Psychology
2012. Vol.3, No.12, 1005-1009
Published Online December 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.312151
Mental Health of Caribbean Women with HIV/AIDS
Donna S. Baird1, Lisa D. Jones1, Fayetta Martin2, Edilma Yearwood3
1Global Center for Behavi o ural Health, Washington DC, USA
2School of Social Work W ay ne State University, Detr o i t, USA
3School of Nursing and H ea l t h S tu d i es G eo rgetown University, Washington DC, USA
Received September 21st, 2012; revised October 15th, 2012; accepted No v e mber 14th, 2012
Caribbean women have the highest HIV-infection rates in the Americas, yet the mental health and
well-being of infected women and adolescent girls in the region has been neglected. Unlike this study
many studies have that examined the mental health of women and adolescent girls affected by HIV/AIDS
have primarily been conducted outside of the Caribbean. Further, gender inequality, stigma and poverty,
and their subsequent behavioral manifestations are noted “structural drivers” of this pandemic across the
Caribbean region. This paper focuses on Caribbean women and girls as a culturally vulnerable group, as
well as addressing possible pre-existing psychiatric or psychological factors that may contribute to un-
successful prevention of HIV/AIDS and poor disease management in this population.
Keywords: HIV/AIDS; Women; Mental Health; Caribbean; Psychology; Psychiatry
Introduction
Caribbean women have the highest HIV-infection rates
among women in the Americas. The percentage of reported
HIV cases among women in the Caribbean has recently ex-
ceeded 50% but only in a small minority of relatively large
Caribbean countries. (The Department For International De-
velopment [DFID], World Health Organization/Pan American
Health Organization [WHO/PAHO], The Global Fund to Fight
AIDS, Tuberculosis and Malaria [GFATM], The Joint United
Nations Programme on HIV/AIDS [UNAIDS] Secretariat and
the World Bank, 2005), yet the mental health and well-being of
infected women and adolescent girls in the region has been
neglected.
It has been well documented that the Caribbean ranks second
only to sub-Saharan Africa in worldwide HIV/AIDS prevalence
rates (Figueroa, 2004; Gupta, 2002; Kaiser Family Founda tion,
2006). Studies that examine the mental health of women and
adolescent girls affected by HIV/AIDS have primarily been
conducted outside of the Caribbean. Gender inequality, stigma
and poverty, and their subsequent behavioral manifestations are
noted “structural drivers” of this pandemic across the Caribbean
region (Kaiser Family Foundation, 2006; Piot, 2006). Individu-
ally, these factors have profound mental-health ramifications,
but, collectively, they serve as barriers to effective interventions.
Consequently, clinicians and program planners must recognize
that HIV/AIDS can severely impact an individual’s health and
mental-health status (UNAIDS, 2008) and that psychiatric dis-
orders and symptoms are very common among at-risk and
HIV-infected individuals (Harris, 1995; Atkinson et al., 2008).
The Joint United Nations Program on HIV/AIDS (Dube,
Benton, Cruess, & Evans, 2005) estimates that approximately
40 million people worldwide are living with HIV. Ninety per-
cent of these individuals live in developing countries where
social, economic and/or political instability exists (UNAIDS,
2006). In the Caribbean, women account for roughly 50% of
the people living with HIV/AIDS in the region (Gupta, 2002;
Dube et al., 2005; PAHO, 2001). In some Caribbean countries,
six times as many HIV cases are reported among adolescent
females age 15 - 19 as among males of the same age group
(Neely-Smith, 2003; Inciardi, Syvertsen, & Surratt, 2005). The
prevalence of HIV/AIDS in the region is further shown by
AIDS-related deaths. In 2005, there were approximately 27,000
AIDS-related deaths among 15 - 44 year-olds. AIDS is now the
leading cause of death for this age group (Dube et al., 2005) .
In 2000, WHO specifically identified women’s mental health
as a serious public health concern (Voisin, Baptiste, Martinez,
& Henderson, 2006). The following year, the United States (US)
Surgeon General spearheaded the development of the document
Mental health: Culture, race and ethnicity which posited that
mental health was, “important for personal well-being, family,
interpersonal relationships, and for successful contributions to
community or society” (WHO, 2000: pp. 5-6). The document
further noted that, “While these elements of mental health may
be identifiable, mental health itself is not easy to define, and
any definition is rooted in value judgment that may vary across
individuals and cultures” (WHO, 2000: p. 6).
This paper will focus on Caribbean women and girls as a
culturally vulnerable group, as well as address possible pre-
existing psychiatric or psychological factors that may contrib-
ute to unsuccessful prevention of HIV/AIDS and poor disease
management in this population. We postulate that a woman in
declining physical health due to the sequela of HIV/AIDS in-
fection will also experience a decline in her mental health. As
more women of childbearing age become infected, HIV/AIDS
increasingly becomes a disease that involves the entire family.
