NEUROPSYCHIATRIC ASPECTS

OF HIV/AIDS
PRESENTER: DR. N. MANJUSHA (2NDYR PG)
CHAIRPERSON: DR. K. NARASIMHA REDDI
(HOD)
SCHEME OF PRESENTATION :-
▪ INTRODUCTION
▪ EPIDEMIOLOGY
▪ ETIOLOGICAL AGENT
▪ ETIOLOGY AND CLASSIFICATION OF HIV/AIDS
▪ NEUROLOGICAL MANIFESTATIONS OF HIV
▪ PSYCHIATRIC MANIFESTATIONS OF HIV
▪ SPECIAL ISSUES IN HIV
▪ HIV SPECIFIC PSYCHOTHERAPEUTIC ISSUES
▪ CONCLUSION
▪ REFERENCES
INTRODUCTION :-
▪ The human immunodeficiency virus (HIV)
epidemic continues to be a major public health
problem > 20 years after the initial discovery of
the infection & of the routes by which it is
spread.
▪ Psychiatric disorders play a role in the epidemic
by increasing risk behaviour for infection &
decreasing access to treatment.
▪ HIV infection is an unfortunate consequence of
a defined set of behaviours that expose one
person to infectious body fluids from an already
infected person.
▪ Many of the behaviours that can result in HIV
infection are those that are associated with the
brain's reward systems.
▪ HIV: A retrovirus, previously called the human T-
cell lympho-tropic virus (HTLV).
▪ This virus infects cells important for the human
immune response, especially helper T cells, &
leaves its host vulnerable to opportunistic
infections.
▪ AIDS: A clinical syndrome defined by HIV
infection with certain associated signs & / or
symptoms, known as AIDS-defining conditions.
HISTORY :-
▪ One of the earliest documented HIV
infections was discovered in a preserved
blood sample taken in 1959 from a man
from Belgian 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 /
psychiatric aspects of AIDS by Holtz &
colleagues.
▪ First psychiatrist to address these issues
was Stuart E. Nichols in his article in
Psychosomatics.
▪ HIV was originally recognized through a
series of case descriptions involving
young homosexual men with
Pneumocystis carinii (now Pneumocystis
jeroveci) pneumonia in the early 1980s in
Los Angeles.
EPIDEMIOLOGY :-

