The human immunodeficiency virus (HIV) epidemic was identified in
the 1980s and neurologists described several HIV-related central nervous system
(CNS) syndromes within the first several years of the epidemic. Mental health
professionals from nursing, social work, psychology, and psychiatry followed the
plight of patients of the epidemic and helped to mobilize interest and galvanize
a response. Initially, much of the work focused on grief and loss issues, as
well as supportive psychotherapy, but quickly broadened to recognize a number of
specific psychiatric conditions, including acquired immune deficiency syndrome
(AIDS) dementia, the associated AIDS mania, increased rates of major depression,
and psychiatric consequences of CNS injuries.
The first case of AIDS was reported in 1981. Analysis of specimens
retained from persons who died before 1981, however, has shown that HIV
infections were present as early as 1959. This suggests that in the 1960s and
1970s, HIV-related disorders and AIDS were increasingly common but unrecognized,
particularly in Africa and North America. According to the Centers for Disease
Control and Prevention (CDC), in 2005 almost 950,000 persons in Americas were
diagnosed with full-blown AIDS since 1981. There were about 43,000 new
infections, in 2004 with about 15,000 deaths. The CDC estimates that
approximately 460,000 person are living with AIDS in the United States. The
World Health Organization (WHO) estimates that, worldwide, 2.5 million adults
and 1 million children have AIDS and about 30 million persons are infected with
HIV. The CDC statistics on epidemiological data on AIDS in the United States is
listed in Table 11-1.
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. At least 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 (Table 11-2).
The chance of becoming infected after a single exposure to an
HIV-infected person is relatively low: 0.8 to 3.2 percent for unprotected
receptive anal intercourse, 0.05 to 0.15 percent with unprotected vaginal sex,
0.32 percent after puncture with an HIV-contaminated needle, and 0.67 percent
after using a contaminated needle to inject drugs. The probability of
transmission, however, could be higher, depending on the viral load of the
contact person (which tends to be higher at the beginning and end of the course
of the illness) or other factors, such as sexually transmitted diseases. 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.
Although 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.
Some studies have shown that about 50 percent of the regular sex partners of
persons with HIV infection become infected themselves, a statistic suggesting
that some persons do not yet understand immunity or resistance to HIV
infection.
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. The risk of infection of health care workers after a
needlestick is rare, about 1 in 300 incidents.
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. In practice, however, the incidence of such transmission is very low,
and almost all reported cases have been traced to accidental punctures with
contaminated hypodermic needles. 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 person's bodily fluids, such as blood and semen, should be
avoided (Table 11-3).
After infection with HIV, AIDS is estimated to develop in 8 to 11
years, although this time is gradually increasing because
of early treatment. 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 cell's 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 patient's entire complement of T4 lymphocytes.
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of early treatment. 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 cell's 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 patient's entire complement of T4 lymphocytes.
Table 11-1 The Centers for Disease Control and
Prevention (CDC) Statistics on Epidemiological Data on Acquired Immunodeficiency
Syndrome (AIDS) in the United States
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Table 11-2 AIDS Safe-Sex
Guidelines
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Table 11-3 Centers for Disease Control and
Prevention (CDC) Guidelines for the Prevention of HIV Transmission from Infected
to Uninfected Persons
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Diagnosis
Serum 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. Those with a negative HIV test result have
either
not been exposed to the HIV virus and are not infected or were exposed to the HIV virus but have not yet developed antibodies, a possibility if the exposure occurred less than a year before the testing. Seroconversion most commonly occurs 6 to 12 weeks after infection, although in rare cases seroconversion can take 6 to 12 months.
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not been exposed to the HIV virus and are not infected or were exposed to the HIV virus but have not yet developed antibodies, a possibility if the exposure occurred less than a year before the testing. Seroconversion most commonly occurs 6 to 12 weeks after infection, although in rare cases seroconversion can take 6 to 12 months.
Table 11-4 Possible Indications for Human
Immunodeficiency Virus (HIV) Testing
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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
(Table 11-4), any person who wants to be tested should
probably be tested. The reasons for requesting a test should be ascertained to
detect unspoken concerns and motivations that may merit psychotherapeutic
intervention.
