HIV-AIDS has broader range of course of illness. It is essential for the healthcare workers, specially for psychiatric nurses to know the importance of Counseling as therapeutic modality for clients with HIV-AIDS, as later stages are also attached with psychosis and illnesses like HIV-AIDS are stigmatized in society which also contributes for patient to develop mental health problems. Nurse has roles of advocacy, observant, therapists and comprehensive care giver.

1. PRESENTED BY,
AKASH R. GHORPADE
M.SC. PSYCHIATRIC NURSE

2. OBJECTIVES
 AIM: To inculcate the best therapeutic counselling practices among group in relation to HIV-AIDS victims.
 GENERAL OBJECIVE: At the end of Seminar, group will be able to develop the counselling skills within, for care of
clients with HIV-AIDS.
 SPECIFIC OBJECTIVE: At the end of Seminar, group will be able to;
1. discuss the typology of HIV infection.
2. state the neuropathology & pathophysiology of HIV-AIDS.
3. determine the association of specific conditions with HIV-AIDS.
4. classify the behavioural & neurological manifestations associated with HIV/ AIDS.
5. explain management for HIV-AIDS.
6. identify relation between ‘Covid-19’ and ‘HIV infection’.

3. HIGH RISK GROUPS FOR HIV/AIDS
 African American and Hispanic populations
 Homosexual and bisexual men who do not practice safe sex
 Individuals with multiple sexual partners
 Adolescents who do not practice safe sex
 Older adults who have unprotected sex, use alcohol, or inject drugs.
 Heterosexual intravenous drug users
 Heterosexual men and women who have had sex with a person from one of the previously mentioned groups.
 Persons with haemophilia and others who have received blood transfusions.
 Infants born to mothers carrying the AIDS virus
 Persons who are occupationally exposed.

4. DIFFERENCE BETWEEN HIV & AIDS
Sr. no. HIV AIDS
1. HIV is acronym for Human Deficiency Virus. AIDS is acronym for Acquired Immune Deficiency
Syndrome.
2. It’s a Virus that invades the human immune
system- CD4+ cells (helper T- lymphocytes).
It’s a final (4th) stage condition of HIV infection and
features the broad spectrum of illnesses thus called
as syndrome.
3. A person can have HIV without getting AIDS. Anyone who has AIDS has HIV.
4. HIV is diagnosed with the blood or saliva test. AIDS diagnosis involves the count for CD4 cells, but
since it’s the final stage mostly it goes undiagnosed.

5. 5. HIV just produces flu-like symptoms because
immune system manages to keep them in
control.
AIDS manifests numerous of symptoms as the
virus progresses in the final stage of illness.
6. Life expectancy of HIV clients has increased
with the medical progress in recent times
before AIDS develops.
Once HIV develops into AIDS, the patient’s life
expectancy drops exponentially. This is because its
difficult to repair the damage done by the virus to
immune system at this point.

6. 1. TYPOLOGYOF HIV INFECTION
BY INTERNATIONALAIDS SOCIETY (IAS)
Sr.
no.
Typology Description
1.
Low-level HIV
epidemics
Although HIV may have existed for many years, it has
never spread to significant levels in any sub-
population. (E.g.: Sex workers, drug injectors, men having
sex with other men).
2.
Concentrated-
HIV epidemics
HIV has spread rapidly in a defined sub-population but
is not well-established in the general population.
3.
Generalized-HIV
epidemics
HIV is firmly established in the general population.
Although sub-populations at high risk may contribute
disproportionately to spread of HIV.

7. SUPPORTIVE SERVICES PROVIDED,
ACCORDING TO TYPOLOGY OF HIV INFECTION:
Concentrated and
Low- level epidemic condition
Generalized
epidemic condition
STI services Medical inpatient and out- patient facilities, including
TB clinics
Services for most at risk populations Antenatal, childbirth, and postpartum health services
Antenatal, childbirth, and postpartum health
services
Services for most at risk populations
TB services Services for children under 10 years of age, Services for
adolescents, Surgical services, Reproductive health
services, including family planning.