▪ Recent estimates indicate that up to 40

million people are infected worldwide,
while another 20 million have died from
HIV disease.
▪ Currently, 750,000 babies are born each
year with HIV infection.
▪ Some estimate that 16,000 new
infections occur each day & that one
individual is infected with HIV about
every 10 seconds.
▪ Chances of becoming infected after a single
exposure to an HIV infected person:
0.8 to 3.2 % for unprotected receptive anal
intercourse
0.05 to 0.15 % with unprotected vaginal sex
0.32 % after puncture with an HIV-
contaminated needle
0.67 % after using a contaminated needle to
inject drugs
▪ Male-to-male transmission has been the most
common route of sexual transmission in North
America.
▪ Male-to-female & female-to-male transmissions
are increasing, & they represent most common
transmission worldwide.
The populations at highest risk are :
▪ Homosexual men
▪ Intravenous drug users
▪ Female partners of intravenous drug users
Those who trade sex for money /
drugs.
▪ Health workers
▪ India has about 3 million
sufferers of AIDS & the southern
states (TN, Andhra &
Karnataka) & NE states of
Manipur, Nagaland, Mizoram
account for a large number of
cases.
▪ Mother-to-foetus transmission originally
occurred in 25 to 30 % of live births
depending on delivery type & severity
of HIV disease.
▪ It has been dramatically curtailed in the
United States to <2 % by the
development of antiviral treatment &
prophylaxis at parturition.
▪ Zidovudine & protease inhibitors taken
by the HIV infected pregnant woman
prevent peri-natal transmission in > 95%
of cases.
 AGENT :-
▪ AIDS is caused by Human Immunodeficiency
Virus (HIV) which belongs to Retroviridae family
& subfamily Lentiviridae.
▪ It was thought that HIV was a “slow virus” that
integrated into the cell genome & then was
latent until activated much later.
▪ It has 2 types HIV 1 & HIV 2, the former causes
most human infections.
▪ The virus is an icosahedral particle (outer
envelope & viral core)RNA virus with 2 major
envelope proteins gp120 & gp41.
▪ The main receptor for gp120 is CD4 molecule on
T lymphocyte helper cell.
▪ HIV is a single-stranded ribonucleic acid (RNA)
virus.
▪ Carries the enzyme reverse transcriptase (RNA-
dependent deoxyribonucleic acid [DNA]
polymerase).
▪ Reverse transcriptase synthesizes viral DNA from
the viral RNA strand.
▪ The viral envelope is lined with the matrix
protein (MA) referred to as p17.
▪ The cone-shaped core is made of capsid
protein p24 & contains nucleic capsid
protein p7 associated with 2 copies of
single stranded viral RNA & the enzymes
reverse transcriptase (RT) & integrase (IN).
▪ 3 “structural” genes that code for the
proteins in the structure of the virus
include the gag region, pol region, & the
env region.
VIRUS CELL CYCLE :-
1. Infection with HIV virus
2. Virus primarily targets T4 (helper) lymphocytes,
also called CD4+ lymphocytes, to which the virus
binds with the help of glycoprotein (gp120).
3. The virus injects its RNA into the infected
lymphocyte, where the RNA is transcribed into
DNA by the action of reverse transcriptase.
4. The resultant DNA can then be incorporated into
the host cell's genome & translated & eventually
transcribed.
5. After viral proteins have been produced by
lymphocytes, the various components of the virus
assemble, & new mature viruses bud off from the
host cell.
6. The process of budding may cause lysis of the
lymphocyte.
CLASSIFICATION SYSTEMS :-
▪ AIDS is defined as any individual whose CD4
count has fallen below 200/μL or persons with
higher CD4 counts but who develop
opportunistic infections.
▪ “AIDS defining illness” are a number of
conditions which when developed lead to a
diagnosis of AIDS even in pts with CD4 level
above 200/μL .
▪ HIV classification system :
1. CDC staging system
2. WHO staging system
 The CDC disease staging system
Most recently revised in 1993.

Assesses the severity of HIV disease by CD4 cell

counts & by the presence of specific HIV-related
conditions.
Clinical categories of HIV :-

Category A includes :

▪ one / more of the conditions listed below

in an adolescent / adult (greater than or
equal to 13 years) with documented HIV
infection.
▪ Asymptomatic HIV infection
▪ Persistent generalized Lymphadenopathy
▪ Acute (primary) HIV infection
Category B includes at least one of the
following criteria :
(a) the conditions that are attributed to HIV
infection/ are indicative of a defect in
cell-mediated immunity.
(b) the conditions are considered by
physicians to have a clinical course / to
require management that is complicated
by HIV infection.
(c) conditions in an HIV-infected adolescent
/ adult that are not included among
conditions listed in clinical Category C.
Examples of conditions in clinical
Category B include:

▪ Bacillary angiomatosis
▪ Candidiasis , oropharyngeal (thrush)
▪ Candidiasis , vulvovaginal ; persistent,
frequent, / poorly responsive to therapy
▪ Cervical dysplasia (moderate or
severe)/cervical carcinoma in situ
▪ Constitutional symptoms, such as fever
(38.5°C) / diarrhea lasting >1 month
▪ Hairy leukoplakia, oral
▪ Herpes zoster (shingles), involving at least
two distinct episodes or more than one
dermatome
▪ Idiopathic thrombocytopenic purpura
▪ Listeriosis
▪ Pelvic inflammatory disease, particularly
if complicated by tubo-ovarian abscess
▪ Peripheral neuropathy.
Conditions Included as AIDS-Defining Illnesses
WHO Clinical Staging & Disease
Classification System