Past practices that may have put the testee at risk for HIV
infection and safe sexual practices should be discussed (Table
11-5). During posttest counseling (Table 11-6),
counselors should explain that a negative test finding implies that safe sexual
behavior and the avoidance of shared hypodermic needles are recommended for the
person to remain free of HIV infection. A positive test result indicates that
the person is infected with HIV and can spread the disease. Those with positive
results must receive counseling about safe practices and potential treatment
options. They may need additional psychotherapeutic interventions if anxiety or
depressive disorders develop after they discover that they are infected. Common
issues and concerns are fear of disclosure, relationships with friends and
family, employment and financial security, medical condition, and such
psychological issues as self-esteem and self-blame. A person may react to a
positive HIV test finding with a syndrome similar to posttraumatic stress
disorder. Concern about minor physical symptoms, insomnia, and dependence on
health care workers commonly arise. Adjustment disorder with anxiety or
depressed mood may develop in as many as 25 percent of those informed of a
positive HIV test result. Clinical interactions with patients should emphasize
the meaning of a positive test result and should encourage reestablishment of
emotional and functional stability.
Table 11-5 Pretest HIV
Counseling
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Table 11-6 Posttest HIV
Counseling
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Couples who are considering taking the HIV antibody test must
decide who will be tested and whether to go alone or together. The therapist
should ask why they are considering taking the test; partners often for the
first time discuss issues of commitment, honesty, and trust, such as sexual
contacts outside the relationship. They need to be prepared for the possibility
that one or both are infected and must discuss what effect this will have on
their relationship.
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.
Clinicians should be aware of the laws about such issues, which vary among the
states. These guidelines also apply to inpatient psychiatric wards when a
patient who is HIV infected is believed to be sexually active with other
patients.
Clinical Features
Nonneurological 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-Barré syndrome.
In the United States, the median duration of the asymptomatic
stages is 10 years, although nonspecific symptoms—lymphadenopathy, chronic
diarrhea, weight loss, malaise, fatigue, fevers, night sweats—may variably
appear. During the asymptomatic period, however, the T4 cell count almost always
declines from normal values (>1,000/mm3) to grossly abnormal
values (<200/mm3).
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.
Diagnosis is made with fiberoptic bronchoscopy and alveolar lavage. The
pneumonia is usually treatable with trimethoprim and sulfamethoxazole (Bactrim,
Septra) or pentamidine isethionate (Pentam), which can also be used for
prophylaxis against the pneumonia. The other disease that was initially
associated with the development of AIDS is Kaposi's sarcoma, a previously rare,
blue-purple-tinted skin lesion. For unknown reasons, Kaposi's sarcoma is less
commonly associated with cases of recently diagnosed AIDS.
Although Pneumocystis carinii pneumonia
and Kaposi's sarcoma are the two classic AIDS-related infectious and neoplastic
disorders, the severely disabled cellular immune system of patients infected
with HIV permits the development of a staggering array of infections and
neoplasms. 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.
For psychiatrists, the importance of these nonneurological,
nonpsychiatric complications lies in their biological effects on patients' brain
functions (e.g., hypoxia with Pneumocystis carinii
pneumonia) and their psychological effects on patients' moods and anxiety
states. Further, because each of the conditions is usually treated by an
additional drug, psychiatrists need to be aware of the adverse CNS effects of
many medications.
Neurological Factors
An extensive array of disease processes can affect the brain of a
patient infected with HIV (Table 11-7). The most important
diseases for mental health workers to be aware of are HIV
mild neurocognitive disorder and
HIV-associated dementia. The latter is a cortical or subcortical type of dementia that can affect 50 percent of patients infected with HIV to some degree. Other diseases and complications of treatment must also be considered in the differential diagnosis of a patient who is HIV infected with neuropsychiatric symptoms. Symptoms such as photophobia, headache, stiff neck, motor weakness, sensory loss, and changes in level of consciousness should alert a mental health worker that the patient should be examined for possible development of a CNS opportunistic infection or a CNS neoplasm. HIV infection can also result in a variety of peripheral neuropathies that should prompt mental health clinicians to reconsider the extent of CNS involvement.
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HIV-associated dementia. The latter is a cortical or subcortical type of dementia that can affect 50 percent of patients infected with HIV to some degree. Other diseases and complications of treatment must also be considered in the differential diagnosis of a patient who is HIV infected with neuropsychiatric symptoms. Symptoms such as photophobia, headache, stiff neck, motor weakness, sensory loss, and changes in level of consciousness should alert a mental health worker that the patient should be examined for possible development of a CNS opportunistic infection or a CNS neoplasm. HIV infection can also result in a variety of peripheral neuropathies that should prompt mental health clinicians to reconsider the extent of CNS involvement.