8.  Direct Neuronal Damage:
 CNS infection by the HIV virus leads mainly to sub-cortical damage, however, recent work has also shown the
presence of cortical atrophy. In the subcortical area, there is evidence of inflammatory changes with severe
vacuolation and gliosis. The main ultimate damage further leads to HIV encephalitis.
 Entry of virus into CNS: HIV does not enter the CNS as a viral particle and can not infect directly as the CNS
cells do not have a CD4 viral receptor. Instead, the virus enters the CNS in a latent form inside a monocyte,
commonly known as the ‘Trojan Horse’ mechanism.
 Brain damage because of opportunistic infection and tumours:
 The majority of CNS damage is caused by the opportunistic infections which include infections such as
cryptococcal meningitis, toxoplasmosis, and opportunistic viral infections
2. NEUROPATHOLOGYOF HIV

9.  Patho-physiology of HIV on the CNS:
Initial systemic HIV
infection
Crosses Blood Brain Barrier
via infected macrophage
Viral replication in infected
astrocytes & monocytes
Low grade
Neuroinflammatory response
Neurotoxic effect on brain
parenchyma
Neurological & Psychiatric
Sequelae

10. 3. ASSOCIATIONOF SPECIFICCONDITIONS
WITHHIV INFECTION
 The substances like alcohol, cannabis, poppers, cocaine, hallucinogens, and heroin.
 The consistent findings are a higher incidence of high-risk sexual behaviour with poppers, alcohol, and cannabis
intake.
1. SUBSTANCE ABUSE & HIV INFECTION

11.  HIV-related diagnosis of Substance Abuse Disorder:
 The prevalence of this comorbidity is exceeding high: about 50 percent of those in HIV care have a comorbid mental
illness.
 DUAL diagnosis: refers to patient who has both a drug use disorder and another psychiatric disorder.
 TRIPLE diagnosis: refers to dual diagnosis patient who has HIV.
 Steps for treatment of substance abuse disorder:
 Role induction and motivation to change
 Detoxification
 Treatment of co-morbid conditions
 Rehabilitation
 Relapse prevention

12. Sr. Symptom Description
1. Disinhibition of
sexual
behaviour
Alcohol and cannabis have both been related to sexual disinhibition and failure to use
condoms. Relapse into high risk behaviour, after following safer sex practices, has also been
reported in men when under the influence of intoxicants.
2. Effect of
substance on
cognition and
decision making
Recreational drugs and alcohol affect both information processing and psychomotor
performance. When intoxicated, the person may not remember to use condoms and may
also have faulty judgement in his choice of sexual preference.
3. Social and
Cultural
learning
Patients might indulge in various behaviours based on what is expected out of them in given
social context. By various means, people learn to associate substance use with high risk
sexual activity, particularly through media and situation co-occurrence of sexual activity and
substance availability. This is particularly happening in bars and highway hotels.

13. Sr. Symptom Description
4. Personality factors Aspects of an individual’s personality such as sensation seeking and impulsivity,
might influence substance use associated with sexual risk taking. In some, this
might be the basis for such behaviour, while in others it may be way of coping
with loneliness and stress.
5. Biological factors Studies have shown a high association of poppers and cocaine use with HIV
infection among gay men. This has been hypothesized to be due to fragility of
the rectal mucosa, which increases rectal bleeding and the ability of infected
semen to enter the blood stream of receptive partner.

14.  The relative risk is approximately 20 times that of the general population.
 Risk factors for suicide in seropositive:
a) Knowledge of disease:
 The risk of suicide in the period following diagnosis of the infection has been emphasized. Factors that lead to
suicide at this stage (6- weeks following revelation) are due to inadequate pre and post-test counselling, the way
news is revealed and the availability of emotional support.
b) Stage of disease:
 As a patient progress in the course of disease and immunosuppression sets in, there is an increase in suicidal
ideation. Presence of dementia and organic brain syndromes also lead to a higher incidence of deliberate self-harm.
2. SUICIDE AND HIV INFECTION

15. C) Psychosocial risk factors:
 Multiple psychological stressors.
 Perceived social isolation
 Perception of self as a victim
 Denial as the central and only defence.
 Drug abuse
 Perceived poor social support
 History of personality disorder or deliberate self-harm.

