategies [2].Transmission of HIV in this population is mainly through males, which can be substantiated by male dominated society [3].High rate widowed/separated population urges to promote remarriage and supporting strategies [4].Around 16% of the clients were traveling more than 100 kms to collect their drugs which may be due to lack of ART centers nearby or avoidance of nearby ART centers due to self stigma [5].Three fourth of the clients were illiterate    or less than primary schooling.Three fourth of the clients know about ART centre through the government healthcare system which proves the impact of HIV related government programs.Clients who missed their doses need to be addressed to prevent the emergence of resistance and treatment failure [6][7][8][9][10][11][12].One third of the study population is widowed or separated which might have an impact in treatment and prevention strategies due to lack of socio-economic support to them [13].Sleep disturbances noted in this population is high compared to other psychological problems.Psychological problems, Pill burden/pill fatigue and missed doses in this population which may affect immunity and adherence needs focused counseling which includes coping strategies on these issues [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28].

Conclusion
This study supports effectiveness of free ART program and effective case referral from government institutions through Integrated Counseling and Testing Centers (ICTC).High percentage of major or minor psychological problem warrants further exploratory study and may need psychological interventions including targeted counseling in this population.

Figure 1 .Figure 2 .
Figure 1.HIV status of the spouses, as per the interviewed clients.

Figure 3 .Figure 4 .
Figure 3. Missed doses of ART drugs as per the clients and records.

Figure 5 .
Figure 5. Psychological problems perceived by the clients.