PSYCHIATRIC ASPECTS OF HIV.pptx hiv hivPSYCHIATRIC ASPECTS OF HIV.pptx hiv hiv

Psychiatrist

1. PSYCHIATRIC ASPECTS OF HIV/AIDS Group 5

2. Introduction It is recognized that a significant number of patients with HIV/AIDS have co-morbid psychiatric manifestations.

3. Introduction HIV: A retrovirus, infects cells that are important to the human immune response especially helper T cells (T4). Thus leaving the host vulnerable to opportunistic infections. AIDS: A clinical syndrome defined by HIV infection and AIDS-defining conditions (signs/symptoms/illnesses)

4. History Earliest documented HIV infection: 1959 AIDS epidemic: 1981 Earliest literature documenting psychosocial and psychiatric aspects of HIV/AIDS: 1983

5. HIV/AIDS in Tanzania 5% prevalence (1.4 million) in Tanzania (2013) 6.2% in women as compared to 3.8% in men Decreasing prevalence due to lower number of new sexually transmitted infections per year, also due to PMTCT. Decreased death rate due to AIDS/related illnesses

6. Mental illness Risk Adherence Outcomes

7. HIV/AIDS -> Mental illness HIV diagnosis as a predisposing factor and precipitating factor. AIDS-related Illness as maintaining and enhancing factors Insufficient and substandard pre- and post-test counselling Post-diagnosis PTSD/MDD 65% HIV-infected co-morbid with MDD [Atkinson et al, 1988] At least 1 episode of MDD in IVDU within 3 years of diagnosis [Johnson et al, 1999] Stigma

8. HIV/AIDS -> Mental illness Direct effects of HIV on the brain (Pathophysiology) Autopsy results: HIV-1 can activate macrophages -> generates neurotoxins -> OFRs -> neural degeneration. Dementia, Delirium, Mania Effects of ARVs [Neuronal and psychiatric adverse effects – Shazan et al] Other HIV-associated CNS manifestations Toxoplasmosis, Cryptococcal meningitis, Tuberculoma , Kaposi’s sarcoma etc

9. I mpacts of ARVs

10. Mental illness -> HIV/AIDS Personality disorders ( esp cluster B), behaviour towards adherence (impulse control and emotional regulation) Adjustment disorders (sad, hopeless, overwhelmed) Mood disorders ( esp Mania) Substance abusers Psychosis

11. Dementia Late stages of HIV infection leading to damage of the nerve cells leading to dementia. Unlike almost all other forms of dementia, it tends to occur in younger people. Presentation ; Slowed thinking and expression, difficulty concentrating, and apathy, but insight is not affected. Movements are slow, muscles are weak, and coordination may be impaired. In some people, a psychosis, such as hallucinations, delusions, or paranoia, develops. Some people become manic. That is, they become very restless and overactive. They may speak rapidly and act without good judgment.

12. Delirium In advanced stage HIV, presence of opportunistic infections and the damage to nerve cells in the brain can lead to delirium. It can also be due to the effects of ARV drugs Presentation: Decrease in alertness and cognition, ability to concentrate and emotional instability. Sleep wake cycle can be reversed as well as irritability and apathy. Subtypes – hypoalert , hyperactive.

13. Mania Late-stage disease complicated by neurocognitive impairment. Also due to more severe form of immunosuppression . Presentation : Increased energy level, decreased need for sleep, overtalktativeness , grandiosity, increased activity with incomplete actions, tendency towards over expenditure, increased libido ( hypersexuality ). With or without hallucinations/delusions.

14. Depression Neurocognitive damage as well as the effects of the diagnosis, living with HIV and stigma, associated illnesses etc. Presentation: sleep disturbances, guilt, low energy, decreased appetite and weight loss, isolation, lack of concentration, suicidality. * Risk of overdiagnosis (opportunistic infections)

15. Anxiety Anxiety can develop from the time of diagnosis; fear of abandonment, stigma or being discovered. Presentation : Patients tend to avoid socializing, have irrational fears as well as physical symptoms (hyperventilating, chest pain, sweaty palms)

16. Investigations Rapid tests ( Ditamine / Unigold ) – for diagnosis CD4 count (baseline, peak, current) Viral load FBP CT/MRI RFT/LFT BS for MPS Hormonal assay for T3/T4 Urine d rug tests (THC, alcohol)

17. Management For most psychiatric illnesses that occur secondary to HIV/AIDS, fully managing the HIV/AIDS itself helps to reduce the severity of the condition COUNSELLING Pre-test counselling : Information about the HIV test: why/what it’s for Info about HIV: transmission/prevention/treatment Reassuring confidentiality Make the patient understand what a positive/negative result means to them Post-test counselling : Interpreting the results Confirmation test If positive: explain effects of HIV, how to protect others, treatment options.

18. Pharmacotherapy ARVs, most common first line treatment TLE Prophylaxis against opportunistic infections – CTX Depending on the presentation, also give medication to treat the psychiatric illness. Identify the underlying cause (HIV) Supportive treatment Treat the symptoms eg . Cognitive enhancers (Methylphenidate, methylhexanamine ), Ach inhibitors, antipsychotics.

19. Psychotherapy Individual therapy : help to deal with self-blame/self-harm/ suicidality ), inappropriate behaviours that need to be changed related to the reason of infection. Exploring health care decisions, continue/change ARV therapy, terminal care, life support systems. Occupational therapy : Employment, career options and plans, life insurance and medical benefits. Family therapy : Addressing issues concerning stigma and relationships with family members and friends.

20. Therapist-related Issues Acknowledge your own attitude towards sexual behaviours , orientation, substance use in order to avoid judgment which can interfere with treatment.

21. Thank you