When confronted with the knowledge of the individual’s illness,
sexual risk-taking behaviors or lifestyle, family members can
become confused, sad, angry or rejecting (DHHS, 2001; Roldan,
2003).
The correlation of psychiatric disorders or mental illness
symptoms with and susceptibility to sexual risk behaviors and
treatment adherence has been the focus of several studies
(Rutledge & Abell, 2005; Clay, 2000; Cook et al., 2002).

D. S. BAIRD ET AL.
However, questions exist about the relationship between psy-
chiatric disorders and HIV/AIDS deterioration and how best to
intervene during critical stages of HIV/AIDS disease progres-
sion (acquisition, understanding and management) in the pres-
ence of co-occurring psychiatric disorders and symptoms.
Moreover, to what extent are these factors understood when
placed within a context of culture- and gender-specific needs?
We conducted a literature search of MEDLINE, CINAHL and
PUBMED (National Li brary of Medici ne database) using th ese
key words: HIV/AIDS, women, mental health and the Carib-
bean region from 1995-2007. We found few studies that spe-
cifically address the HIV/AIDS crisis from a mental-health
perspective among women in the anglophone Caribbean. It is
unclear whether studies exist, but have not been published, or
whether research has not been conducted with this focus.
HIV/AIDS and Mental Illness
Pre-existing psychological and psychiatric disorders can be-
come aggravated with a diagnosis of HIV, or may develop dur-
ing the course of living with HIV/AIDS (Mellins, Kang, Leu,
Havens, & Chesney, 2003). The most common are mood dis-
orders, such as depression, dysthymia, mania and, anxiety dis-
orders, such as generalized anxiety, panic and post-traumatic
stress (Mellins et al., 2003; Golub et al., 2003; Cook et al.,
2004; Hamer, 2000; Sikkema, 2003). HIV/AIDS disease pro-
gression can impact neurological and neurocognitive status.
Cognitive slowing may be a result of the disease process or
may be secondary to depression. Another consequence may be
HIV-associated dementia, with accompanying characteristics of
irritability, aggression or psychosis (Atkinson, 2008).
Morrison et al. (Zambrana, 2004) conducted a study in the
southeastern part of the US with a sample of 93 HIV-infected
women and 62 non-infected women, comparing the rates of
depression and anxiety in both groups. Findings revealed a rate
of depression that was four times higher in the HIV-infected
women. Cook et al. (2002) assessed 1716 women over a 7-year
period and found that chronic, untreated depression was sig-
nificantly associated with AIDS-related mortality. When the
same women received therapy and pharmacologic intervention,
their depression declined, treatment adherence improved, and
the women achieved greater longevity. Dube and colleagues
(2005) emphasized the need to treat existing psychiatric symp-
toms when diagnosed, in order to facilitate adherence to
HIV/AIDS disease management regimens.
Mellins et al. (2003) studied 97 mothers living with HIV in a
large city in the US and found that half met the criteria for a
psychiatric disorder, and 25% were positive for a substance-
abuse disorder. Researchers further identified significant corre-
lations between mental health symptoms (e.g., depression, post
traumatic stress disorder [PTSD], and a nxiety), pare nting stress
and substance abuse with failure to take medication and missed
medical appointments. Furthermore, dual diagnoses of mental
illness and HIV correlated with increased anger, suicidal idea-
tion and untreated depression (Morrison, 2002).
Braithwaite & Thomas (Moser, 2001) surveyed 132 col-
lege-aged African-American and Caribbean women in the US
to determine measures on HIV/AIDS knowledge, attitudes,
sexual risk-taking behaviors, self-esteem, self-efficacy and
sexual communication. The authors identified cultural differ-
ences between the two groups. Although the Caribbean women,
on average, were slightly older than the African-American
women, they were less knowledgeable about HIV/AIDS, and
engaged in more high-risk sexual behaviors. The Caribbean
women also appeared to have higher levels of open sexual
communication with their partners, which contradicted cultural
data available from the region that indicated that Caribbean
women do not engage in open sexual communication with their
partners (Figueroa, 2004; PAHO, 2001; Braithwaite & Thomas,
2001).
