HIV PSYCHIATRY and its associated stigma 083948.ppt

Increase awareness to reduce HIV associated stigma

1. PSYCHIATRIC MANIFESTATIONS OF HIV/AIDS
BY: Dr Florent Ishimwe
SHO-3
KIU-Psychiatry Department

2. INTRODUCTION
•HIV: A retrovirus, previously called the human T-cell
lymphotropic virus (HTLV). This virus infects cells
important for the human immune response, especially
helper T cells, and leaves its host vulnerable to
opportunistic infections.
•AIDS: A clinical syndrome defined by HIV infection with
certain associated signs and / or symptoms, known as
AIDS-defining conditions.

3. History
•One of the earliest documented HIV infections was
discovered in a preserved blood sample taken in
1959 from a man from Congo.
•In 1981 the AIDS epidemic was first described in the
medical literature, it was in 1983 that the first articles
were published about the psychosocial or psychiatric
aspects of AIDS by Holtz & colleagues.
•First psychiatrist to address these issues was Stuart E.
Nichols in his article in Psychosomatics.

4. HIV IN Uganda
•Estimated prevalence is 6.3% among adults
•Prevalence in women is 8.1%
•Prevalence in men is 6.3%
•3.7% of adolescents and young adults aged between
15-24 years are living with HIV.

5. MODIFIERS OF HIV PSYCHIATRY
•Psychiatric manifestations of HIV disease are a complex
–Biological
–Psychological
–Social circumstances associated with this illness
•Bi-directional relationship between HIV and mental illness

6. Psychiatric manifestations of HIV/AIDS infection
HIV MI
1. Direct effects of HIV on brain
2. Indirect Effects Of HIV On The Brain
MI HIV
Vulnerability of Persons with severe mental illness to HIV infection
1.Mood disorders
2.Psychosis
3.PTSD
4.Personality disorders
5.Anxiety and phobic disorders
6.Adjustment disorders

7. Direct effects of HIV on brain
1.Delirium
2.HIV-associated neuro-cognitive disorder (HAND)
3.Mild cognitive and motor disorders
4.Dementia
5.Mental disorders(psychosis,BAD,..)

8. 1.Malignant course of HIV
infection and the
associated stigma.
2. Tumours & Opportunistic
infections
1.Toxoplasmosis
2.CMV infection
3.Progressive multifocal
leukoencephalopathy
4.Cryptococcal meningitis
5.Metastatic tumours eg Kaposi's
sarcoma
3. Effects of drugs
1.Anti Retroviral drugs
2.Acyclovir & Ganciclovir
3.Anti-tuberculosis drugs
4.Steroids
5.Chemotherapeutic agents.
4. Substances use
Indirect Effects Of HIV On The Brain

9. Direct effects of HIV on brain
•HIV can be isolated from the cerebrospinal fluid (CSF) and can also be found
in brain tissue, which suggests that the virus can cross the blood–brain barrier.
•Postmortem neuropathological examinations of HIV positive patients have
revealed the presence of virus in cortical and sub-cortical structures- frontal
lobes, sub-cortical white matter and the basal ganglia
• Some have suggested that the caudate nucleus and the basal ganglia are the
primary areas of pathogenesis
•HIV enter CNS within weeks after exposure

10. Pathogenesis of neuropsychiatric manifestations
-HIV crosses the blood–brain barrier by a Trojan-horse–type
mechanism using macrophages it infects
-Once in the brain, HIV targets and infects glial cells, from which
it later secretes neurotoxins that lead to neuronal damage
and death
- The extent of this neuronal damage is thought to be linked to the
level of clinical neurologic deficits

11. Delirium
•It is a state of global derangement of cerebral function.
Characterized by inattention, disorganized thinking, or
confusion, fluctuation in level of consciousness, hallucinations
and delusion
•Point prevalence in hospitalized AIDS patients - 30-40%
•Higher rates of new cases of delirium at the time of HIV
seroconversion.
•Patients with HIV associated dementia are at increased risk of
developing Delirium
•The clinical presentation in HIV patients is the same as those in non-
HIV-infected individuals

12. HAND (HIV-Associated Neurocognitive
Disorder)
•Encompass a hierarchy of progressively more severe
patterns of central nervous system (CNS) involvement -
•Asymptomatic neurocognitive impairment
(ANI)
•Minor neurocognitive disorder (MND)
•HIV-associated dementia (HAD)
12

13. Diagnosing HAND
-European AIDS clinical society (EACS) 2013 Guidelines
suggested screening –
-3 screening questions (Simioni et al., AIDS 2009)
1.Do you experience frequent memory loss (e.g. do you
forget the occurrence of special events even the more
recent ones, appointments, etc.)?
2. Do you feel that you are slower when reasoning, planning
activities, or solving problems?
3. Do you have difficulties paying attention (e.g. to a
conversation, a book, or a movie)?
13

