HIV/AIDS AND MENTAL ILLNESS: TODAY’S CHALLENGE<br />Prof SegganeMusisi MD, FRCP (C)<br />Department Of Psychiatry<br />Mak...
ACKNOWLEDGEMENTS<br />MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY<br />MAKERERE UNIVERSITY  COLLEGE OF HEALTH SCIENCES<br...
Overview of Presentation:<br /><ul><li>History of The Epidemic
Progression Of The Epidemic
Nature & Extent Of The Mental Health Problems
Etiological Factors
The Mental Health Problems Themselves
Mental Health Problems Of HIV/AIDS In Children
Orphans & Caregivers
HIV/AIDS Among The Elderly
The Challenge
Conclusions & Recommendations: The Future & Research</li></li></ul><li>THE HIV/AIDS BURDEN IN AFRICA<br />
PROGRESSION OF THE EPIDEMIC<br />STARTED IN EARLY 1980s<br />MOST ADVANCED & SERIOUS IN SUB-SAHARAN AFRICA<br />LINKED TO ...
OBSERVATIONS :THE AIDS WAVES<br />EARLY 1980s – FIRST AIDS CASES<br />INFECTION WAVE<br />Very physically ill – Wasted : S...
IK Missoula 2003<br />
IK Missoula 2003<br />
WHY MENTAL HEALTH PROBLEMS OCCUR<br /><ul><li>SEXUAL DISEASE
FAMILY DISCORD
STIGMA (Cultural, Religious & Disease Factors)
INFECTIOUS
FATAL
CHRONIC
DISFIGURING
INVOLVES CNS
OPPORTUNISTIC INFECTIONS
THE MEDICATIONS</li></li></ul><li>THE MENTAL HEALTH PROBLEMS<br />PREMORBID  PSYCHOPATHOLOGY  &  ADJUSTMENT PROBLEMS<br />...
PERSONALITY DISTURBENCES<br />PREMORBID ADJUSTMENT<br />PERSONALITY CHANGES<br />Antisocial behaviour<br />Irresponsibilit...
PREMORBID PSYCHOPATHOLOGY<br /><ul><li>PRE-EXISTING  PSYCHIATRIC ILLNESS
Bipolar Disorder
Depression
Schizophrenia
MR
SUBSTANCE ABUSE
Alcohol
Marijuana, Mayirungi
IV Drug use
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Musisi hiv and mental illness

  1. 1. HIV/AIDS AND MENTAL ILLNESS: TODAY’S CHALLENGE<br />Prof SegganeMusisi MD, FRCP (C)<br />Department Of Psychiatry<br />Makerere University<br />Global Mental Health and Africa: Opportunities, Challenges And Collaborations<br />Mbarara University Of Science And Technology: Aug. 15th - 16th , 2011<br />
  2. 2. ACKNOWLEDGEMENTS<br />MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY<br />MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES<br />ACADEMIC ALLIANCE FOR AIDS CARE AND PREVENTION IN AFRICA (IDI)<br />UGANDAN MENTAL HEALTH ASSOCIATIONS: <br />UPA, APRO, MHRC<br />RESEARCH GRANTS: <br />ARCH, ROGERS FOUNDATION, SIDA/SAREC, USHS, FULBRIGHT COMMISSION, NIH. <br />MY STUDENTS AND RESEARCH COLLEAGUES<br />
  3. 3. Overview of Presentation:<br /><ul><li>History of The Epidemic
  4. 4. Progression Of The Epidemic
  5. 5. Nature & Extent Of The Mental Health Problems
  6. 6. Etiological Factors
  7. 7. The Mental Health Problems Themselves
  8. 8. Mental Health Problems Of HIV/AIDS In Children
  9. 9. Orphans & Caregivers
  10. 10. HIV/AIDS Among The Elderly
  11. 11. The Challenge
  12. 12. Conclusions & Recommendations: The Future & Research</li></li></ul><li>THE HIV/AIDS BURDEN IN AFRICA<br />
  13. 13. PROGRESSION OF THE EPIDEMIC<br />STARTED IN EARLY 1980s<br />MOST ADVANCED & SERIOUS IN SUB-SAHARAN AFRICA<br />LINKED TO POVERTY & LOW EDUCATION<br />70% OF PLWHA ARE IN SUB-SAHARAN AFRICA<br />RAN ITS COURSE, PEAKED & HAS SHOWN DIFFERENT WAVES. <br />
  14. 14. OBSERVATIONS :THE AIDS WAVES<br />EARLY 1980s – FIRST AIDS CASES<br />INFECTION WAVE<br />Very physically ill – Wasted : SLIM Disease<br />Early death<br />Ran mad : Bewitched (From Tanzania)<br />DEATH WAVE<br />Widows<br />Orphans<br />ORPHAN WAVE<br />COTOs<br />HIV-positive Adolescents<br />THE ELDERLY HIV- POSITIVE WAVE<br />Effect of HAART<br />Effect Of Ageing<br />
  15. 15. IK Missoula 2003<br />
  16. 16. IK Missoula 2003<br />
  17. 17.