Women, Tradition and HIV-Risk Factors
Risk factors for HIV and decreased mental-health function-
ing includes: gender inequality, being female, poverty and vio-
lence, burden associated with unequal responsibility for multi-
ple roles and violence (Voisin, 2006). These confounding social
issues increase the likelihood of psychological consequences
for women. A theoretical framework to understand these risk
factors can be found in Hale and Vasques (2011) in describing
violence against women with HIV, use concepts of structural,
cultural and direct violence. The concept of structural violence
was initiated by Johan Galtung and further developed by Paul
Farmer who was influenced by his experiences working with
people with HIV in Haiti in the Caribbean (Farmer, 1990;
Farmer, Nyeze et al., 2006). Class, race, gender, area of resi-
dence and processes such as globalisation can affect suscepti-
bility to HIV and mental health problems as well as experiences
following diagnosis including subsequent mental health (Hale
& Vasquez, 2011). Among these, in the Caribbean context it is
important to consider the highly dependent position of the Car-
ibbean in the world economy that has led to widespread poverty
and unemployment. This is based on a history of colonialism
and slavery that have left a long legacy of racial stratification
and insecurity in the region, the mental health consequences of
which are most clearly described by the French Caribbean psy-
chiatrist, Frantz Fanon, in “Black Skin, White Masks” (Fanon,
1967). It would be important to consider how these historical
dynamics have affected the vulnerability of women of African
descent of lower socio-economic status, both to HIV and to
mental health challenges before and after HIV infection.
Though not directly about mental health, one of the few Car-
ibbean studies among people with HIV shows that use of con-
doms at last sex was significantly associated with economic
security, a fact that points to the association of economic vul-
nerability and HIV and the need for economic empowerment to
prevent onward transmission (Allen, Simon et al., 2010). Nu-
merous, mostly qualitative studies in the region have pointed to
the importance of transactional sex with usually older, more
powerful men as a means for economic and social advancement
for women and girls whose prospects are otherwise very limited
(these are referenced in (Bombereau & Allen, 2008)). Some of
this transactional sex may be to do with low self-esteem associ-
ated with poverty and racial discrimination. Studies in the UK
and elsewhere have pointed out that the higher rates of psy-
chotic disorders among people of African descent may be asso-
ciated with their experiences of social marginalization (Shar-
pley, Hutchinson et al., 2001).
Another important aspect of mental health that is surprisingly
absent from the analyses is HIV-related stigma and discrimina-
tion. This may be understood as a form of cultural violence. In
the Caribbean context stigma and discrimination are often con-
nected to moral condemnation of sex work and homosexuality,
with some studies showing that attitudes to people living with
1006

D. S. BAIRD ET AL.
HIV are connected to perceptions of how people contracted the
disease. Mental health among women with HIV may be con-
nected to how they perceive themselves relative to these moral
judgments. Stigmatizing attitudes in the Caribbean have also
been shown to be related to fears of physical contact, and are at
high levels with regard to sharing food or drink. As women are
the principal providers of food and drink in the region they may
be the principal recipients of discrimination based on these
attitudes. The association of HIV with multiple partnerships
also brings strong moral judgments against women since these
challenges ideals of monogamy and chastity associated with
traditional feminine roles (Castro & Farmer, 2005; White &
Carr, 2005; Norman, Carr et al., 2006; Royes, 2007). Direct
violence against women is also associated with susceptibility to
HIV and experiences following diagnosis and this should be
factored into any discussion of mental health. Violence against
women and girls in the Caribbean in several forms (child abuse,
domestic violence, sexual coercion/rape) has been shown to be
associated with HIV risk factors in the Caribbean (e.g. lack of
condom use, multiple partnerships) (Allen & Odlum, 2011).
Violence against women with HIV has not been studied in the
region but is likely to be important given the other forms of
violence referred to above (Hale & Vasquez, 2011).
Mental Health Neglected
Recent data suggest that by 2010 approximately 176 million
people living with a mental disorder (e.g., depression or sub-
stance abuse disorders) will reside in the Americas, however
75% of these persons are not likely to receive any treatment
(Kohn, 2005).
Kohn et al. (2005), Kohn et al. (2004) and Hickling (2005)
reviewed studies published on mental illness in Latin America
and the Caribbean between 1980-2004 and concluded that there
were significant gaps between the number of individuals with
diagnosable psychiatric disorders and those receiving treatment.
Over the years, very little research had been conducted on the
most prevalent mental-health disorders such as anxiety and
depression and the frequently accompanying behaviors of sui-
cide attempts and completions.
Discussion
A HIV-positive result can trigger a range of emotions (denial,
fear, anger, grief, depression, hopelessness and acceptance). As
a result of these emotions, the individual might present as pre-
occupied; hopeless; ruminating about loss of significant others
because of the disease; delay in accessing treatment; not adher-
ing to treatment protocols; experiencing difficulty in managing
work and family routines; and ultimately becoming at risk for
poorer physical and mental health and overall quality of life
(Rutledge & Abell, 2003; Starace et al., 2002). Wilk and Bolton
(2002) in their qualitative interviews of individuals residing in
two Ugandan communities affected by the HIV/AIDS epidemic
investigated the perceptions of the epidemic’s mental-health
effects. Participants in that study described loss of hope, worry,
self-pity, social isolation, apathy, stigmatization, anger, grief
and suicidal ideation they experienced after learning their HIV
test results were positive.
