Neuropsychiatric aspects of hiv infection and aids
Neuropsychiatric Aspects of HIV Infection and AIDS
Overview of HIV Transmission• Human immunodeficiency virus is a retrovirus related to the human T-cell leukemia viruses (HTLV) and to retroviruses that infect animals, including nonhuman primates.• two types of HIV have been identified, HIV-1 and HIV-2.• HIV-1 is the causative agent for most HIV-related diseases; HIV-2, however, seems to be causing an increasing number of infections in Africa.• Other subtypes of HIV may exist, which are now classified as HIV-O.
• HIV is present in blood, semen, cervical and vaginal secretions, and, to a lesser extent, in saliva, tears, breast milk, and the cerebrospinal fluid of those who are infected.• HIV is most often transmitted through sexual intercourse or the transfer of contaminated blood from one person to another.• Unprotected anal and vaginal sex are the sexual activities most likely to transmit the virus.• Oral sex has also been implicated, but rarely.• Health providers should be aware of the guidelines for safe sexual practices and should advise their patients to practice safe sex .
Pathogenesis• Once a person is infected with HIV, the virus primarily targets T4 (helper) lymphocytes, also called CD4+ lymphocytes, to which the virus binds because a glycoprotein (gp120) on the viral surface has a high affinity for the CD4 receptor on T4 lymphocytes.• After binding, the virus can inject its RNA into the infected lymphocyte, where the RNA is transcribed into DNA by the action of reverse transcriptase.• The resultant DNA can then be incorporated into the host cells genome and translated and eventually transcribed, once the lymphocyte is stimulated to divide.• After viral proteins have been produced by lymphocytes, the various components of the virus assemble, and new mature viruses bud off from the host cell.• Although the process of budding may cause lysis of the lymphocyte, other HIV pathophysiological mechanisms can gradually disable a patients entire complement of T4 lymphocytes.
AIDS Safe-Sex GuidelinesRemember: Any activity that allows for the exchange of body fluids of one person through the mouth, anus, vagina, bloodstream, cuts, or sores of another person is considered unsafe at this time.Safe-sex practices:• Massage, hugging, body-to-body rubbing• Dry social kissing• Masturbation• Acting out sexual fantasies (that do not include any unsafe-sex practices)• Using vibrators or other instruments (provided they are not shared)
Low-risk sex practices:• These activities are not considered completely safe: – French (wet) kissing (without mouth sores) – Mutual masturbation – Vaginal and anal intercourse while using a condom – Oral sex, male (fellatio), while using a condom Oral sex, – female (cunnilingus), while using a barrier – External contact with semen or urine, provided there are no breaks in the skin
Unsafe-sex practices: • Vaginal or anal intercourse without a condom • Semen, urine, or feces in the mouth or the vagina • Unprotected oral sex (fellatio or cunnilingus) • Blood contact of any kind • Sharing sex instruments or needles
• The presence of sexually transmitted diseases, such as herpes or syphilis, or other lesions that compromise the integrity of skin or mucosa, further increases the risk of transmission.• Transmission also occurs through exposure to contaminated needles, thus accounting for the high incidence of HIV infection among drug users.• HIV is also transmitted by infusions of whole blood, plasma, and clotting factors, but not immune serum globulin or hepatitis B vaccine.
• male-to-male transmission has been the most common route of sexual transmission in North America, male-to- female and female-to-male transmissions are increasing, and they represent most transmission worldwide.• Transmission by contaminated blood most often occurs when those abusing a substance intravenously (IV) share hypodermic needles without proper sterilization techniques.• Transmission of HIV through blood transfusions, organ transplantation, and artificial insemination is no longer a problem now that donors are tested for HIV infection.• Many hemophilia patients, however, received transfusions of HIV-infected blood products before HIV was identified as the causative agent.
• Children can be infected in utero or through breast-feeding when their mothers are infected with HIV.• Zidovudine (Retrovir) and protease inhibitors taken by the HIV-infected pregnant woman prevent perinatal transmission in more than 95 percent of cases.• Health workers are theoretically at risk because of potential contact with bodily fluids from HIV-infected patients.• No evidence has been found that HIV can be contracted through casual contact, such as by sharing a living space or a classroom with a person who is infected, although direct and indirect contact with an infected persons bodily fluids, such as blood and semen, should be avoided .
Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of HIV Transmission from Infected to Uninfected PersonsInfected persons should be counseled to prevent the further transmission of HIVby:1. Informing prospective sex partners of their infection with HIV, so they can take appropriate precautions. Abstention from sexual activity with another person is one option that would eliminate any risk of sexually transmitted HIV infection.2. Protecting a partner during any sexual activity by taking appropriate precautions to prevent that persons coming into contact with the infected persons blood, semen, urine, feces, saliva, cervical secretions, or vaginal secretions. Although the efficacy of using condoms to prevent infections with HIV is still under study, the consistent use of condoms should reduce the transmission of HIV by preventing exposure to semen and infected lymphocytes.3. Informing previous sex partners and any persons with whom needles were shared of their potential exposure to HIV and encouraging them to seek counseling and testing.
4. For IV drug abusers, enrolling or continuing in programs to eliminatethe abuse of IV substances. Needles, other apparatus and drugs mustnever be shared.5. Never sharing toothbrushes, razors, or other items that couldbecome contaminated with blood.6. Refraining from donating blood, plasma, body organs, other tissue,or semen.7. Avoiding pregnancy until more is known about the risks oftransmitting HIV from the mother to the fetus or newborn.8. Cleaning and disinfecting surfaces on which blood or other bodyfluids have spilled, in accordance with previous recommendations9. Informing physicians, dentists, and other appropriate healthprofessionals of antibody status when seeking medical care, so thatthe patient can be appropriately evaluated
DiagnosisSerum Testing:• Techniques are now widely available to detect the presence of anti-HIV antibodies in human serum.• The conventional test uses blood (time to result, 3 to 10 days) and the rapid test uses an oral swab (time to result, 20 minutes).• Both tests are 99.9 percent sensitive and specific.• Health care workers and their patients must understand that the presence of HIV antibodies indicates infection, not immunity to infection.• Those with a positive finding on an HIV test have been exposed to the virus, have the virus within their bodies, have the potential to transmit the virus to another person, and will almost certainly eventually develop AIDS.
Counseling• The major issues in counseling persons about HIV serum testing are who should be tested; why a particular person should or should not be tested; what the test results signify; and what the implications are.• Although specific groups of persons are at high risk for contracting HIV and should be tested , any person who wants to be tested should probably be tested.
Possible Indications for HumanImmunodeficiency Virus (HIV) Testing
Confidentiality• Confidentiality is a key issue in serum testing. No one should be given an HIV test without previous knowledge and consent, although various jurisdictions and organizations, such as the military, now require HIV testing for all inhabitants or members.• The results of an HIV test can be shared with other members of a medical team, although the information should be provided to no one else except in the special circumstances discussed below.• The patient should be advised against disclosing the results of HIV testing too readily to employers, friends, and family members; the information could result in discrimination in employment, housing, and insurance.
• The major exception to restriction of disclosure is the need to notify potential and past sexual or IV substance use partners. Most patients who are HIV positive act responsibly.• If, however, a treating physician knows that a patient who is HIV infected is putting another person at risk of becoming infected, the physician may try either to hospitalize the infected person involuntarily (to prevent danger to others) or to notify the potential victim.
Clinical FeaturesNonneurological Factors:• About 30 percent of persons infected with HIV experience a flulike syndrome 3 to 6 weeks after becoming infected; most never notice any symptoms immediately or shortly after their infection.• When symptoms do appear, the flulike syndrome includes fever, myalgia, headaches, fatigue, gastrointestinal symptoms, and sometimes a rash.• The syndrome may be accompanied by splenomegaly and lymphadenopathy. Rarely, acute aseptic meningitis develops shortly after infection, as does encephalopathy or Guillain-Barr syndrome.
• The most common infection in persons infected with HIV who have AIDS is Pneumocystis carinii pneumonia, which is characterized by a chronic, nonproductive cough, and dyspnea, sometimes sufficiently severe to result in hypoxemia and its resultant cognitive effects.• The other disease that was initially associated with the development of AIDS is Kaposis sarcoma, a previously rare, blue-purple-tinted skin lesion
• The most common infections are from protozoa such as Toxoplasma gondii; fungi such as Cryptococcus neoformans and Candida albicans; bacteria such as Mycobacterium avium-intracellulare; and viruses such as cytomegalovirus and herpes simplex virus.
Neurological Factors• An extensive array of disease processes can affect the brain of a patient infected with HIV.• The most important diseases for mental health workers to be aware of are HIV mild neurocognitive disorder and HIV-associated dementia.
Conditions Associated with Human Immunodeficiency Virus (HIV) Infection
Treatment• Primary prevention involves protecting persons from getting the disease; secondary prevention involves modification of the diseases course.• All persons with any risk of HIV infection should be informed about safe-sex practices and about the necessity to avoid sharing contaminated hypodermic needles.• Many public health officials have advocated condom distribution in schools and the distribution of clean needles to drug addicts.