Psychiatric Syndromes
HIV-Associated Dementia
The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR) allows the diagnosis of dementia due to HIV disease in “the
presence of a dementia that is judged to be the direct pathophysiological
consequence of human immunodeficiency virus (HIV) disease.†(See Table 10.3-7.)
Although HIV-associated dementia is found in a large proportion of
patients infected with HIV, other causes of dementia in these patients must be
considered. These causes include CNS infections, CNS neoplasms, CNS
abnormalities caused by systemic disorders and endocrinopathies, and adverse CNS
responses to drugs. The development of dementia is generally a poor prognostic
sign, and 50 to 75 percent of patients with dementia die within 6
months.
Mild Neurocognitive Disorder
A less severe form of brain involvement is called HIV-associated neurocognitive disorder, also known as HIV encephalopathy. It is characterized by impaired
cognitive functioning and reduced mental activity that interferes with work,
homemaking, or social functioning. No laboratory findings are specific to the
disorder, and it occurs independently of depression and anxiety. Progression to
HIV-associated dementia usually occurs but may be prevented by early
treatment.
Delirium
Delirium can result from the same causes that lead to dementia in
patients infected with HIV (Table 11-7). Clinicians have
classified delirious states characterized by both increased and decreased
activity. Delirium in patients infected with HIV is probably underdiagnosed, but
it should always precipitate a medical workup of a patient infected with HIV to
determine whether a new CNS-related process has begun.
Anxiety Disorders
Patients with HIV infection may have any of the anxiety disorders,
but generalized anxiety disorder, posttraumatic stress disorder, and
obsessive–compulsive disorder are particularly common.
Adjustment Disorder
Adjustment disorder with anxiety or depressed mood has been
reported to occur in 5 to 20 percent of patients infected with HIV. The
incidence of adjustment disorder in persons infected with HIV is higher than
usual in some special populations, such as military recruits and prison
inmates.
Depressive Disorders
A range of 4 to 40 percent of those infected with HIV have been
reported to meet the diagnostic criteria for depressive disorders. The pre-HIV
infection prevalence of depressive disorders may be higher than usual in some
groups who are at risk for contracting HIV. Another reason for the reported
variation in prevalence rates is the variable application of the diagnostic
criteria; some of the criteria for depressive disorders (poor sleep and weight
loss) can also be caused by the HIV infection itself. Depression is higher in
women than in men.
Mania
Mood disorder with manic features, with or without hallucinations,
delusions, or a disorder of thought process, can complicate any stage of HIV
infection, but most commonly occurs in late-stage disease complicated by
neurocognitive impairment.
Substance Abuse
Substance abuse is a problem both for IV substance abusers who
contract HIV-related diseases and for other patients with HIV, who may have used
illegal substances only occasionally in the past but may now be tempted to use
them regularly to deal with depression or anxiety.
Suicide
Suicidal ideation and suicide attempts may increase in patients
with HIV infection and AIDS. The risk factors for suicide among persons infected
with HIV are having friends who died from AIDS, recent notification of HIV
seropositivity, relapses, difficult social issues relating to homosexuality,
inadequate social and financial support, and the presence of dementia or
delirium.
Psychotic Disorder
Psychotic symptoms are usually later stage complications of HIV
infection. They require immediate medical and neurological evaluation and often
require management with antipsychotic medications.
Worried Well
The so-called worried well are those in high-risk groups who,
although they 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.
Treatment
Prevention is the primary approach to HIV infection. Primary
prevention involves protecting persons from getting the disease; secondary
prevention involves modification of the disease's 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. Preventive
strategies, however, are complicated by the complex societal values surrounding
sexual acts, sexual orientation, birth control, and substance abuse. 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.
The assessment of patients infected with HIV should include a
complete sexual and substance-abuse history, a psychiatric history, and an
evaluation of the support systems available to them. Clinicians must understand
a patient's history with regard to sexual orientation and substance abuse, and
the patient must feel that the therapist is not judging past or present
behaviors. A therapist can often encourage a sense of trust and empathy in the
patient by asking specific, well-informed, straightforward questions about the
homosexual or substance-using culture. The therapist must also determine the
patient's knowledge about HIV and AIDS.
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The homosexual community has provided a significant support system
for those infected with HIV, particularly for persons who are gay and bisexual.