A dual diagnosis of HIV/AIDS and mental illness poses
complex needs, as well as complex management issues. In or-
der to maximize adherence to both mental health and medical
regimens, these needs must be addressed, with attention to
gender-specific characteristics and desires and cultural varia-
tions. Managing both a psychiatric disorder and a potentially
life-threatening disease such as HIV/AIDS can overwhelm and
overburden an already vulnerable individual, and increase the
likelihood of ineffective management of both conditions.
While these behaviors may be common across all groups, the
concern is that, regarding the Caribbean region, these issues
have not been fully researched or addressed. Identifying com-
mon mental-health symptoms and potential disorders during
HIV screening can lead to timely linkages to appropriate ser-
vices for prevention, care and treatment. Ultimately, this may
help in the containment of the disease and reduce transmission
of the virus.
To gain a better understanding of the dynamics of mental
health and HIV/AIDS in the Caribbean region, it’s very impor-
tant to be familiar with the communities within the region.
Hutchinson et al. (Hutchinson, 2007) conducted an elicitation
study in Jamaica with adolescents to learn more about cultural
factors affecting their HIV-risk behaviors. These authors found
that cultural beliefs affect condom use, sense of control over
personal actions and also drive myths about transmission and
“cure”. They recommend that similar studies be conducted
throughout the region to expand knowledge about culture-spe-
cific influences.
Each island is unique and cultural views and practices vary
across communities. Many of the communities are quite small
and intact, and both mental illness and HIV/AIDS are seen as
deviant and stigmatizing. Subsequently, persons are resistant to
both HIV testing and mental-health treatment because they are
fearful that others will learn about their status. The perception
is that one will experience rejection, ridicule or be ostracized by
the community. Even if the individual moves beyond the fear of
stigma associated with a positive HIV status, there are stressors
around getting tested and waiting for results. Symptoms that
may be experienced by individuals who fear learning of their
HIV status include difficulty concentrating, excessive worry,
and insomnia, problems completing tasks, somatization, and
physiologic changes. All of these factors can interfere with
sound decision-making and impact mental and psychological
well-being. Neely-Smith (2003) described the psychological
strain experienced by HIV-positive Caribbean women to in-
clude anxiety, depression, anger, fear, isolation and overall
burden.
Conclusion
While current literature focuses on the changing picture of
HIV/AIDS globally, there remains a dearth of culture-specific
information about the mental health of infected women in the
Caribbean. Therefore, one recommendation from this review
would be that there is a need to engage in research looking at
HIV/AIDS and mental health specific to women in this region,
where the disease is taking a toll. It is imperative that research
conducted in the region be culturally relevant, participatory and
translated back to the population to reduce stigma, enhance
knowledge and support health-related needs.
Health care professionals need to be informed about the po-
tential pre-morbid presence of psychiatric symptoms or disor-
ders among those with HIV/AIDS and the potential adherence
implications that may exist with these co-morbid illnesses. It is
also important that health care professionals use standardized

D. S. BAIRD ET AL.
psychological assessments that are culturally relevant and sen-
sitive when working with this population.
To arrive at culturally sensitive intervention strategies that
hold some hope of efficacy, researchers must look at a variety
of issues including socio-cultural factors, self-concept, gender,
mental health status and sexual practices. Neely-Smith (2003)
reminded us that in the Bahamas, which has relatively progres-
sive health care and a good tracking system for sexually trans-
mitted infections, there has been fairly accurate documentation
of the continuous rise of HIV infection rates among women of
childbearing age. Neely-Smith further suggested that socio-
cultural oppression of women, stigma, concerns about confi-
dentiality, cost of medications and cultural beliefs (e.g., HIV/
AIDS is punishment from God) are some of the challenges that
must be considered when developing interventions for use with
Caribbean women.
Improved mental-health status has been positively correlated
with treatment adherence, sense of personal efficacy and better
decision-making. As it relates to Caribbean women, efforts
should be made to address those cultural beliefs and practices
that may serve as conduits for HIV risks and transmission.
Moreover, specific attention should be paid to conditions that
threaten the mental health of individuals as part of HIV/AIDS
prevention and treatment strategies in the region. To do other-
wise, is to ignore the obvious synergistic relationship that exists
between HIV/AIDS and mental health.
Health care providers working with this population should
also be aware of the needs of family members, because the
burden of HIV/AIDS infection usually extends to others in the
family network. More importantly, workers must remember
that a cultural norm among Caribbean women is providing care
to others, which can potentially jeopardize the health and timely
access to diagnosis and treatment for the woman herself.
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