▪ Revised in 2007.
▪ Classifies HIV disease on the basis of clinical
manifestations that can be recognized &
treated by clinicians in diverse settings.
▪ It does not require a CD4 cell counts.
▪ This staging system is used in many countries to
determine eligibility for antiretroviral therapy,
particularly in settings in which CD4 testing is
not available.
NEUROLOGICAL COMPLICATIONS OF HIV
& AIDS

▪ Opportunistic infections
▪ CNS Neoplasms
▪ Direct CNS manifestations of HIV
▪ Peripheral Nervous system disorders
Opportunistic Infections :-
Toxoplasmosis
▪ Causative agent :- Toxoplasma gondii, a
protozoan acquired most commonly from
cat faeces / uncooked meat.
▪ Infection generally occurs in pts with <200
CD4 cells per microlitre.
Symptoms of CNS infection are:
▪ Fever
▪ change in level of alertness
▪ Headache
▪ focal neurological signs (approx 80 % of
cases)
▪ partial / generalized seizures (approx 30 % of
▪ CT & MRI scans usually show
multiple, ring-enhancing lesions
in the basal ganglia / at the
gray–white matter junction.

▪ CSF studies shows mild monocytosis.

▪ Serum T. Gondii IgG is generally helpful in the
diagnosis.
▪ Brian biopsy provides the definitive diagnosis.
▪ Treatment consists of pyrimethamine plus
sulfadiazine / clindamycin
▪ Treatment must be continued for a full 6 weeks, &
then prophylaxis, usually with the treating agents.
Cytomegalovirus :-
▪ Cytomegalovirus (CMV) infection is found at
autopsy in about 30 % of brains from HIV-
infected patients.
▪ Other tissues affected include retina, blood,
adrenal glands & gastrointestinal tract.
▪ There are 2 distinct syndromes of CMV CNS
infection :
1. ENCEPHALITIS WITH DEMENTIA :
more common.
Sub-acute onset.
Clinical features :- periods of delirium,
confusion, apathy, & focal neurological
deficits.
 2.VENTRICULOENCEPHALITIS:
▪ CMV infects the ependymal cells lining the
ventricles.
▪ Rapid progression from delirium to death.
▪ cranial nerve deficits & ventriculomegaly.
INVESTIGATIONS :-
▪ Examination of the retina
▪ Electrolyte studies to look for adrenal
insufficiency,
▪ Viral blood cultures
▪ CT scan may show ventriculomegaly /
decreased attenuation diffusely throughout the
parenchyma.
▪ MRI may show increased signal intensity
around the ventricles.
▪ CSF studies may be normal / show high
protein, low glucose, & pleocytosis.
▪ PCR may reveal the presence of the virus.
▪ Brain biopsy provides a definitive diagnosis.
▪ Treatment is mostly supportive.
▪ Ganciclovir & foscarnet may be prescribed.
▪ Trials of a promising new medication, cidofovir,
are underway.
Cryptococcal Meningitis :-
▪ Cryptococcus neoformans
▪ It occurs in approx 8 - 10 % of AIDS pts.
▪ Clinically fever, delirium & seizure may be seen
but meningeal signs may / may not be present.
▪ CT scans are normal, but gadolinium-
enhanced MRI may show meningeal
inflammation.
▪ Intracranial pressure is elevated in 50% of
patients.
▪ CSF studies shows mild to moderate
monocytosis , elevated protein, decreased
glucose,& positive fungal cultures.
▪ The fungus can be seen on India ink stain of
CSF about 60 – 80% of the time.
▪ There is also a test for C. neoformans antigen,
which is usually positive in both serum & CSF.
▪ Treatment for cryptococcal meningitis requires
amphotericin B & flucytosine.
▪ Patients who survive must receive prophylaxis
against recurrence.
▪ Prophylaxis can be prescribed as oral
fluconazole / intermittent intravenous
amphotericin B.
Progressive Multifocal Leukoencephalopathy :-