Public education campaigns within this community have resulted in significant
(more than 50 percent) reductions in the highest risk sexual practices, although
some gay men still practice high-risk sex. Homosexual men are likely to practice
safe sex if they know the safe-sex guidelines, have access to a support group,
are in a steady relationship, and have a close relationship with a person with
AIDS. Partly because of the many biases against them, IV substance users with
AIDS have received little support, and little progress has been made in
educating these persons who are a major reservoir for spread of the virus to
women, heterosexual men, and children.
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. In 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. Table 11-8 lists some of the available agents in each of these
four categories.
The antiretroviral agents have many adverse effects. Of importance
to psychiatrists is that protease inhibitors are metabolized by the hepatic
cytochrome P450 oxidase system and, therefore, can increase levels of certain
psychotropic drugs that are similarly metabolized. These include bupropion
(Wellbutrin), meperidine (Demerol), various benzodiazepines, and selective
serotonin reuptake inhibitors (SSRIs). Therefore, caution must be exercised in
prescribing psychotropic drugs to persons taking protease inhibitors.
Table 11-8 Antiretroviral
Agents
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Beyond treatment directed specifically against HIV, many
interventions are available to prevent and treat various complications of
immunodeficiency caused by opportunistic viral, bacterial, fungal, and protozoan
infections. Both survival and quality of life have improved substantially
because of early diagnosis and treatment of these opportunistic
conditions.
The use of combination antiretroviral regimens in conjunction with
more specific treatments of complications has prolonged the survival of persons,
both asymptomatic and symptomatic HIV infected. Despite progress in maintaining
patients longer and in better states of health, the ultimate outcome, however,
is still uncertain; that is, it is unclear at present whether any person who is
HIV infected can expect to escape developing AIDS and ultimately dying. Those
who are HIV infected are keenly aware of this prognosis, and their concern
sometimes takes the form of psychiatric disturbances.
Novel treatments may also be useful. Neuronal excitotoxicity,
mediated through the activation of glutamatergic receptors by the HIV envelope
protein gp120, is a potentially important mechanism by which brain dysfunction
might occur in HIV infection. Memantine is an open-channel antagonist of
N-methyl-d-aspartate (NMDA)-type glutamate receptors that is generally well
tolerated. It is currently being used as a treatment for dementia of the
Alzheimer's type in Europe. On the assumption that an agent that could dislodge
gp120 from neural receptor sites might be useful, an octapeptide called
d-ala-peptide-t-amide (peptide t) has been used in phase II clinical trials.
Compared with placebo, peptide t was associated with neuropsychological
improvement in cognitively impaired individuals (with CD4 counts <200) and a
reduced likelihood of progression of impairment on 6-month follow-up. Calcium
channel inhibitors, which theoretically seemed potentially useful, have not
proved successful.
The remaining forms of treatment are principally supportive. The
most important step is to exclude other potentially treatable conditions, such
as secondary infections or neoplasia, metabolic abnormalities with low-grade
delirium, or other psychiatric disorders (e.g., major depressive disorder). Once
the diagnosis is clear, then the usual supportive measures for neurocognitively
impaired persons should be used. These include identifying areas of cognitive
strength and deficit, reducing emphasis on areas that are now impaired (e.g.,
divided attention, speeded processing), emphasizing efforts to maintain good
orientation and reality testing, and avoiding medications that might further
compromise cognitive function, in particular, benzodiazepine drugs. If they must
be used, such medications should be given at lower than usual doses.
Antidepressant and antipsychotic agents, if indicated, may also have to be
prescribed in much lower dosages (e.g., 25 percent of the usual recommended
dosage).
Psychotherapy
Approaches
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.
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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.
Among the fears that must be confronted is the concern that once
the individual's serostatus has been revealed, he or she has lost control of who
next learns of the seroconversion. In deciding whether or not to tell others,
patients must also address their sense of betrayal if they are not told. The
same issues apply to the person's work environment. As a practical matter, the
individual may need to decide whether to tell a trusted colleague in case of a
job-related accident that might put others at risk of infection. Similarly,
parents must decide when or whether to tell their children. Some parents want to
tell very young children as soon as possible, whereas other parents prefer to
withhold this information until their child's teenage years, for fear of
“taking away their childhood.†The question of custody of children after the
parent's death must be considered. The same question of timing will arise about
when to tell children that they are seropositive. The parent must balance fears
that telling the child's school will lead to discrimination while guarding their
child's and others' safety in case of an accident.
The psychiatrist may have a special role regarding HIV treatment.
