This document discusses the neuropsychiatric manifestations of HIV infection. It begins by describing the history and epidemiology of HIV, noting it was first isolated in 1983 in West Africa and North America. It then covers the etiological agent of HIV, the virus itself. The majority of the document discusses the neurological and psychiatric manifestations of HIV, including opportunistic infections of the central nervous system like toxoplasmosis and cryptococcal meningitis, direct effects on the brain, and psychiatric conditions like delirium. It provides clinical features and treatment approaches for many of the conditions presented.

1. NEUROPSYCHIATRIC
MANIFESTATIONS OF
HIV INFECTION
DR.ASHWATHI.J
FINAL YEAR PSYCHIATRY RESIDENT
SSIMS & RC
21ST JUNE 2019

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3. • VIRUS ISOLATED – 1983 WEST AFRICA AND NORTH AMERICA; FIRST NAMED –
LYMPHADENOPATHY ASSOCIATED VIRUS AND LATER AS HUMAN T-CELL
LYMPHOTROPIC VIRUS TYPE 3 AND LATER CALLED AS HIV ; CROSS SPECIES
TRANSMISSION FROM CHIMPANZEE BLOOD AND MUCOSAL SECRETIONS DURING
HUNTING OR WHEN EATING RAW CONTAMINATED MEAT
• 1986; DR, SUNITI SOLOMON AND DR. SELLAPAN NIRMALA AMONGST FEMALE SEX
WORKERS IN CHENNAI TAMIL NADU. NATIONAL AIDS CONTROL ORGANISATION IN
1992- FOR FORMULATION OF POLICY AND IMPLEMENTATION OF PROGRAMS FOR
PEVENTION AND CONTROL OF HIV OR AIDS
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5. CONTENTS
• INTRODUCTION
• EPIDEMIOLOGY
• ETIOLOGICAL AGENT
• ETIOLOGY AND CLASSIFICATION OF HIV/AIDS
• NEUROLOGICAL MANIFESTATIONS OF HIV
• PSYCHIATRIC MANIFESTATIONS OF HIV
• SPECIAL ISSUES IN HIV
• HIV SPECIFIC PSYCHOTHERAPY
• CONCLUSION
• BIBLIOGRAPHY
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6. INTRODUCTION
• The human immunodeficiency virus (HIV) epidemic - major public health problem more than
25 years after the initial discovery of the infection and of the routes by which it is spread.
• Behaviours that expose one person to infectious body fluids from an already infected person.
behaviours that associated with the brain's reward systems.
• Psychiatric disorders - by increasing risk behaviour for infection & decreasing access to
treatment
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7. EPIDEMIOLOGY
• 1981 ; cases of Pneumocystis carnii pneumonia & Kaposi’s sarcoma were
reported from California & New York in previously healthy men who were
both homosexual and immunocompromised.
• According to UNAIDS in 2017,
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8. CONTINUED...
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9. CONTINUED...
• In 2017, 21.7 million people living with HIV were accessing ART globally, an
increase of 2.3 million since 2016.
• In 2017, 940 000 people died from AIDS-related illnesses worldwide, compared
to 1.4 & 1.9 million in 2010 & 2004.
• majority - in low- and middle-income countries.
• In 2017, 80% of pregnant women living with HIV had access to ART , up from
47% in 2010.
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10. CONTINUED...
• Rate of infection:
0.8 to 3.2 % - unprotected receptive anal intercourse
0.05 to 0.15 % - unprotected vaginal sex
0.32 % - HIV-contaminated needle puncture
0.67 % - contaminated needle to inject drugs.
• Male-to-female & female-to-male transmissions – most common transmission.
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11. CONTINUED...
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12. ETIOLOGIC AGENT
• AIDS is caused by HIV ; Retroviridae family & subfamily Lentiviridae.
• 2 types - HIV 1 and 2; former - most human infections.
• An icosahedral particle (outer envelope and viral core) RNA virus with 2
major envelope proteins gp 120 and gp41.
• Main receptor for gp120 - CD4 molecule on T lymphocyte helper cell.
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13. CONTINUED...