  18. 18. WHY MENTAL HEALTH PROBLEMS OCCUR<br /><ul><li>SEXUAL DISEASE
  19. 19. FAMILY DISCORD
  20. 20. STIGMA (Cultural, Religious & Disease Factors)
  21. 21. INFECTIOUS
  22. 22. FATAL
  23. 23. CHRONIC
  24. 24. DISFIGURING
  25. 25. INVOLVES CNS
  26. 26. OPPORTUNISTIC INFECTIONS
  27. 27. THE MEDICATIONS</li></li></ul><li>THE MENTAL HEALTH PROBLEMS<br />PREMORBID PSYCHOPATHOLOGY & ADJUSTMENT PROBLEMS<br />PSYCHO-BEHAVIORAL PROBLEMS : PERSONALITY & SUBSTANCE ABUSE DISORDERS<br />THE ANXIETY DISORDERS<br />THE HIV-RELATED AFFECTIVE (MOOD) DISORDERS<br />THE HIV-RELATED PSYCHOTIC PROBLEMS<br />THE HIV-RELATED COGNITIVE DISORDERS<br />HIV/AIDS MENTAL HEALTH PROBLEMS IN CHILDREN<br />HIV-POSITIVE CHILDREN<br />HIV-NEGATIVE ORPHANS<br />FAMILY PROBLEMS<br />
  28. 28. PERSONALITY DISTURBENCES<br />PREMORBID ADJUSTMENT<br />PERSONALITY CHANGES<br />Antisocial behaviour<br />Irresponsibility<br />Giving up<br />Irresponsible Sexuality<br />
  29. 29. PREMORBID PSYCHOPATHOLOGY<br /><ul><li>PRE-EXISTING PSYCHIATRIC ILLNESS
  30. 30. Bipolar Disorder
  31. 31. Depression
  32. 32. Schizophrenia
  33. 33. MR
  34. 34. SUBSTANCE ABUSE
  35. 35. Alcohol
  36. 36. Marijuana, Mayirungi
  37. 37. IV Drug use
  38. 38. HIGH HIV RISK POPULATIONS
  39. 39. 4H Club
  40. 40. Prostitutes & Truck drivers
  41. 41. Professionals
  42. 42. The War-affected</li></li></ul><li>SUBSTANCE ABUSE->Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.<br />SUBSTANCE PERCENTAGE<br /> Alcohol 48<br /> Cigarettes 9<br /> Marijuana 2<br /> Pipe smoking 6<br /> None 35<br /> Partner Use Of Alcohol 54<br />
  43. 43. ADJUSTMENT AND REACTIVE DISORDERS<br />ACUTE STRESS DISORDER<br />SUICIDALITY<br />ADJUSTMENT DISORDERS:<br />WITH ANXIOUS MOOD<br />WITH DEPRESSED MOOD<br />WITH DISTURBENCE OF CONDUCT<br />WITH MIXED FEATURES<br />
  44. 44. ANXIETY DISORDERS<br /><ul><li>ANXIETY DISORDER : ACUTE & RECURRENT
  45. 45. Kuganda S. (2011): M.Med (Psychiatry)Thesis, MakCHS
  46. 46. 6% Psychological Distress
  47. 47. 27% Panic Attacks & 27% Generalised Anxiety Disorder
  48. 48. Factors associated with Anxiety Disorder:
  49. 49. Unemployment
  50. 50. Poor Social Support
  51. 51. Oral Thrush
  52. 52. Other researchers : AIDS Phobia, OCD, PTSD</li></li></ul><li>MOOD DISORDERS<br />HIV-RELATED DEPRESSION<br />Akena’s et al: (2010) African Journal Of Psychiatry Vol 13, No. 1<br />F>M. Later age of onset. Negative F/H. Cognitive impairment. Widowhood.<br /> Frequent medical illnesses. Severer sleep & appetite disturbances. Guilt.<br />HIV-RELATED MANIA<br />Nakimuli et al: (2006) Am J. Psychiatry 163: 8<br />F>M. Later age of onset. Severer Psychosis. Negative F/H. Cognitive impairment. Widowhood<br />BIPOLAR DISORDER<br />Nakimuli et al: (2008) Psychosomatics Journal 49:530-534<br />Early onset: Bipolar I; Later onset: Secondary mania. Quick Rx response<br />
  53. 53. PSYCHOTIC DISORDERS<br />HIV-RELATED PSYCHOSIS:<br />SCHIZOPHRENIA-LIKE<br />PARANOID<br />MIXED<br />PRE-EXISTING SCHIZOPHRENIA<br />Maling’s et al: (2011). AIDS Care, Vol. 23, No. 2, 171-178<br />18.4% Prevalence in First Episode Psychosis<br />F>M; Older age of onset (41 years). More auditory, visual & tactile hallucinations. More likely to remit.<br />