• These issues remain controversial, although condom use has been shown to be a fairly (although not completely) safe and effective preventive strategy against HIV infection.• Those who are conservative and religious argue that the educational message should be sexual abstinence.• Many university laboratories and pharmaceutical companies are attempting to develop a vaccine to protect persons from infection by HIV. The development of such a vaccine, however, is probably at least a decade away.
Pharmacotherapy• A growing list of agents that act at different points in viral replication has raised for the first time the hope that HIV might be permanently suppressed or actually eradicated from the body.• At the time of this writing, the active agents were in two general classes: reverse transcriptase inhibitors and protease inhibitors.• The reverse transcriptase inhibitors are further subdivided into the nucleoside reverse transcriptase inhibitor group and the nonnucleoside reverse transcriptase inhibitors. I• n addition to the new nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors, other classes of drugs are under investigation.• These include agents that interfere with HIV cell binding and fusion inhibitors (e.g., enfurvitide [Fuzeon]), the action of HIV integrase, and certain HIV genes such as gag, among others.
PsychotherapyApproaches:• Major psychodynamic themes for patients infected with HIV involve self-blame, self-esteem, and issues regarding death.• The psychiatrist can help patients deal with feelings of guilt regarding behaviors that contributed to infection or AIDS. Some patients with HIV and AIDS feel that they are being punished.• Difficult health care decisions, such as whether to initiate or continue taking antiretroviral medication and terminal care and life-support systems, should be explored, and here denial of illness may be evident.• Major practical themes involve employment, medical benefits, life insurance, career plans, dating and sex, and relationships with families and friends.• The entire range of psychotherapeutic approaches may be appropriate for patients with HIV-related disorders. Both individual and group therapy can be effective.• Individual therapy may be either short term or long term and may be supportive, cognitive, behavioral, or psychodynamic.• Group therapy techniques can range from psychodynamic to completely supportive in nature.
Therapist-Related Issues:• Countertransference issues and burnout of therapists who treat many patients infected with HIV must be evaluated regularly.• Therapists must acknowledge to themselves their predetermined attitudes toward sexual orientation and substance use so that those attitudes do not interfere with the treatment of the patient.• Issues regarding the therapists own sexual identity, past behaviors, and eventual death may also give rise to countertransference issues.
• Psychotherapists who have practices with many patients infected with HIV can begin to have their effectiveness impaired by professional burnout.• Some studies have found that seeing many such patients in a short time seems to be more stressful to therapists than seeing a smaller number of those infected with HIV over a longer period.
Involvement of Significant Others:• The patients family, lover, and close friends are often important allies in treatment.• The patients spouse or lover may have guilt feelings about possibly having infected the patient or may experience anger at the patient for possibly infecting him or her.• The involvement of members of the patients support group can help the therapist assess the patients cognitive function and can also aid in planning financial and living arrangements for the patient.• The patients significant others may themselves benefit from the attention of the therapist in helping them cope with the illness and the impending loss of a friend or family member.
Partner Notification:• Although no clear consensus has been reached, recommendations are that patients who are sexually active and infected with HIV should be counseled about potential risk to their sexual partners.• Additionally, known partners should be notified of exposure risk and potential infection as well.• Partner notification has been an extremely hotly debated topic; however, many states have developed legislation requiring or allowing either physicians or health department officials to notify partners of patients who are HIV infected of their risk.• The current standard, despite the controversy, appears to be an obligation on the part of health care professionals to notify anyone who could be construed as clearly at risk and clearly identifiable and who may be unaware of their risk.
• A particularly difficult situation is that of sex-industry workers known to be HIV infected and known to be working actively as prostitutes.• Public health issues exist that pose a risk both for these patients and, depending on the politics of the circumstances, for their potential partners, clients, customers, victims, or victimizers.• The response to this problem has ranged from a sense that sex-industry workers and their clients can make their own decisions and should be responsible for their own behavior all the way to the sentiment that such people should be arrested and jailed for attempted murder.
• It has additionally been noted that some sex-industry workers are impaired by a variety of psychiatric conditions, including cognitive impairment, major mental illness, personality disorder, and substance abuse disorders.• These may further contribute to the sense that some sex- industry workers may be less than fully responsible for their behavior.• Recommendations have been made for voluntary and involuntary interventions regarding these patients.• Specific psychiatric interventions regarding competency, ability to consent, capacity, and, most importantly, treatment for the conditions that impair such people are critical to the mental health needs of patients with HIV.