AIDS and Mental health

AIDS & MENTAL HEALTH
DR.VIGNESHVAR CHANDRASEKARAN
ASSISTANT PROFESSOR, PSYCHIATRY, MGMCRI, SBV
AIDS & MENTAL HEALTH 1

OUTLINE
Introduction
How is Psychiatry and HIV related?
HIV and Psychiatry – Interplay among Psychiatric disorders
Special areas of interest
Conclusion

INTRODUCTION
 HIV is considered an epidemic and has
donned the mantle of a chronic illness
 The highly effective HAART therapy
inhibits viral replication and has
prolonged the longevity of treated
individuals

INTRODUCTION
Population at highest risk:
 Homosexual men
 IV drug abuser and their partners
 Commercial sex workers

HOW IS PSYCHIATRY AND HIV RELATED?
Psychiatric conditions are associated with
 Increased high risk behaviors for infection
 Decreased access to care
 Decreased adherence to HIV therapies
 Increased medical comorbidity

High risk behaviors:
 Majority of individuals contract HIV due to engaging in high risk
behaviors
 Most of the high risk behaviors are associated with reward seeking
behaviors such as unprotected sex and substance use
 Individuals with untreated psychiatric illness have increased propensity
for above mentioned behaviors

Decreased access to care:
 Vulnerable population tend to lag in access to healthcare
Impaired adherence to antiviral regimen:
 Mentally ill individuals are prone for non adherence to antiviral regimen
leading to increased viral load – increased infectivity
 More viral load leading to more immunosuppression and further to more
morbidity and mortality

PSYCHIATRY NEEDS TO BE
A PART OF INTEGRATED
CARE IN HIV

DELIRIUM
9 AIDS & MENTAL HEALTH
State of global derangement of
cerebral function
Prevalence – 43-65%
• Altered sensorium
• Reversal of sleep wake cycle
• Behavioral disturbances
• Emotional and cognitive disturbances
Characterized by

DELIRIUM
Management of delirium
 Identification and treatment of underlying cause
 Reorientation measures
 Control of behavioral symptoms – Low dose antipsychotics
 Avoid drugs with anticholinergic properties
 Benzodiazepines can be used with caution
 Physical restraint maybe necessary

HIV
ASSOCIATED
DEMENTIA
Rapidly progressing neurocognitive disturbances finally
leading to death
A sub cortical dementia with HIV as a causative factor
Characterized by
• Loss of attention and concentration
• Motor slowing
• Behavioral symptoms
Decreased incidence with onset of HAART therapy

MAJOR
DEPRESSION
Most common complication of any chronic
illness
Often underrecognized, underdiagnosed, and
undertreated
Role of the immune axis in major depression
is highly relevant in HIV infected individuals
By comorbidities such as toxoplasmosis,
cryptococcal meningitis, lymphoma, syphilis

MAJOR DEPRESSION
High rates of major depression have been found in homosexual men and
patients with substance use disorders
Major depression is a risk factor for HIV infection by virtue of its impact on
• On behavior
• Intensification of substance abuse
• Exacerbation of self harm behaviors
• Promotion of poor partner choice in relationships.

MAJOR DEPRESSION
 Depression has a negative impact on adherence with medical treatments, quality of
life, and treatment outcome
 Patients with HIV suffering from major depression frequently present with multiple
somatic symptoms such as
 Headache, gastrointestinal (GI) disturbances, musculoskeletal or visceral pain,
cardiac symptoms, dizziness, tinnitus, weakness, and anesthesia

MAJOR DEPRESSION
Treatment
 Pharmacotherapy – SSRIs
 Psychotherapy : Cognitive behavioral therapy – Individual or group
 Supportive psychotherapy

BIPOLAR
DISORDER
 Manic episodes - associated with increased
rates of substance abuse and impulsive
behavior
 Associated with late stage HIV infection
 Quite severe in its presentation and
malignant in its course
 Rx – Mood stabilizers/ Antipsychotics
 Drug specific adverse effects and interaction
with HAART medications needs to be taken
into consideration

SCHIZOPHRENIA
 Prevalence around 4-19%
 High rates of unprotected sex, multiple sex
partners, trading sex for money or other
goods, and sex while intoxicated.
 Patients with more positive symptoms
(Delusions and Hallucinations) and impulse
control problems are at increased risk of
high-risk sexual behavior
 Rx
 Antipsychotics
 Rehabilitation with psychosocial support

PERSONALITY
FACTORS
Extraversion is associated with sexual
promiscuity, desire for sexual novelty, multiple
sex partners
Neuroticism is related to unprotected anal
sex.
Psychoticism is associated with number of
sexual partners and unprotected sex in
several studies

PERSONALITY FACTORS
 Sensation seeking - positive expectancies about the effect of
alcohol on sexual pleasure or sexual behavior increases the
likelihood that alcohol will be used in sexual situations
 Having sex when under the influence of alcohol is associated with
an increased likelihood of having unprotected sex.