16. A) HIV associated mild Neuro-cognitive disorder:
American Academy of Neurology, describes both the cognitive and motor dysfunction As: The motor
disorder is characterized by slowed movements and incoordination.
 Common neurocognitive symptoms are:
 Impaired memory
 Word finding/ retrieval
 Concentration
 Slowing
 Motor activity
 Abstraction
3. COGNITIVE DISORDERS ASSOCIATED WITH HIV INFECTION:

17. B) HIV associated Dementia or AIDS Dementia:
 This represent the more advanced cognitive disorder associated with HIV infection. The signs include marked impairment
in attention, concentration, and information processing. There is also impairment in acquisition of new information and
recall, problems in fluency and naming, and incoordination and propensity to aphasia.
 Generally seen in late stages of HIV illness where, (CD4+ count <200 cells/ml).
 Prevalence reported to be 15%
 Risk factors: Higher HIV RNA load, lower educational level, older age, anaemia, illicit drug & female sex.
 Presentation: Trait of symptoms like memory and psychomotor speed impairments, depressive symptoms, and movement
disorders
 HIV associated dementia is rapidly progressive usually ending in death within two years.
 Management: Modified HIV dementia scale is used for bedside screening of disease progression. HAART (Highly active
Antiretroviral therapy) may be some benefit in slowing progression. Some people remain stable with HAART, others will
progress to frank dementia.

18. C) HIV Delirium:
 Affective changes in the form of liability and depression may occur occasionally. The patients may become apathetic
and dull, or there may be delirium or even an acute psychosis imposed on the dementia. The difference between the
mild cognitive disorder and dementia lies in the severity of symptoms and interference with daily functioning.
 It is a state of global derangement of cerebral function.
 Prevalence is reported to be between 43- 65%.
 The clinical presentation of Dementia is same as those in non-HIV infected individuals.
 Management of delirium:
 Identification and removal of identifying cause.
 Reorientation of patient by maintaining diurnal variation of life cycle.
 Management of behaviour/ psychosis by low dose of high potency antipsychotics

19. A) HIV- RELATED DEPRESSION:
4. MOOD DISORDERS ASSOCIATED WITH HIV INFECTION
Risk factor for acquiring
HIV due to depression
Consequences of HIV
leading to depression
 Impact on behaviour  Caused by direct injury to
subcortical areas
 Intensification of substance
abuse
 Chronic stress
 Exacerbation of self-
destructive behaviours
 Social isolation & intense
demoralization
 Promotion of poor partner
choice in relationship.
 HIV related medical conditions
& medications.

20.  Depression & HIV relationship:
Depression
Increase in cortisol levels
Decrease in circulating lymphocytes
Reduced ability of lymphocytes to produce lymphokines
Increased expression of HIV by mononuclear cells

21. B) AIDS Mania:
 Associated with late-stage HIV infection.
 Consequences of brain involvement.
 Progressive cognitive decline prior to onset of mania
 Irritable mood is more characteristic than euphoria.
 Psychomotor with cognitive slowing of AIDS dementia will replace the expected hyperactivity of mania.
 Lack of previous episodes or family history.
 Has chronic course rather than episodic.

22.  The family of an AIDS client experiences severe psychological stress and trauma.
 Shame & Guilt: The issue of the individual’s sexuality and lifestyle, of which the family often was not aware, may create an
additional crisis when they are confronted with the knowledge that their son, daughter, or sibling has terminal illness.
 The pressure on family system causes members to respond with anger, confusion, and possible rejection of the AIDS client and
his or her entire lifestyle. Families may blame the client’s partner for the condition.
 Families also are forced to assume financial responsibility, which can further magnify their anger, guilt, and frustration. Some
families can achieve resolution of their own painful psychological conflicts and provide the necessary physical and emotional
support to AIDS client.
 In response to this familial abandonment, the individual with AIDS often develops an alternate family that assumes the support
and caretaker role. This new family may include a gay partner and close gay and straight friends who significantly alter their
lifestyles to care for the client. These friends experience the same sense of loss, isolation, and bereavement as the more
traditional family, but are denied the customary social support systems and public recognition for their role.
5. EFFECTS OF HIV/AIDS ON FAMILY DYNAMICS:

23.  Bacterial infections (multiple or recurrent)
 Candidiasis of bronchi, trachea, oesophagus, and
lungs.
 Cervical cancer (invasive)
 Cryptococcosis (extrapulmonary)
 Cryptosporidiosis (chronic intestinal, >1 month)
 Cytomegalovirus rhinitis (with loss of vision)
 Encephalopathy (HIV related)
 Chronic ulcers (bronchitis or esophagitis, >1 month)
 Lymphoma (Burkitt’s)
 Lymphoma (immunoblastic)
 Mycobacterium tuberculosis (pulmonary or
extrapulmonary)
 Pneumocystis pneumonia
 Progressive multifocal leukoencephalopathy
 Salmonella septicaemia (recurrent)
 Toxoplasmosis of brain
 Wasting syndrome (HIV related)
 Kaposi’s sarcoma
 Herpes simplex
6. PHYSIOLOGICAL & MENTAL ILLNESSES ASSOCIATED WITH
HIV- INFECTION:

24.  Psychiatric illnesses associated with HIV Clients:
1. Anxiety disorders:
a. Panic disorder (death anxiety)
b. Generalized anxiety disorder
2. Adjustment disorders:
a. With anxious and depressed mood
b. Major depression
c. Mania (mostly in late stage of disease due to neurocognitive impairment).
d. Suicidal ideation (because of relapses, inadequate social and financial support and presence of delirium and
dementia).

25. 3. Organic Mental Disorders/ Psychotic disorders:
a. Dementia (AIDS dementia complex)
b. Delirium
c. Organic mood disorders
d. Organic personality disorder
e. Organic hallucinosis
f. Organic delusional disorder
4. Substance use disorders:
a. Alcohol
b. IV drug abuse

26. 5. Worried well:
The so called worried well are those in the high-risk groups, who are seronegative and disease free, are anxious about
contracting the virus. Some are reassured by repeated negative serum test results, but others cannot be reassured. Their worried
well status can progress quickly to generalized anxiety disorder, panic attacks, obsessive- compulsive disorder and
hypochondriasis- (belief and fear of having or getting serious illness, even after several medical reassurance).
 Characteristics of the Worried Well:
 Repeated negative HIV tests.
 Low risk sexual history, including covert and guilt inducing sexual activity.
 Poor post adolescence sexual adjustment
 Social isolation
 Dependence in close relationships (if any)
 Multiple misinterpreted somatic features usually associated with undiagnosed viral or post viral states (not HIV) or anxiety or depression.
 High level of anxiety, depression, and obsessional disturbance.
 Increased potential for suicidal gestures.

27. MANAGEMENT OF THE HIV/ AIDS CLIENTS IN
PSYCHIATRY
1. HIV is not death sentence, but it is perceived in that way by the victims.
2. There is no cure for HIV and AIDS, but treatment is available.
3. Antiretroviral therapy (ART) and Post-exposure prophylaxis (PrEP) reduces the viral load. Controlling the infection and decreasing
the risk of AIDS developing.
4. PrEP is a medical treatment that can help prevent HIV infection in people who are at substantial risk for contracting the virus:
 Those in serodiscordant relationship- (relationship in which one partner is infected with HIV and one is not).
 Those who do not use condoms consistently with partners of unknown HIV status.
 Gay or bisexual men who have recently been diagnosed with a sexually transmitted infection or who have unprotected sex.
 Those who share needles.