The advent of protease inhibitors and the promise of additional increasingly
effective therapies have brought hopes of a “cure†to patients and
physicians alike. Even patients who have failed one or more rounds of
combination therapies may find that family, friends, and physicians continue to
be optimistic. The psychiatrist may be the only “safe†person to whom the
patient can express discouragement, weariness, fear of treatment failure, and
fury or guilt for not being able to tolerate successful therapy or for not
responding to regimens that have benefited others. The psychiatrist also may be
the only one confronting unrealistic expectations of cure or the assumption that
safe sex practices are no longer relevant. Paradoxically, the therapeutic task
also may be to examine the patient's reaction to a reprieve from certain
death—the so-called second-life agenda.
Direct counseling regarding substance use and its potential adverse
effects on health of the patient who is HIV infected is indicated. Specific
treatments for particular substance-related disorders should be initiated if
necessary for the total well-being of the patient.
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 therapist's 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 patient's family, lover, and close friends are often important
allies in treatment. The patient's 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 patient's
support group can help the therapist assess the patient's cognitive function and
can also aid in planning financial and living arrangements for the patient. The
patient's 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.
References
Becker JT, Lopez OL, Dew MA, Aizenstein HJ. Prevalence of cognitive
disorders differs as a function of age in HIV virus infection. AIDS. 2004;18[Suppl 1]: S11–S18.
Castellon SA, Hardy DJ, Hinkin CH, Satz P, Stenquist
PK, van Gorp WG, Myers HF, Moore L. Components of depression in HIV-1 infection:
Their differential relationship to neurocognitive performance. J Clin Exp Neuropsychol.
2006;28(3):420–437.
Davis HF, Skolasky RL Jr, Selnes OA, Burgess DM,
McArthur JC. Assessing HIV-associated dementia: Modified HIV dementia scale
versus the grooved pegboard. AIDS Reader
2002;12:29–31, 38.
Grant I, Atkinson JH Jr. Neuropsychiatric aspects of HIV infection and
AIDS. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's
Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Baltimore:
Lippincott Williams & Wilkins; 2000:308.
Hilsabeck RC, Castellon SA, Hinkin CH.
Neuropsychological aspects of coinfection with HIV and hepatitis C virus. Clin Infect Dis. 2005;41:S38–S44.
Maldonado JL, Fernandez F, Levy JK. Acquired immunodeficiency
syndrome. In: Lauterbach EC, ed. Psychiatric Management in
Neurological Disease. Washington, DC: American Psychiatric Press;
2000:271.
Martin L, Tummala R, Fernandez F. Psychiatric
management of HIV infection and AIDS. Psychiatr Ann.
2002;32:133.
P.380
Olley BO, Zeier MD, Seedat S, Stein DJ. Post-traumatic
stress disorder among recently diagnosed patients with HIV/AIDS in South Africa.
AIDS Care. 2005;17:550–557.
Paul RH, Brickman AM, Navia B, Hinkin C, Malloy PF,
Jefferson AL, Cohen RA, Tate DE, Flanigan TP. Apathy is associated with volume
of the nucleus accumbens in patients infected with HIV. J
Neuropsychiatry Clin Neurosci. 2005;17:167–171.
Paul RH, Flanigan TP, Tashima K, Cohen R, Lawrence J,
Alt E, Tate D, Ritchie C, Hinkin C. Apathy correlates with cognitive function
but not CD4 status in patients with human immunodeficiency virus. J Neuropsychiatry Clin Neurosci.
2005;17:114–118.
Pieper AA, Treisman GJ. Drug treatment of depression
in HIV-positive patients: Safety considerations. Drug
Saf. 2005;28(9):753–762.
Roseengarten M, Imrie J, Flowers P, Davis MD, Hart GJ.
After euphoria: HIV medical technologies from the perspective of their
prescribers. Sociol Health Illn.
2004;26(5):575–596.
Stoff DM, Mitnick L, Kalichman S. Research issues in the multiple
diagnosis of HIV/AIDS, mental illness and substance abuse. AIDS Care. 2004;16[Suppl 1]:S1–S5.
Treisman GJ, Angelino AF, Hsu J, Lyketsos CG. Neuropsychiatric aspects
of HIV infection and AIDS. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry.
8th ed. Vol. 1. Baltimore: Lippincott Williams & Wilkins;
2005:426.
von Giesen HJ, Haslinger BA, Rohe S, Roller H, Arendt
G. HIV Dementia scale and psychomotor slowing—The best methods in screening
for neuro-AIDS. J Neuropsychiatry Clin Neurosci.
2005;17:185–191.
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