PERSONALITY
DISORDERS
Antisocial personality disorder (ASPD) is
the most common risk factor for HIV
infection.
Individuals with personality disorder,
particularly ASPD, have
• Higher rates of Substance abuse
• More likely to inject drugs and share needles
• Higher numbers of lifetime sexual partners,
• Engage in unprotected anal sex, and contract STDs

PERSONALITY DISORDERS
Therapy Focus on thoughts, not feelings.
Use a behavioral contract
Emphasize constructive rewards
Use relapse prevention techniques

SUBSTANCE USE
AND HIV
 Substance use is a primary vector for
the spread of HIV.
 This impact is directed not only at
injection drug users and their sexual
partners but also at those who are
disinhibited or cognitively impaired by
intoxication, causing them to act
impulsively and engage in unsafe sexual
practices

SUBSTANCE USE AND HIV
 Injection drug use is obviously a primary risk factor for contracting HIV
by needle sharing
 Alcohol use can lead to risky sexual behaviors during intoxication by way
of cognitive impairment and disinhibition.
 The rewarding properties of drugs and alcohol to “self-medicate”
dysphoria and anhedonia can be a perpetuating factor

 Patients infected by HIV are often demoralized, become hopeless, and
are more likely to use drugs and engage in high-risk behaviors.
 Patients with substance use disorders may not seek health care or may
be excluded from health care because of stigmatization.
 Intoxication and the behaviors necessary to obtain drugs interfere with
adherence to medication regimens and medical appointments.

SUBSTANCE
USE AND HIV
Substance use and HIV –
How deadly is it?
 The accumulation of
medical sequelae from
chronic substance abuse can
accelerate the process of
immunocompromise and
amplify the progressive
burden of the HIV infection
itself.

 Injection drug users are at higher risk of developing bacterial infections
such as pneumonia, sepsis, soft tissue infections, and endocarditis.
 Tuberculosis, STDs, viral hepatitis infection, and coinfection with human CD4
cell lymphotropic virus occur more commonly in IV drug users infected with
HIV.
 Certain malignancies, lymphomas in particular, occur more frequently in HIV-
infected drug users.

 Alcohol users experience faster progression of HIV and poorer response to
antiretroviral therapy due to the immunosuppressive effects of alcohol.
 Active substance use is highly associated with nonadherence and reduced
access to antiretroviral medication
 Interaction between substances of abuse and HIV medications

AIDS & MENTAL HEALTH
SUBSTANCE USE
AND HIV -
MANAGEMENT
PRINCIPLES
28
1. Induction of patient role
2. Detoxification
3.Treatment of comorbid conditions
4. Rehabilitation
5. Relapse prevention

PSYCHOLOGICAL
TRAUMA IN HIV
Patients with HIV
 Have more incidences of severe trauma
 High rates of PTSD and anxiety
PTSD increases the likelihood of engaging in
destructive behaviors such as:
 Substance abuse,
 Sexual promiscuity
 Prostitution

PERIPHERAL
NEUROPATHY
IN HIV
 Most often in the feet but occasionally in
the hands.
 Paresthesia
 Burning pain
 Decreased sensation in the distal
extremity compared to more proximal
points
 Rx
 TCAs, pregabalin, gabapentin, or other
antiepileptic drugs

FATIGUE IN HIV
 Fatigue is a common symptom in HIV-
infected patients
 Often overlooked, improperly assessed
or inadequately investigated
 Fatigue is a nonspecific symptom and
may have varied etiology

FATIGUE IN HIV - ETIOLOGY
 Medical causes include pneumonia, bronchitis, hypothyroidism, hepatitis,
heart failure, renal failure, malignancies, and myopathy.
 Fatigue can also be caused by major depression
 As a side effect of medications such as antihypertensives, anticonvulsants,
benzodiazepines, antidepressants, narcotic analgesics, antipsychotics,
antiemetics, antihistamines, and most importantly HAART
 Rx - Identification and treatment of the cause/ Activating antidepressants can
be used

HIV / HCV CO-
INFECTION
 Special monitoring should be performed
during the period of treatment with
interferon-alpha
 Early recognition and treatment of
affective symptoms.
 Alcohol hastens the progression of HCV
disease and should be strongly
discouraged in any amount.
 Drug use may exacerbate
neuropsychiatric side effects of
interferon-alpha

PRE TEST
COUNSELING
 Individuals at risk are often reluctant to get
tested
 Psychoeducation directed at encouraging
patients to get tested, provides good results
 Prior to testing, informed consent regarding
the meaning of a positive and a negative test.
 It should be stressed that a negative test
does not mean that a patient is immune and
cannot become infected later, and that a
positive result does not mean that a person
has AIDS, is going to die, or will suffer from
opportunistic infections.
 Also include information on safe sex, safe
needle, and other risk-reduction
interventions.

POSTTEST
COUNSELING
 Post test interventions in both negative and
positive patients.
 Psychoeducation regarding the meaning of test
results, recommendations for treatment, risk
reduction interventions to control spread of
infection.
 At the time of test results being given to patients,
a variety of intense psychological reactions
including suicidal feelings, anger, homicidal
thoughts directed at potentially infecting
partners, overwhelming grief, and complete
psychological breakdown.
 Patients with poor coping skills, poor impulse
control, history of suicidal feelings and behaviors,
substance abuse disorders, and lack of social
supports are at increased risk of impulsive
behaviors and self-destructive behaviors.

PARTNER
NOTIFICATION
 Highly debated topic
 Tarasoff case
 Patients who are sexually active and
infected with HIV must be counseled
about potential risk to their sexual
partners.

ADHERENCE
COUNSELLING
 The single most important factor in outcome
of HIV treatment is the patient’s ability to
adhere to prescribed regimen
Factors improving adherence include
 Psychosocial support networks
 Individual coping skills
 Cognitive behavioral psychotherapy,
structured psychoeducational
psychotherapy, supportive psychotherapy,
and group interventions
 Pill box and timer reminders, less complex
pharmacological interventions, decreased
pill burdens

CONCLUSION
HIV and AIDS are conditions intimately linked to psychiatry.
Psychiatric disorders can be seen as vectors of HIV
transmission and complicate the treatment of HIV.
HIV in turn produces a number of psychiatric conditions and
exacerbates many others.
This interplay needs to be considered when a comprehensive
and integrated care is provided to HIV infected individuals

AIDS and Mental health

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