South Africa’s staggering and apparently out-of-control AIDS epidemic received substantial attention earlier this summer when that country hosted the 13th International Conference on AIDS. Confronted with extremely limited AIDS-treatment resources and overwhelmed by the size of the population that needs them, South Africa has had little money or time to spend trying to prevent future HIV infections.

Seeing an area in which they could make a real difference, psychiatrist Pamela Collins, M.D., and several of her colleagues at Columbia University traveled to South Africa earlier this year to lend their expertise in helping the country develop desperately needed HIV/AIDS prevention programs.

Collins, an assistant professor of clinical psychiatry at Columbia, has been involved in mental health programs in South Africa for several years. After she returned from the AIDS conference, she told Psychiatric News that her involvement arose from her interest in how various cultural groups think about HIV and mental health issues. In particular, she has been intrigued by how social context impacts HIV risk.

Until late last year, her efforts were devoted largely to collaborating with South Africa’s health officials as they develop community-based psychiatric facilities to accommodate patients deinstitutionalized from psychiatric hospitals. One focus of those efforts was impressing on local health planners the importance of including HIV prevention.

In 1998 Collins and psychiatrists Ezra Susser, M.D., chair of epidemiology in the School of Public Health at Columbia, and Alan Berkman, M.D., were invited to South Africa as advisers to a pilot project ensuring that the country’s program of deinstitutionalization and development of community services is successful. She said they used the opportunity to discuss with health officials how HIV prevention could be included in the community-care programs. The same year Collins got a grant to assess providers’ perceptions of HIV risk in their patients.

After more than three months of work in several South African provinces, Collins said she showed her report to Melvin Freeman, a psychologist who heads the country’s Directorate of Mental Health. The report described how vulnerable mentally ill individuals are to behaviors that increase their HIV risk and emphasized how important it was for the staff caregivers to be trained in prevention strategies.

Freeman’s response was to ask Collins and Susser to begin to train providers in HIV prevention. Collins pointed out that she was able to obtain an NIMH grant at about this time, which was designed to provide training for HIV-prevention efforts in developing countries. The directorate chose two sites for demonstration projects to train mental health staff to implement and conduct prevention programs.

Collins and two colleagues from the psychiatry department at Columbia, Francine Cournos, M.D., and Milton Wainberg, M.D., went to South Africa in January and again in July to help conduct the pilot projects.

During the July trip Freeman, the South African mental health director, asked the psychiatrists to expand their mission and help psychiatric hospitals develop policy guidelines related to treating HIV-infected patients in their care. They used several of APA’s HIV/AIDS-related policy statements as templates, Collins said, with some changes for local considerations. The policies included ones on confidentiality, HIV testing, treating neuropsychiatric manifestations of AIDS, universal anti-infection precautions, dealing with HIV-infected staff, and sexuality in psychiatric hospitals.

To illustrate several of the obstacles they and their South African colleagues faced in developing AIDS prevention programs in psychiatric hospitals, Collins described their experiences at Bophelong Hospital in Northwest Province, an area in which between 20 percent and 25 percent of the population is infected with HIV.

No routine testing is done in the province, for example, so hospital staff have no way of knowing which of the patients they treat are HIV-positive. The staff indicated that they were in a quandary about what they should do if they discover that a patient is infected and wants guidance on procedures. Collins said the message they stressed was that hospital staff "can’t make treatment decisions on the basis of the status of individual patients and can’t operate out of fear" of working with these patients. Hospitals need a formal policy on which they can rely in their decision making, she noted.

Another confounding issue, and one that is not unique to South Africa, is sexual activity among patients, Collins pointed out. "People are most comfortable turning a blind eye to this issue," she said, "but it can’t be ignored if the risk of HIV infection is to be reduced." What made it a challenge in South Africa, however, was a statute—recently withdrawn—that declared it illegal for any institutionalized woman to have sexual intercourse. As a result, she explained, "staff were afraid that if they gave out condoms they would be charged with violating the mental health act." Bophelong Hospital does in fact make condoms available, but only on men’s wards. But there the troubling issue for staff and administrators is whether they can then be accused of condoning sexual activities.

A related issue the trainers had to confront was "cultural taboos about addressing sexuality," she said. Almost all of the nursing staff are women, who expressed considerable discomfort about discussing sexual issues such as condom use with older male patients.

Collins and her colleagues responded to the concerns by stressing that with HIV prevalence rates so high, "responsible clinical care means making condoms available" to everyone, but while they are deciding on a formal policy, hospital officials should continue to ensure that condoms are available.

Wainberg, who is director of medical education at Columbia’s HIV Mental Health Training Project, explained that one aim of the training was in helping staff move from "focusing on a pervasive ‘why me?’ and ‘why us?’ response" to the epidemic to understanding that there were steps they could take that would have a positive effect.

"We explained how the language they use can make a difference," Wainberg said, and taught skills on how to communicate better with their patients. "We tried to show people how to take advantage of the tools they had and how important it is to share information with each other," he said.

An essential element of the training sessions for hospital staff involved role playing to devise solutions to dilemmas that arise involving HIV infections, Collins said. As sessions progressed, she could see positive changes in the way the staff viewed and planned to deal with patients who might be HIV infected.

Wainberg stressed that another issue complicating prevention efforts through- out South Africa is the country’s history of racial discrimination and stigmatization of its nonwhite populations. South Africans view HIV infection as another devastating form of stigma, Wainberg said, and hospital staff and others are troubled by having to tell people they are HIV-positive when they have little if any help to offer.

Next month the Columbia University psychiatrists will conduct HIV-prevention training at Midlands Hospital complex in KwaZulu-Natal Province, Collins said.

While the American psychiatrists go to South Africa to help with "a dire situation and a staggering loss of life," Collins said it is important to emphasize how much she and her colleagues get out of their work in that country. "We’ve come to appreciate what’s involved in working in a very different cultural situation and to understand the complexities of working in a country where issues of race, resource constraints, and a raging epidemic" all have to be addressed together or strategies will be doomed to failure.

Wainberg said that if he returns to South Africa after a few years, he hopes to see such changes as people willing to discuss HIV testing openly, medical personnel finally using medications such as bactrim that are available there but not used, and psychiatric patients involved in discussions of sexual activity and safer-sex practices with their physicians or other caregivers.