28.  HIV related services recommended by “International Aids Society”
(IAS) for implementation of provider-initiated HIV testing and
counselling in health care facilities:
1. Assessment of Individual or group pre-test information.
2. Basic prevention services for persons diagnosed “HIV- Negatives”:
 Post- test HIV prevention counselling for individuals or couples that includes information about prevention services.
 Promotion and provision of male and female condoms.
 Needle and syringe access and other harm reduction interventions for injecting drug users.
 Post-exposure prophylaxis, where indicated.

29.  Basic prevention services for persons diagnosed “HIV- Positives”:
 Individual post-test counselling by a trained provider that includes information about and referral to prevention, care,
and treatment services, as required.
 Support for disclosure to partner and couples counselling.
 HIV testing and counselling for the partners and children.
 Safer sex and risk reduction counselling with promotion and provision of male and female condoms.
 Needle and syringes access and other harm reduction interventions for injecting drug users.
 Interventions to prevent mother to child transmission for pregnant women, including antiretroviral prophylaxis.
 Reproductive health services, family planning counselling and access to the contraceptive methods.

30.  Basic care and support services for persons diagnosed “HIV-Positive”.
 Education, psychosocial and peer support for management of HIV.
 Periodic clinical assessment and clinical staging.
 Management and treatment of common opportunistic infections.
 Co-trimoxazole prophylaxis.
 Tuberculosis screening and treatment when indicated, preventive therapy when appropriate
 Malaria prevention and treatment, where appropriate
 STI case management and treatment
 Palliative care and symptom management
 Advice and support prevention interventions, such as safe drinking water.
 Nutrition advice
 Infant feeding counselling
 Antiretroviral treatment, where available

31.  PRE-TEST HIV COUNSELLING:
1. Discuss meaning of a positive result and clarify distortions (e.g.:If the test detects exposure to the HIV virus,
it’s not a test for AIDS).
2. Discuss the meaning of a negative result (e.g.: seroconversion requires time, recent high- risk behaviour may
require follow-up testing).
3. Be available to discuss the patients fears and concerns (unrealistic fears may require appropriate
psychological interventions).
4. Discuss why the test is necessary. (Not all patients will admit to high-risk behaviours).
5. Explore the patient’s potential reactions to a positive result (e.g.: “I’ll kill myself if I’m positive”). Take
appropriate necessary steps to intervene in a potentially catastrophic reaction.

32. 6. Explore past reaction to severe stressful situations.
7. Discuss the confidentiality issues relevant to the testing situation (e.g.: is it an anonymous or non- anonymous
setting?). Inform the patient of other possible testing options where the counselling and testing can be done
completely anonymously. (E.g.: where the result is not made a permanent part of a hospital care). Discuss who
has access to the test results.
8. Discuss with the patient how being seropositive can be potentially affect social status. (E.g.: health and life
insurance coverage, employment, housing).
9. Explore high-risk behaviour and recommended risk- reducing interventions.
10. Document discussions in chart.
11. Allow the patient time to ask questions.

33.  Possible indications for Human Immunodeficiency Virus (HIV) Test:
1. Patients who belong to a high-risk group
a) Men who have has sex with another man since 1977.
b) Intravenous drug abusers since 1977.
c) Haemophiliacs and other patients who have received blood or blood product transfusions and not screened
for HIV, since 1977.
d) Sexual partners of people from any of those above groups.
e) Sexual partners of people with known HIV exposure- like people with cuts, wounds, sores, or needlesticks
whose lesions have had direct contact with HIV- infected blood.

34. 2. Patients who request testing. Not all patients admit to the present the risk factors, because of shame and fear.
3. Patients with symptoms or acquired immunodeficiency symptoms (AIDS).
4. Women belonging to a high-risk group who are planning pregnancy or who are pregnant.
5. Blood, semen, or organ donors.

35.  Informed Consent:
 Minimum information for informed consent:
 The reasons why HIV testing and counselling is being recommended.
 The clinical and preventive benefits of testing and the potential risks, such as discrimination, abandonment, or violence.
 The services that are available in the case of an HIV- positive test result, including whether antiretroviral treatment is available.
 The fact that the test result will be treated confidentially and will not be shared with anyone other than health care providers directly
involved in providing services to the patient.
 The fact that patient has right to decline the test and that testing will be performed unless the patient exercises that right.
 The fact that declining an HIV test will not affect the patients access to services that do not depend upon knowledge of HIV status.
 In the event of an HIV-positive test result, encouragement of disclosure to other persons who may be at risk of exposure to HIV.
 An opportunity to ask the health care providers questions.