  54. 54. DISORDERS OF COGNITION<br />HIV-RELATED DELIRIUM<br /><ul><li>Musisi et al.(2000): Makerere Medical School Journal</li></ul>40% of all C-L referrals. Early & Late stages of HIV/AIDS. Se/CRAG<br /><ul><li>Lukwago et al. (2009): Delirium. In Psychiatric Problems Of HIV/AIDS & Their Management In Africa. Fountain Publishers</li></ul>38% of ER attendees at Mulago Hospital. Associated with OI & ↑ viremia<br />HIV ASSOCIATED DEMENTIA<br /><ul><li>Sactor N, Nakasujja N et al (2005): AIDS 19:1367-1374
  55. 55. The IHDS can screen for Dementia in Uganda/Africa
  56. 56. 31% prevalence Of Dementia: Cognitive impairment ↓ with HAART
  57. 57. Question: When can we start HAART with CD4>200?
  58. 58. Nakasujja N et al(2010): BMC Psychiatry 10:44</li></ul>Depressive & cognitive symptoms are common in HIV/AIDS <br />Cognitive deficits persist despite adequate treatment for depression<br />
  59. 59. FAMILY PROBLEMS<br />FAMILY TYPES AND CONJUGAL PRACTICES AMONG HIV-POSITIVE CLIENTS IN CARE IN UGANDA IN PAST 5 YEARS :<br />->Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.<br /><ul><li>64% started off in monogamous unions, 28% got separated/divorced & 10% got into visiting unions with many partners,
  60. 60. About 60% reported having lived in visiting unions at one point
  61. 61. Conclusion: Considerable flexibility, variability and volatility of marital unions & conjugal practices among the HIV-positive TASO clients.</li></ul>DISCORDANT COUPLES: 10%<br />WIDOWS: 30%<br />
  62. 62. DISCLOSURE OF HIV STATUS TO PARTNERLwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.<br />
  63. 63. CONDOM USELwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.<br />
  64. 64. PARTNER VIOLENCELwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.<br />
  65. 65. HIV/AIDS AND CHILDREN(Wakhweya et al, 2000) <br /> ORPHANS<br />>2 million orphans in Uganda, >14 million orphans in Africa<br />Types of Orphans:<br />Paternal orphans (50%)<br />Double orphans (30%)<br />Maternal Orphans (20%) <br />Classification Of AIDS orphans:<br />HIV-positive orphans<br />Have all the neuropsychiatric disorders, many physical illnesses associated with HIV + psychosocial problems <br />HIV-negative orphans<br />Have only psychosocial problems but no major disorders<br />Elderly caretakers (30%), Child-headed households<br /> Poverty , Prostitution, Destitution<br />Mother to Child Transmission (25%)<br /> >90% of infected children are orphans<br /> >60% are in stage III of illness by 10 yrs <br />
  66. 66. Impact Of HIV/AIDS-related Parental Death On Children’s Home Life<br />Increased:<br />. Poverty<br />. Household responsibility<br />. Psychosocial distress<br />. Vulnerability to sexual & labor abuse,<br />. Stigma and isolation<br />. Hunger and malnutrition<br />Reduced:<br /> - Access to food<br /> - Access to health services<br /> - Access to school<br /> - Material goods : clothes, supplies<br /> - Guidance, protection, and love<br />
  67. 67. HIV-POSITIVE CHILDREN IN UGANDA.- Musisi S & Kinyanda E (2009), East African Medical Journal, Vol. 86, No. 1, 16-24. <br /><ul><li>97% of HIV-infected children are orphans
  68. 68. >60% are in stage III of illness by 10 yrs
  69. 69. They manifest major psychiatric disorders:</li></ul>Anxiety (58.5%) Depression,(42%) <br /><ul><li> Psychosis, (30%) Mania(7.2%)
  70. 70. HPE (4.9%) Seizures(8.5%)
  71. 71. Suicide, (20%) , Substance Abuse(4.8%).