• single-stranded RNA virus.
• Cone- shaped core contains enzyme reverse
transcriptase(RNA-dependent deoxyribonucleic acid
polymerase) & Integrase.
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14. ETIOLOGY OF THE DISEASE
Infection with HIV
virus
targets CD4+ lymphocyte
& binds via gp120
injects its RNA into the
infected lymphocyte, &
RNA is transcribed into
DNA by RT
resultant DNA
incorporated into the host
cell's genome and
translated & eventually
transcribed
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. Budding - cause lysis of
the lymphocyte
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15. DEFINITION OF CASE
• AIDS case - any individual whose CD4 count has fallen below 200/μL or
persons with higher CD4 counts but who develop opportunistic infections
• “AIDS defining illness” - conditions which when developed lead to a
diagnosis of AIDS even in patients with CD4 level above 200/μL .
• classification system:
1. CDC staging system
2. WHO staging system
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16. CDC DISEASE STAGING SYSTEM
• Most recently revised in 1993
• Assesses the severity of HIV disease by CD4 cell counts and by the
presence of specific HIV-related conditions.
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17. CONTINUED...
• Category A includes:
one or more of the conditions listed below in an adolescent or adult with
documented HIV infection
1. Asymptomatic HIV infection
2. Persistent generalized lymphadenopathy
3. Acute (primary) HIV infection
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18. CONTINUED...
• Category B includes at least 1 of the following criteria:
(a) the conditions are attributed to HIV infection
(b) the conditions are considered by physicians to have a clinical course or
to require management that is complicated by HIV infection.
(c) conditions that not included among conditions listed in clinical
Category C
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19. CONTINUED...
Examples of conditions :
• Bacillary angiomatosis, Candidiasis
• Cervical dysplasia (moderate or severe)/cervical carcinoma in situ
• Constitutional symptoms (fever / diarrhoea lasting > 1 month)
• Hairy leucoplakia
• Herpes zoster
• ITP
• Listeriosis
• PID
• Peripheral neuropathy.
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20. CONTINUED...
• Category C
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21. WHO CLINICAL STAGING AND DISEASE
CLASSIFICATION SYSTEM
• Revised in 2007.
• Classified based on clinical manifestations that can be recognized and
treated by clinicians in diverse settings.
• Does not require a CD4 cell counts.
• Used in many countries to determine eligibility for ART, particularly in
settings in which CD4 testing is not available.
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22. CONTINUED...
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23. CONTINUED...
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24. CONTINUED...
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25. NEUROLOGICAL COMPLICATIONS OF HIV
AND AIDS
• Opportunistic infection
• CNS Neoplasms
• Direct CNS manifestations of HIV
• Peripheral Nervous system disorder
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26. OPPORTUNISTIC INFECTIONS
1) Toxoplasmosis
• Toxoplasma gondii - cat faeces or uncooked meat.
• < 200 CD4 cells/ml
• Symptoms of CNS infection are:
change in level of alertness, Headache, FND, seizures
• Serum T. gondii IgG & brain biopsy – Dx
• Rx- pyrimethamine plus sulfadiazine or clindamycin
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27. CONTINUED...
2) Cytomegalovirus
• 30 percent of brains from HIV-infected patients.
• 2 distinct syndromes of CMV CNS infection:
(a) ENCEPHALITIS WITH DEMENTIA:
o more common.
o Sub-acute onset.
o CF - delirium, apathy, FND
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28. (b) VENTRICULOENCEPHALITIS:
o infects the ependymal cells lining the ventricles.
o rapid progression from delirium to death.
o cranial nerve deficits & ventriculomegaly.
• PCR & brain biopsy - Dx
• Rx - Ganciclovir and foscarnet
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29. 3) Cryptococcal Meningitis
• Cryptococcus neoformans
• 8 to 10 % of AIDS patients.
• CF –delirium, seizure (+/-meningeal signs)
• Rx - amphotericin B and flucytosine.
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30. CONTINUED...
4) Progressive Multifocal Leukoencephalopathy
• demyelinating disease of white matter in immunocompromised patients.
