Each time Nate* tried to kill himself—he attempted suicide three times between 1987 and 1993—he regretted it right away. “Almost instantly,” he says, “I thought, Oh, why did I do that? Suicide wasn’t the only thing I could do.”
 
Today, Nate is getting his degree in social work. He has all the makings of a great counselor. He’s handsome and warm and he has acres of empathy. The empathy makes sense. He’s been through it all—except he almost didn’t make it.
In the ’90s, Nate was very much a work in progress. He had lived through childhood abuse, which he repressed for many decades (until therapy helped him face it); he coped with an HIV diagnosis long before it was considered a manageable condition; and he had fallen into serious addiction. It took trying to kill himself for him to hit bottom.
Nate is not alone. Far too many HIV-positive people contemplate and attempt suicide. The introduction of HIV combo therapy has lead to a sharp reduction in suicide, but the rates stubbornly continue to be high. Stigma and hopelessness remain potent in the age of the HIV med cocktail. In a 2008 study done in the United Kingdom, one in three people with HIV had thought about suicide in the preceding week.

When Nate first learned he was positive, he was stunned. “I wondered, Why me, why now? I’d quit drinking, I was counting days sober.” He noticed his partner was not looking healthy. “I noticed the sinews on his neck and thought, Christ, he’s lost a lot of weight,” he remembers. His lover had AIDS. Nate himself was never ill—didn’t even need meds until after the advent of protease inhibitors.

The moment when a person first learns he or she is positive is obviously very difficult. Bruce Kellerhouse, PhD, a psychiatrist in private practice in New York City, believes that the present paradigm for counseling the newly diagnosed comes up woefully short. “In the best of all possible worlds,” he says, “we would have intensive post-test referrals and follow-up. I would love it, when [diagnosis] happens in a medical setting, to see [people] going right to a social worker.”

Addiction, Isolation and HIV

Living with HIV day in, day out is even more damaging to a person’s psyche than that initial shock. All too often, positive people retreat into isolation and/or substance abuse. National Institutes of Health research in 2009 found that one in four people living with HIV reported alcohol or drug use at a level that necessitated treatment. And, as in Nate’s case, suicide among people with HIV is frequently related to addiction. Nate’s psychotherapist throughout the ’90s, Nancé Agresta, insisted he go to Alcoholics Anonymous the first night they met, when his wrists were still bandaged from his second suicide attempt. Her firm approach was exactly what he needed.
Kellerhouse applauds 12-step programs such as AA and Crystal Meth Anonymous (gay men who use crystal meth seem to be at special risk of suicide), particularly when people are hitting bottom and even as they start trying to stay sober. But he believes people who have been around longer have a special responsibility to reach out to those who are struggling. “Are they receiving mental health care? Help them get connected to someone or something,” he says.

With crystal meth abuse, a physiological phenomenon—the drug’s depletion of dopamine receptors in the brain—is the central obstacle. Dopamine is linked to feelings of contentment and euphoria; depletion of dopamine receptors can lead to depression. The most serious problem for people who are chronically using, Kellerhouse says is that they’re never getting to normal dopamine levels. He recommends treating people with medication to help them through their early months of sobriety. “And then there may be ongoing [treatment] if the depression continues.”

Nate’s journey back from the abyss was not easy, and he had to put in the work. He was hospitalized three times, for periods ranging from four days (he was kicked out because of insurance issues) to four months. “I thought substance abuse [mostly alcohol and cocaine] was the problem,” he says. “I was surprised when depression presented itself after I cleaned up. Mostly the suicide stuff hatched from my childhood abuse.” When he was two years sober, he started having nightmares. “I couldn’t get a grasp on it until I went on antidepressants. [The memories] had just taken over, way out of the darkness of my mind.”

Nate believes only his final suicide attempt, in 1993, was HIV-related. “I decided it’d be better for my partner and me and the world if I were not here,” he says. As depressed as he was, each time Nate realized he hadn’t succeeded in killing himself, he was glad to be alive. “There was always guilt—people care about you. And if there is a God you just said ‘Fuck you.’ But I also immediately felt relief that I hadn’t succeeded,” he says.


Reaching Out

In addition to excellent psychiatric care and support from comrades in AA, Nate has developed a great relationship with his HIV doc. “Dr. Paul Bellman has been a friggin’ hero,” Nate says. “Many years ago he told me, ‘HIV isn’t going to kill you.’”
Shortly after his diagnosis in 1991, Nate also began attending the “big group” at Friends in Deed, a crisis center in Manhattan for people suffering from life-threatening illness. “They let me know that what I was going through was difficult, but it wasn’t an unmanageable tragedy. That I could get through. They helped me ignore what my mind was telling me: that I was going to get KS lesions and everyone was going to leave me. They kept saying, ‘No, actually, this is what we know…’ Not many people want to face that how they react to [their diagnosis] is going to have a huge impact on how it effects their life.”
 
“Social isolation leads to problems,” Kellerhouse says. “It’s too bad that something has to go wrong in order [for people] to be part of a larger group that is struggling together.” He recalls the early ’90s, when people would have to find out they were HIV positive in order to discover the wonderful supportive community—including Gay Men’s Health Crisis (GMHC), Body Positive and Friends in Deed—that was available to them. “The same thing happens with people going into recovery,” Kellerhouse says. “They find this wonderful, supportive community of people working together to get better. If you don’t have those difficulties, why is it so hard to access a community? I don’t have the answer to that question.”

Nate eventually stopped seeing Agresta; she counseled him for eight years, at which point she told him, “You’re cooked. Get out of here!” But he understands that he will likely battle depression for the rest of his life. He isn’t daunted; he has learned to stay in the moment. “There’s just no way to know what’s gonna happen tomorrow,” he says. “All we know is this moment. How we relate to it is up to us.”

 *not his real name