  72. 72. Somatoform Disorders (18.3%)
  73. 73. No special services are available for them.</li></li></ul><li>The Psychosocial Problems Of Orphans (Musisi S, Kinyanda E, Nakasujja N (2007): African Health Sciences Journal, 7(4)<br />Emotionally needy - No parental guidance, love, support, & security <br />Are materially deprived, abused, isolated & neglected, <br />Lack Scholastic materials, Fees, Food, Clothing , Shelter, Protection.<br />Need Role Modeling , Social & Vocational Skills, and Health care.<br />Live in poverty & exploitation (labor, sexual, spiritual & inheritances)<br />Lack family & individual counseling / support & community resources<br />Live in Fear & engage in survival behavior: – <br />Girls: Prostitution, early marriage or domestic help for girls. <br />Boys: Street children with petty theft , child labor & fights <br />Have high rates of depression, suicide & substance abuse<br />
  74. 74. Shelter: To build and/or repair houses<br />
  75. 75. Psycosocial Interventions: Care, Protection, Schooling<br />
  76. 76. School fees, scholastic materials and LUNCH<br />
  77. 77. Contributing to a better future…<br />
  78. 78. ELDERLY HIV-POSITIVES<br />NEW WAVE & INCREASING<br />↑ STIGMA, ↑ SECRECY, with ↓ACCESS TO CARE <br />MULTIPLE PHYSICAL & MENTAL PROBLEMS<br />HAD Vs OTHER DEMENTIAs<br />SEXUALLY ACTIVE, SOME HAD >1 PARTNER. FEW USED CONDOMS<br />↓ SOCIAL SUPPORT, ARV TREATMENT & CLINIC ATTENDANCE<br />NO SPECIFICALLY TARGETTED PREVENTION PROGRAMS<br />LAXITY OF CARE ON THE PART OF THE STAFF<br />
  79. 79. Elderly HIV-Positive Age Distribution (N=118)<br />
  80. 80. The Elderly Sexual Behavior (last 3 months)<br />
  81. 81. The Challenge in Uganda’s HIV/AIDS Care:<br /><ul><li>The Apparent Absence of Mental Health In HIV-care
  82. 82. Problems In Scaling Up HIV care
  83. 83. Adherence, Resistance: The role of mental health
  84. 84. Substance Abuse
  85. 85. Unreached Pockets Of Infection : The marginalised (Trauma , mentally ill, elderly, orphans, disabled)
  86. 86. Interventions & Policy</li></li></ul><li>THE FUTURE<br />INTEGRATED MENTAL HEALTH IN ALL HIV CARE PROGRAMS.<br />ORPHAN POLICY : <br />ORPHAN REGISTRY, LEGAL PROTECTION, <br />CHILDRENS AID SERVICES<br />LEGAL GUARDIANSHIP, <br />SCHOOLING,SHELTER, HEALTHCARE FOOD SECURITY<br />CHILD PSYCHOLOGY & GUIDANCE, <br />DISTRICT RUN FAMILY SERVICES<br />RESEARCH INTO :<br />HIV CARE FOR THE ELDERLY, <br />LONG TERM OUTCOME OF MENTAL HEALTH DISORDERS OF HIV/AIDS,<br /> COMFOUNDING MENTAL HEALTRH FACTORS IN HIV CARE IN UGANDA, <br />TASK SHIFTING APPROACH TO MENTAL HEALTH CARE PROVISION IN PHC HIV SETTINGS<br />ADHERENCE & MENTAL HEALTH SERVICES IN HARD TO REACH HIV COMMUNITIES<br />MENTAL HEALTH INITIATIVES TO ENHANCE THE SCALE UP OF HIV CARE IN UGANDA<br />
  87. 87. LETS MOVE FORWARD IN PARTNERSHIP<br />

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