• polyoma virus-JC virus - John Cunningham Virus
• Transmission route-respiratory
• 1 - 10 % of AIDS patients
• CF - hemiparesis, dysarthria, gait problem, dementia, coma and eventual death. Usually no
fever or headache
• Rx- supportive and HAART
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31. CONTINUED...
5) CNS Neoplasms
• Lymphoma - MC neoplasm seen in AIDS patients; 0.6 - 3 %.
• CF: afebrile, Seizures
• MRI - enhanced lesions that may be difficult to differentiate from CNS
toxoplasmosis, but thallium SPECT helps to differentiate the two disorders
• Dx - Brain biopsy
• Rx- radiation therapy and steroids with adjunctive chemotherapy.
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32. DIRECT CNS MANIFESTATIONS OF HIV
Guillain-Barré Syndrome
• an inflammatory demyelinating polyneuropathy causing symmetrical
paralysis (few sensory symptoms- beginning in the lower extremities &
progressing upward.
• serious if abdominal musculature is involved(impair respiration)
• autoimmune in etiology ; self-limiting
• IV immunoglobulin & plasmapheresis have been used to shorten the course.
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33. CONTINUED...
Vacuolar Myelopathy of the spinal cord
• history of P. carinii & M. avium-intracellulare infections - more severe
immunosuppression.
• Multinucleated giant cells are seen on histological examination.
• CF - spastic paraparesis, loss of proprioception and vibration sense, bowel and
bladder urgency or incontinence, Impotence
• Rx- supportive
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34. CONTINUED...
PERIPHERAL NEUROPATHIES
• MC - feet
• CF - parasthesia to burning pain, a vibratory-sense gradient with decreased
sensation in the distal extremity compared to more proximal points.
• Treatment of peripheral neuropathy may include:
Tricyclic antidepressants, Pregabalin, Gabapentin (Neurontin)
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35. PSYCHIATRIC CONDITIONS IN HIV
People infected with HIV may develop various psychiatric, psychological
and psychosocial problems either due to direct viral effect or by indirect
mechanisms.
• Psychiatric patients infected with HIV face a particularly difficult and
complex problem - unable to avoid high risk behaviours which increase
chances of their contracting the disease at the first place, vulnerable to
non-adherence to pharmacological and non pharmacological treatment
regimes thus placing them at high risk of drug resistance, high viral load,
more morbidity and mortality
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36. ACUTE PSYCHOLOGICAL REACTIONS
• Observed at the time of notification of a +ve serological test result
• Principle manifestations – acute shock, bewilderment & anxiety – last for
several weeks
• Denial – dangerous disregard of medical advice & failure to take
precautions against infecting others.
• Perry et al - diminishes within 10 weeks after notification
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37. DELIRIUM
• Prevalence -43 - 65% in the course of AIDS
• CF - inattention, disorganized thinking or confusion, and fluctuations in
level of consciousness; Acute or sub-acute onset.
• Risk factors - older age, multiple medical problems, multiple medications,
impaired visual acuity, previous episodes of delirium, patients with HIV-
associated dementia
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38. CONTINUED...
• DD: HIV-associated dementia, AIDS mania, minor cognitive–motor
disorder, major depression, bipolar disorder, panic disorder, schizophrenia.
• Differentiated - rapid onset, fluctuating level of consciousness & link to a
medical etiology.
• EEG - diffuse slowing of background alpha rhythm
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39. CONTINUED...
• Treatment consists of three parts:
1. Identification and removal of the underlying cause
2. Reorientation of the patient by maintaining a normal diurnal variation of light
cycles, providing orienting stimuli, such as calendars, clocks, and a view of the outside
world, and active engagement and reorientation by staff members, family, and friends.
3. Management of behaviour or psychosis- antipsychotic agents, benzodiazepines
should be used with caution
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40. HIV-ASSOCIATED DEMENTIA
• Dementia – cognitive decline in clear consciousness i/f/o impairments in executive function, processing
speed, attention & learning new information. May or may not interfere with independence in everyday
activities.
• In the ICD -11 – Dementia due to HIV(6D85.3).