36.  Confidentiality:
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.
Clinicians should be aware of the laws about such issues, which vary among the states. These guidelines are also
applied to inpatient psychiatric wards when a patient who is HIV infected is believed to be sexually active with
other patients.

37.  Questions to ask at the time of diagnosis:
1. What has the doctor told you about your or your child’s illness?
2. How can I help you understand what the doctors have told you?
3. What seems to be worrying now you?
4. How do you usually deal with stress?
5. Do you have any religious beliefs that may help you?
6. Who do you usually talk with about how you are feeling?
7. Would you like a counsellor, therapist, social worker, or chaplain to talk with you?
8. What is the best that you are hoping for?
9. What is the worst that you are afraid of?
10. Do you know someone who has been through something like this?
11. What can I do for you now to help ease your mind?
12. Who can I contact to come visit you?

38. POST-TEST HIV COUNSELLING:
1. Interpretation of test result: Clarify distortion (e.g.: “a negative test still means you could contact the virus at a
future time, it does not mean you are immune from AIDS”). Ask questions about the patients understanding
and emotional reaction to the test result.
2. Recommendations for preventing of transmission (careful discussion of high-risk behaviour and guidelines for
prevention of transmission).
3. Recommendations on the follow-up of sexual partners and needle contacts.
4. If the test result is positive, recommendations against donating blood, sperm, or organs and against sharing
razors, toothbrushes, and anything else that may have blood on it.
5. Referral for appropriate psychological support: HIV-positive patients often need access to a mental health team
(access need for inpatient versus outpatient care, consider individual or group supportive therapy). Common
themes include the shock of the diagnosis, the fear of death, and social consequences, grief over potential
losses, and dashed hopes for good news. Also look for depression, hopelessness, anger, frustration, guilt, and
obsessional themes. Activate supports available to patient. (E.g.: family, friends, community services).

39.  Health care providers should:
 Inform the patient of the test result simply and clearly and give the patient time to register it.
 Ensure that the patient understands the result.
 Allow the patient to ask questions.
 Help the patient to cope with emotions arising from the test results.
 Crisis intervention: Discuss any immediate concerns and assists the patient to determine who in her/his social
network attention to the achievable and acceptance to offer immediate support.
 Describe follow-up services that are available in the health facility and in the community, with special attention to the
available treatment. PMTCT (Prevention of Mother to Child Transmission) and care with support services.
• Provide information on how to prevent further transmission of HIV infection, including provision of male and female
condoms and guidance on their use.

40.  Provide information on other relevant preventive health measures such as good nutrition, frequent prescribed
use of co-trimoxazole (antibiotic for bacterial lung infections) in malarial areas, insecticide treated bed nets.
 Discuss possible disclosure of the result, when and how this may happen and to whom.
 Encourage and offer referral for testing and counselling of partners and children.
 Assess the risk of violence or suicide and discuss possible steps to ensure the physical safety of patients,
particularly women.
 Arrange a specific date and time for follow-up visits or referral for treatment, care, counselling, support, and
other services as appropriate (e.g.: tuberculosis screening and treatment, prophylaxis for opportunistic
infections. STI treatment, family planning, antenatal care, opioid substitution therapy, and access to sterile
needles and syringes.

