The stress of coping with the illness is not confined to the person infected, but also encompasses those who care for him or her. The management of HIV infection carries both diagnostic and therapeutic implications that may not be directly related to HIV infection per se. It may be difficult to distinguish depression or anxiety from the AIDS dementia complex, because many symptoms overlap. The treatment is quite different—the dementia complex may respond to drugs that inhibit HIV replication, while depression and anxiety are more likely to respond to antidepressant and antianxiety medications—and so this distinction is clinically important. Since these conditions may also coexist, and the treatments themselves may affect CNS function, clinical management of both domains overlaps.

The bidirectional relationship between psychosocial factors and HIV infection can influence disease progression and the ability to effectively treat related symptoms. These phenomena primarily have been informed by two types of research: psychoneuroimmunology and psychosocial research on coping and caregiving.

PSYCHONEUROIMMUNOLOGY

The neurobiology of AIDS involves the possible influence of the nervous system on immune function and how both respond to HIV infection. In the context of HIV/AIDS, psychoneuroimmunology is the study of how mental states might modify immune defenses and even viral replication within the immune system. Depression and other mental states may have an impact on the immune system through the hypothalamic-pituitary-adrenal axis, the autonomic nervous system, and other pathways. Stress and other nervous system perturbations may alter immune function in both animal models and humans. The complex interactions among HIV infection, immune function, and mental state have been a major theme of AIDS-related research, particularly at NIMH. Although much has been learned about the effects of HIV on psychosocial factors, less is known about the effects of psychosocial factors on HIV. The few studies undertaken so far to examine this relationship show, variously, no effects of stressors (stressful life events) on illness progression (Kessler et al., 1991) and only an indirect relationship (Blaney et al., 1990). Further investigation is needed on when and how such effects may occur (Folkman, 1993).

The direct importance of mental states on progression of HIV infection is uncertain at best, and there is no clear evidence that one or another mental disorder or state either retards or accelerates



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