14. Minor cognitive motor disorder
•The disorder is confirmed when mild impairments are present in
at least two of the following domains:
•Verbal/language, attention, memory (recall or new learning),
abstraction, and motor skills
•The symptoms are indirect & mild manifestations of the same
symptoms seen in HIV-associated dementia: Cognitive and motor
slowing
•Some patients may continue to have minor problems, while another
group will progress to frank dementia
•HAART may be of some benefit in slowing progression

15. HIV associated Dementia
•Prevalence of HIV dementia in infected adult is reported to be
15%
•It is generally seen in late stages of HIV illness, usually when
CD4+ count is below 200 cells per ml
•Risk factors associated are higher HIV RNA viral load, lower
educational level, older age, anaemia, illicit drug use & female sex
•Dementia –triad of symptoms
Memory impairment
Depressive symptoms
Movement Disorders

16. AIDS MANIA
•Associated with late-stage HIV infection.
•Consequences of brain involvement.
•Progressive cognitive decline prior to the onset of mania.
•Irritable mood is more characteristic than euphoria.
•Psychomotor slowing 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.

17. Indirect effectsIndirect effects
Malignant course of HIV infection and the associated
stigma
-There are three broad types of HIV/AIDS-related stigma.
1.Self stigma - occurs through ‘self blame and self-depreciation’.
2.Perceived stigma - related to the fear that individuals have 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
-Role of Pre-test Vs Post-test counselling

18. STIGMA ATTACHED WITH HIV INFECTION
•Stigma is socially constructed and is attributable to cultural,
social, historical and situational factors.
•Stigmatised individuals are subject to ‘‘feelings of shame and
guilt’’.
•Women are more vulnerable to the stigma.

19. •Joining the support groups will help in decreasing stigma by
–Providing more knowledge about the illness.
–How to deal with it.
–Get to know more about others who are in the same
situation as themselves.
–Joining the group makes them realise that they are not
alone in the lonely world of life with HIV/AIDS.

20. Tumours & Opportunistic infections
1.Toxoplasmosis
2. Cytomegalovirus (CMV) infection
3.Progressive multifocal leukoencephalopathy
4.Cryptococcal meningitis
5.Metastatic tumors eg Kaposi's sarcoma

21. Effects of drugs
1.Anti Retroviral drugs
2.Acyclovir & Ganciclovir
3.Anti-tuberculosis drugs
4.Steroids
5.Chemotherapeutic agents

22. EFFECTS OF DRUGS
Diagnosis Implicated agents
Depression Abacavir, Efavirenz(mc), Indinavir,
Nevirapine, IFN-α, Steroids, INH.
Mania Didanosine, Efavirenz, Zidovudine.
Psychosis Abacavir, Efavirenz, Nevirapine,
Acyclo/Ganciclovir, Prednisone.
PTSD Efavirenz.
Anxiety Didanosine, Gancicylovir.
Vivid dreams Abacavir, Nevirapine, Efavirenz.
Suicidal ideation Abacavir, Efavirenz.
Miscellaneous symptoms Efavirenz.

23. Substance abuse
•Substance abuse is a primary vector for the spread
of HIV.
•Often demoralized, become hopeless & are more
likely to engage in high risk behaviours.
•Patients with substance use disorders may not
seek health care or may be excluded from health
care.
•Addiction and high-risk sexual behaviour have
been linked across a wide range of settings.

24. Treatment of substance use disorder in patients
infected with HIV
Education of patients role.
Detoxification
Treatment of comorbid conditions
Rehabilitation
Relapse prevention
24

25. VULNERABILITY OF PERSONS
WITH SEVERE MENTAL ILLNESS
TO HIV INFECTION

26. BIPOLAR ILLNESS
•Treatment of mania in early stage HIV infection is same as that
for the standard treatment of bipolar disorder.
•Mood-stabilizing medications, particularly Lithium salts,
Valproic acid, Lamotrigine, Carbamazepine and Antipsychotic
agents.
•AIDS mania patients typically respond to treatment with
antipsychotic agents alone.

27. •Lithium – problematic because
Delirium, GI side effects, Cognitive difficulties, Polyurea
→
Dehydration, DI, rapid fluctuations in blood levels.
•Valproic acid – hepato toxic, alters hematopoietic function.
•Carbamezapine – sedation, bone marrow suppression
synergistic to HAART.

28. SCHIZOPHRENIA
•Prevalence rates of 4 - 19%.
•No evidence about HIV infection causes schizophrenia.
•There are data to show that schizophrenia contributes to
behaviours that may lead to HIV infection.
•Patients with more positive symptoms & impulse control
problems are at increased risk for high-risk sexual
behaviour.
•Disease generally tend to be more serious in patients
with schizophrenia

29. •Treatment follows same basic principles as any other
patient with schizophrenia, namely control of symptoms
with medications, psychosocial support & rehabilitation.
•Numerous reports suggest that HIV-infected patients may
be vulnerable to extrapyramidal symptoms, including
neuroleptic malignant syndrome and tardive dyskinesia.
•So it is recommended that low doses of high potency
neuroleptics to be used.
•Avoid Efavirenz -based regimens due to a higher risk of
neuro psychiatric side effects.