• Pathogenesis- ‘combined effects’ model – HIV protein, glial & microglial activation mediated through
oxidative stress & glutaminergic excitotoxicity (Scaravilli et al)
• HIV 1 – MC, preventable & treatable cause of cognitive impairment in < 50 yrs.
• Prevalence – 1% (asymp), 3% (initial AIDS), 10- 20% (advanced disease)
• DD- mild : anxiety or depression.
severe : opportunistic infections & neoplasms.
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41. CONTINUED...
• Risk factors: higher HIV RNA viral load, older age, anemia, illicit drug use, female sex
• CF – disabling cognitive impairment accompanied with behavioural change
• O/E : early – rapid eye & limb movements impaired along with hyperreflexia
later – ataxia, leg weakness, clonus, frontal release signs
• Investigations – EEG & neuroimaging
• behavioural change – lethargy, social withdrawal, loss of spontaneity, psychomotor retardation, apathy
• Motor deficits – imbalance/ataxia/ loss of fine hand coordination/ deterioration of handwriting
• Frontal release signs – snout reflex, grasp , palmomental reflex,
• Eeg – diffuse slowing; neuroimaging- cortical atrophy, ventricular dilatation
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42. MINOR COGNITIVE–MOTOR DISORDER
• Criteria proposed by AAN AIDS Taskforce(1991)
I Acquired cognitive, motor or behavioural abnormalities (must have both A and B)
A At least two of the following symptoms present for at least 1 month:
Impaired attention or concentration / Mental slowing / Impaired memory / Slowed
movements / Incoordination / Personality change, or irritability or emotional lability
B Acquired cognitive or motor abnormality, verified by clinical neurological examination
or neuropsychological testing
II mild impairment of work or activities of daily living
III Does not meet criteria for HIV-associated dementia
IV Absence of another cause of the above cognitive, motor or behavioural abnormalities
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43. LONGER- TERM PSYCHIATRIC DISORDER
1) ANXIETY
• 4 – 19 %
• Important concerns – risk of infecting others/ being identified as a
homosexual or drug abuser/ availability of care in the future/ loss of
physical or financial independence.
• Risk – alcohol / drugs abuse to self-medicate
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44. 2) DEPRESSION:
• 2 – 48 %
• Risk of depression is double in seropositive individuals.
• Risk factors- past history of depression
• Anhedonia and diurnal mood variation – discriminating symptoms
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45. 3) OBSESSIVE – COMPULSIVE DISORDER
• with or without depressed mood
• Repeated bodily scrutiny for evidence of progression of disease,
questioning and scrutiny of spouse or partners for evidence of disease
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46. 4) SUICIDE :
• 30 % individuals at the time of serological testing but, falls down significantly
within 2 months.
• Suicide attempts tend to cluster in the first 6 months after a positive test result
thus underlining importance of pre and post test counselling
• Demographic and disease-related factors - white ethnicity, male gender,
homosexuality, physical health complications, frequency of AIDS-related
conditions and rapidity of disease progression
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47. 5) PSYCHOSES:
• Considerably kisser prevalent than depression
• Risk factors – past psychiatric history, lower cognitive performance and
the absence of ART
• Also few drugs in ART has the potential to cause de novo psychoses
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48. 6) MANIA:
• Common & associated with disease progression
• Irritable mood is more prominently seen than elation
• May or may not have associated psychotic symptoms
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49. 6) AIDS PHOBIA/ AIDS PANIC:
• Due to intense public concern aroused by AIDS and the amount of media
attention
• Raised anxieties in people at risk – homosexual or bisexual men
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50. 7) WORRIED WELL :
• A vehicle for hypochondriacal concern
• Anxiety cannot be allayed by repeated negative tests
• Negative tests results may be attributed by the patient to laboratory error, to the
appearance of a ‘new form’ of the virus, or to their inability to form antibodies as other
people do.
• cognitive–behavioural strategy based on cue exposure and response prevention, with
attempts at the reinterpretation of symptoms in terms of their origin in anxiety
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51. 8) FACTITIOUS / FRAUDULENT AIDS :
• present with unfounded claims of having the disease
• a variant of Munchausen’s syndrome - to secure medical attention.