41.  Post-test counselling for HIV-Positive pregnant women:
 Childbirth plans
 Use of antiretroviral drugs for the patient’s own health, when indicated and available, and to prevent mother to child
transmission.
 Adequate maternal nutrition, including iron and folic acid.
 Infant feeding options and support to carry out the mother’s infant feeding
choice.- [Assignment]- (HOW?, WHICH METHOD?)
 HIV testing for the infant and the follow-up that will be necessary.
 Partner testing

42.  Clearance of “Stigma” attached with HIV infection:
 There are three broad types of HIV/AIDS-related stigma.
1. Self-stigma: occurs through self-blame and self- deprecation.
2. Perceived stigma: related to the fear that individuals have- that if they disclose their HIV positive status.
3. Enacted stigma- occurs when individuals are actively discriminated against because of their HIV status.
 The cause of HIV/AIDS stigma is Ignorance, Lack of accurate information about HIV/AIDS &
Misunderstanding about HIV transmission

43.  Joining the support groups will help in decreasing stigma by
1. Providing more knowledge about the illness.
2. How to deal with it.
3. Get to know more about others who are in the same situation as themselves.
4. Joining the group makes them realise that they are not alone in the lonely world of life with HIV/AIDS.
 Support groups for AIDS in INDIA – SAATHII (Solidarity and Action Against the HIV Infection in India) -
Chennai, ASHA Foundation - Bangalore, THE HUMSAFAR TRUST - Mumbai, (INP+) Indian Network for
People Living with HIV/AIDS - Chennai, Bal Raksha, Bharat - Delhi.

44.  Frequency of testing:
 Re-testing every 6-12 months may be beneficial for individuals at higher risk of HIV exposure, such as
persons with a history of STI, sex workers and their clients, men who have sex with men, injecting drug users
and sex partners of people living with HIV. Additional research is needed in diverse settings with varying HIV
epidemiology to determine the optimum interval between HIV tests for specific populations.
 Risks of HIV transmission to the infant are very high in the mother acquires HIV during pregnancy or while
breastfeeding. HIV negative women should be tested as early as possible in each new pregnancy, particularly
in high- prevalence settings and in the case of women who are at high risk of HV exposure.

45.  PSYCHOLOGICAL ISSUES IN HIV/AIDS COUNSELLING:
1. Shock:
 Of diagnosis
 Recognition of mortality
 Of loss of hope for the future
2. Fear and Anxiety:
 Uncertain prognosis
 Effects of medications and treatment/ treatment failure
 Of isolation and abandonment and social/ sexual rejection
 Of infecting others and being infected by them
 Of partner’s reaction

46. 3. Depression:
 In adjustment to living with chronic viral condition
 Over absence of a cure
 Over limits imposed by possible ill health
 Possible social, occupational, and sexual rejection
 If treatment fails
4. Anger and frustration:
 Over becoming infected
 Over new and involuntary health/lifestyle restrictions
 Over incorporating demanding drug regimens, and possible side effects, into daily life.
5. Guilt:
 Interpreting HIV as a punishment, (e.g.: for being gay or using drugs).
 Over anxiety caused to partner/ family.

47. COVID-19 & HIV / AIDS
(ACCORDING TO INTERNATIONAL AIDS SOCIETY)
 How does COVID-19 affect the people living with HIV?
 It is thought that people living with HIV who have achieved viral suppression through antiretroviral treatment
and do not have a low CD4 count will be affected by COVID-19 in a similar way to what a person not living with
HIV would be, based on other coronavirus-caused disease outbreaks such as SARS (caused by SARS-CoV-1)
and MERS (caused by MERS-CoV), where only a few cases of mild disease among people living with HIV were
reported.
 Does taking PrEP prevent you from getting COVID-19?
 There is no evidence that PrEP prevents you from getting COVID-19 or that it will help you recover quicker if
you use PrEP.

48.  What is the advice for the people living with HIV related to COVID-19?
 Regular handwashing with soap and water for at least 20 seconds. Download a practical guide on how to support community-level
handwashing, particularly in resource-limited settings. Access more resources on handwashing.
 Cover your mouth and nose with a tissue, your sleeve, or your elbow (not your hands) when you cough or sneeze.
 Put any used tissues into the bin immediately.
 Avoid touching eyes, nose, or mouth with unwashed hands.
 Stay away from work, school, public spaces, and other people if you become sick.
 Continue to take your HIV treatment regularly, as prescribed, to keep your immune system as strong as possible.
 People living with HIV who are on treatment should ensure that they have at least 30 days of ARVs with them and, where possible,
a 3 to 6-month supply of ARVs.
 People living with HIV should stay socially connected with networks and communities using technology where possible and address
any stress or anxiety with friends and your healthcare provider.