30. PTSD
•It endangers or exacerbates HIV risk behaviors and
worsen health outcomes.
•Symptoms of PTSD are associated with risk behaviors
and markers of HIV progression.
•In HIV treatment, traumatic stressors and PTSD
symptoms have been associated with a lower CD4 T
cell to CD8 T cell ratio at 1 yr follow-up.
•PTSD is most often comorbid with depression and
substance abuse—both risk factors for HIV

31. •Instruments used for screening for PTSD are Trauma
History Questionnaire & the PTSD Checklist.
•Treatment typically involves behavioural exposure
and flooding.
•Treatment should address coexisting depression or
substance abuse or it may worsen psychiatric status.

32. PERSONALITY DISORDERS
•Prevalence rates of personality disorders among HIV
at risk is 15 - 20%.
•High-risk behaviours among individuals who are HIV-
infected.
•Traditional approaches in risk reduction counselling
emphasize the avoidance of negative consequences in
the future.
•Such approaches have proved ineffective for
individuals with certain personality characteristics.

33. •No specific “alcoholic” or “drug-using” personality.
•Link between substance abuse & either
impulsivity/high novelty seeking or high on
neuroticism/negative emotionality.
•Individuals with both these traits may be at the
greatest risk of addiction.
•In the Psychiatry Service of the Johns Hopkins AIDS
Service (JHAS), about 60% of patients present with
the blend of extroversion & emotional instability.

34. •Antisocial personality disorder is the most common
and is a risk factor for HIV infection.
•High rates of substance abuse, more likely to inject
drugs & share needles, higher numbers of lifetime
sexual partners, engage in unprotected anal sex &
contract STDs.

35. •Personality traits were not directly related to HAART
adherence.
•Non adherence is more common among extroverted or
unstable patients.
•The personality characteristics that are associated with
risk for HIV also reduce the ability to adhere to drug
regimens.
•A cognitive-behavioural approach is most effective in
patients with extroverted and/or emotionally unstable
personalities.

36. Hypochondriacal syndrome
A hypochondriacal syndrome, marked by the persistent
belief in the presence of HIV infection, despite repeated
negative serological tests and clinical examinations.
The clinical features of the 'worried well‘ Include anxiety
with the possible occurrence of panic attacks triggered
by social discussion of the topic.

37. Anxiety based physical symptoms and signs (fatigue,
sweating, skin rashes, muscle pains, diarrhea, palpable
lymph nodes), which are misinterpreted as manifestations
of HIV infection.
Obsessive thoughts(ruminations over past high-risk
sexual practices, threats of infection to the loved ones,
dirtiness or infectivity of bodily fluids)

38. HIV Depression
•women report higher rates of depression than men in the
general population
•Risk group for depression
Who have not disclosed their sero positive status
Who have lost their loved one due to HIV infection
Advancing stage of illness (Two & half fold increase in rates of
depression as CD4+ count decreases below 200
Treatment failure
Antiretroviral drugs also trigger depression

39. Depression HIV
↔
•Depression is a risk factor for HIV - impact on
behaviour, intensification of substance abuse,
exacerbation of self-destructive behaviours &
promotion of poor partner choice in relationships
•HIV increases the risk of developing major
depression - direct injury to subcortical areas of
brain, chronic stress, social isolation, intense
demoralization, HIV related medical conditions &
medications.

40. Suicide & HIV infection
•16 – 17 times higher than general population.
•Accounts for 0.8% of all AIDS death.
•Risk factors include –
Inadequate pre & post test counseling, manner in
which news revealed, emotional support.
Stage of disease.
Psychosocial factors – stress, isolation, denial, drug
abuse, social support.

41. Suicide & HIV infection
•Risk assessment.
•Treatment of underlying depression.
•Treatment of physical complaints.
•Crisis intervention.
•Supportive therapy or CBT.

42. Adjustment and reactive disorders
This describes one’s morbid response to the diagnosis.
May occur in 5-20 % of patients.
Usually associated with poor coping strategies.
Risk factors include:
1.past history of psychiatric problem
2. poor support
3. lack of social acceptance
Clinical manifestations:
Depression
Anxiety
Obsession and compulsions

43. Acute stress reaction
•may be seen, most commonly at the time of learning a positive
test result.
•Depressive features with insomnia, suicidal ideas and
depersonalization may be seen.
•Other reactions may include anger, despair, guilt, increased
drug/ alcohol use, social withdrawal and high risk sexual
behavior.
Management:
Based on pre-test and post-test counseling.

44. References:
Neuropsychiatric aspects of HIV by Dr. victor Robin
Kaplan & Sadocks Comprehensive Textbook of
Psychiatry 9
th
edition
Psychological medicine 1990. from WHO division of
Mental Health Global Programme on AIDS.