• attend hospitals and clinics with a complex history of HIV-related illness,
including opportunistic infections and their treatment, all of which turns
out to have been fabricated
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52. MANAGEMENT OF PSYCHIATRIC DISORDERS:
• Depression & stress : SSRIs[favourable side-effect profile & lack of any
demonstrable effect of immune status] (fluoxetine) and tricyclics (imipramine,
desipramine); Methylphenidate/dexamfetamine – fatigue & amotivation
• Psychoses – HIV patients are more sensitive to EPS and so, low doses and slow
titrations with careful monitoring.
• Mania – sodium valproate - increase HIV replication
Carbamazepine and lamotrigine – have effects on enzyme system;
cautious use
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53. HIGHLY ACTIVE ANTIRETROVIRAL THERAPY
• nucleoside/nucleotide analogue reverse transcriptase inhibitors (NRTIs) –
zidovudine, abacavir, didanosine, stavudine
• non-nucleoside analogue reverse transcriptase inhibitors (NNRTIs) –
nevirapine, delavirdine, efavirenz
• protease inhibitors - indinavir
• fusion inhibitors - enfuvirtide
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54. ANTI RETROVIRAL DRUGS WITH
NEUROPSYCHIATRIC SIDE EFFECTS
• Headache – zidovudine, etravirine, saquinavir
• Peripheral neuropathy- didanosine, stavudine
• Psychosis- Efavirenz, abacavir, zidovudine, nevirapine
• Intracranial bleed- tipranavir
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55. HIV-SPECIFIC PSYCHOTHERAPY
• Pre-test, test & post-test counselling ;
• Risk behaviour reduction in patients at risk or infected with HIV;
• Partner notification in patients infected with HIV;
• HAART adherence
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56. PRE TEST COUNSELLING
• Discuss meaning of a positive test & clarify distortions
• Discuss meaning of a negative result
• Discuss why test is necessary
• Discuss patient’s fears and concern
• Explore patient’s potential reaction to a positive result
• Discuss confidentiality issues relevant to testing
• Discuss how positive result may affect social life
• Explore high risk behaviour and recommend risk reduction
• Document discussion
• Allow patient time to ask questions
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57. POST TEST COUNSELLING
• Interpretation of test results.
• Recommendation for prevention of transmission.
• Recommendation for follow up of sexual partners and needle contacts.
• If result is positive recommendation against donating blood, sperm or
organs.
• Referral for appropriate psychological support.
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58. RISK BEHAVIOR REDUCTION IN PATIENTS
AT RISK OR INFECTED WITH HIV
Interventions include:
• stress management and relaxation techniques
• psychotherapy directed at emotional distress reduction
• education directed at practising safer sex
• assertiveness training
• peer education in bars.
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59. PARTNER NOTIFICATION
• Partners should be notified of exposure risk and potential infection as well.
• Physicians or health department officials to notify partners of HIV-infected
patients of their risk.
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60. HAART ADHERENCE
• Intervention such as cognitive-behavioural psychotherapy, structured
psychoeducational psychotherapy, supportive psychotherapy, and group
interventions have all been used to improve patient adherence to office visits and
medication regimens.
• HIV medication adherence focuses on technical interventions such as pill box and
timer reminders, less complex pharmacological interventions, decreased pill burdens,
and increased access to care.
• Psychotherapy has been shown to improve clinic visit adherence, the best indirect
predictor of medication adherence.
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61. CONCLUSION
HIV disease/ AIDS is closely related to psychiatry with the infection
giving rise to many psychiatric problems and psychiatric illnesses
leading to risk of acquiring HIV. Hence the approach to such a
situation must be holistic with good coordination between medical
specialists and psychiatrists, psychologists to bring maximum
possible benefit to people with such a difficult illness
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62. BIBLIOGRAPHY
• https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics
• LISHMAN’S ORGANIC PSYCHIATRY
• KAPLAN & SADOCK’S COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 10th
EDITION
• GOOGLE (IMAGES)
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63. THANK YOU ☺
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