new AIDS cases, as do racial and ethnic minorities (CDC, 2002). Minorities have higher prevalence of mental illness by virtue of lower SES, as explained above. Thus, because of shared demographic risk factors, the prevalence of MI-HIV comorbidity may climb. Put another way, HIV is rising in the same disadvantaged groups in which MI is concentrated.

Mental Illness and HIV Acquisition or Transmission

People with MI are considered at increased risk of acquiring or transmitting HIV for two reasons: (1) greater likelihood of high-risk sexual behavior or substance abuse and (2) poor adherence with the complex requirements of combination antiretroviral therapy (ARV), which can lead to the emergence and potential transmission of drug-resistant HIV (Cournos and McKinnon, 1997; Johnson, 1997; Carey et al., 1997; Sullivan et al., 1999). Underlying these concerns are the behavioral and cognitive manifestations of the disorders themselves—such as impaired decision making and perception of risks, low motivation, impulsivity, and vulnerability to sexual victimization.

This section summarizes recent studies that empirically examine whether MI can increase the transmission of HIV. The studies give a more nuanced and complex portrait of the problem, suggesting variation in risk depending on the psychiatric diagnosis or nature of symptoms. The findings have important implications for prevention and control of HIV. On the one hand, they suggest that targeted interventions are needed to help people with mental illness reduce risky behavior and improve adherence. On the other hand, they raise the possibility of discrimination against people with mental illness, not on the basis of their ability to adhere to treatment, but on the basis of their membership in a categorical group. There is some evidence that people with MI face discrimination in the form of physicians’ withholding treatment for people with MI-HIV, as this section explains.

HIV Risk-Related Behavior

It has long been hypothesized that people with MI are more likely to engage in high-risk sexual behavior or injection drug use—behaviors that heighten the risk of acquiring or transmitting HIV. But research, when available, has given a mixed picture that varies by diagnosis, level or severity of symptoms, and age. The evidence reveals that serious mental illness—but not depression and anxiety—is associated with risky behavior, and that youth also increases risk. Depression and anxiety are the most common mental disorders among those in HIV care, as noted earlier.

A recent meta-analysis of 34 studies investigated the impact of depression or anxiety on high-risk sexual behaviors, defined as having multiple



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