49.  What about people living with HIV, who are also living with or survived TB Co-infection?
 Given that both pulmonary TB and COVID-19 affect the lungs, high TB burden countries will need to protect
people living with TB and TB survivors from SARS-CoV-2 exposure (SARS-CoV-2 is the virus that causes the
coronavirus disease COVID-19), to differentiate between those with respiratory illness caused by TB vs COVID-
19, which would require different clinical management.
 How much supply of HIV medication should I have during LOCKDOWN?
 People living with HIV who are on treatment should ensure that they have at least 30 days of ARVs with them
and, where possible, 3 to 6 months’ supply of ARVs.
 Before the COVID-19 outbreak, the World Health Organization already recommended that clinically stable
adults, children, adolescents and pregnant and breastfeeding women, as well as members of key populations
(men who have sex with men, people who inject drugs, sex workers and transgender people), could benefit
from multi-month prescriptions and refills.

50.  Can HIV medication be used to treat COVID-19?
 Currently, there is insufficient data to assess the effectiveness of any type of antiretroviral for treating COVID-
19. A recent study published in the New England Journal of Medicine showed that a combination of lopinavir
and ritonavir – both antiretrovirals used to treat and prevent HIV – was not associated with clinical
improvement or mortality in seriously ill patients with COVID-19 compared to standard of care alone.

51. RESEARCH ARTICLE
 Article 1:
The burden of anxiety among people living with HIV
during the COVID-19 pandemic in Pune, India
Ivan Marbaniang 1 2, Shashikala Sangle 3, Smita Nimkar 4, Kanta Zarekar 4, Sonali Salvi 3, Amol Chavan 4, Amita
Gupta 4 5, Nishi Suryavanshi 4, Vidya Mave
Published: 23 October 2020
Cite: Marbaniang, I., Sangle, S., Nimkar, S. et al. The burden of anxiety among people living with HIV during the
COVID-19 pandemic in Pune, India. BMC Public Health 20, 1598 (2020).
https://doi.org/10.1186/s12889-020-09656-8

52. Abstract
 Introduction
Globally, India has the third largest population of people living with HIV (PLHIV) and the second highest number of
COVID-19 cases. Anxiety is associated with antiretroviral therapy (ART) nonadherence. It is crucial to understand the
burden of anxiety and its sources among Asian Indian PLHIV during the COVID pandemic, but data are limited.
 Methods
During the first month of government mandated lockdown, we administered an anxiety assessment via telephone
among PLHIV registered for care at a publicly funded antiretroviral therapy (ART) centre in Pune, India. Generalized
anxiety was defined as GAD-7 score ≥ 10. Sociodemographic and clinical variables were compared by anxiety status
(GAD-7 score ≥ 10 vs GAD-7 score < 10). Qualitative responses to an open-ended question about causes of concern
were evaluated using thematic analysis.

53.  Results
Among 167 PLHIV, median age was 44 years (IQR 40–50); the majority were cisgender women (60%) and had a
monthly family income < 200 USD (81%). Prior history of tuberculosis and other comorbidities were observed in 38
and 27%, respectively. Overall, prevalence of generalized anxiety was 25% (n = 41). PLHIV with GAD-7 score ≥ 10 had
fewer remaining doses of ART than those with lower GAD-7 scores (p = 0.05). Thematic analysis indicated that
concerns were both health related and unrelated and stated temporally. Present concerns were often also projected
as future concerns.
 Conclusions
The burden of anxiety was high during COVID lockdown in our population of socioeconomically disadvantaged
PLHIV in Pune and appeared to be influenced by concerns about ART availability. The burden of anxiety among
PLHIV will likely increase with the worsening pandemic in India, as sources of anxiety are expected to persist. We
recommend the regular use of short screening tools for anxiety to monitor and triage patients as an extension of
current HIV services.

54. THANK
YOU