▪ PML is a demyelinating disease of white matter
in immuno-compromised patients.
▪ Causative agent is a polyoma virus - JC virus.
▪ Transmission route - may be respiratory.
▪ Prevalence in AIDS is b/w 1 & 10 % of patients.
▪ Clinically focal deficits Eg:- Hemiparesis,
Dysarthria, gait problem, dementia, coma &
eventual death.
▪ Usually no fever / headache.
▪ MRI is more useful than CT in diagnosis,
displaying multiple area primarily in the white
matter of brain, although gray matter,
brainstem, cerebellum, & spinal cord lesions
are possible.
▪ CSF studies are generally unhelpful, except for
PCR evaluation for the presence of JC virus,
which is sensitive & specific.
▪ Brain biopsy provides definitive diagnosis but is
rarely used.
▪ Treatment of PML includes support of the
patient & HAART.
CNS Neoplasms :-
▪ Lymphoma is the most common neoplasm seen
in AIDS pts, affecting b/w 0.6 & 3 %.
▪ Clinical features
Afebrile
Mental status change
Seizures present in about 15% of pts.
▪ CT scan of the brain may be normal / show
multiple hypodense / patchy, nodular-
enhancing lesions.
▪ MRI generally shows enhanced lesions that may
be difficult to differentiate from CNS
toxoplasmosis, but Thallium SPECT scanning may
help to differentiate the 2 disorders.
▪ CSF studies may be normal / show a
moderate monocytosis ; cytology
studies reveal lymphoma cells in < 5 % of
pts.
▪ Brain biopsy is required for confirmation
of the diagnosis of CNS lymphoma.
▪ Management includes radiation
therapy & steroids with adjunctive
chemotherapy.
▪ HAART has somewhat improved the
prognosis which was earlier limited to 3-
4 months of survival after diagnosis.
 DIRECT CNS MANIFESTATIONS OF HIV
Guillain-Barré Syndrome :-
▪ It is an inflammatory demyelinatin
polyneuropathy causing symmetrical paralysis &
few if any sensory symptoms, usually beginning
in the lower extremities & progressing upward.
▪ The condition becomes especially serious if
abdominal musculature is involved, as it may
impair respiration.
▪ Thought to be autoimmune in
etiology & generally self-limited.
▪ Intravenous immunoglobulin &
plasmapheresis have been used
to shorten the course. Vacuolar
Myelopathy :-
▪ Associated with history of P. carinii
& M. avium-intracellulare
infections, suggesting that the
development of vacuolar
myelopathy is related to more
severe immunosuppression.
▪ Multinucleated giant cells are
seen on histological examination.
▪ Clinical manifestations appear when the
disease progresses to affect the lateral &
posterior columns & thus includes:
- spastic paraparesis
- loss of proprioception & vibration sense
- bowel & bladder urgency / incontinence
- Impotence
▪ Management is mainly supportive ,
myelopathies in HIV do not respond well to
HAART.
▪ L- methionine has shown promise in one trial.
 PERIPHERAL NEUROPATHIES :-
▪ Involves most often feet but occasionally can occur in the
hands.
▪ The neuropathy may range from parasthesia to burning pain,
& patients will have 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)
Other antiepileptic drugs used to treat neuropathic
pain.
Opiate analgesics should be used sparingly-tolerance &
dependence.
Benzodiazepines are of no use.
PSYCHIATRIC CONDITIONS IN HIV :-
▪ Psychiatric patients infected with HIV face a particularly
difficult & complex problem.
▪ They may be unable to avoid high risk behaviours which
increase chances of their contracting the disease at the
first place.
▪ Also they may be vulnerable to non-adherence to
pharmacological & non pharmacological treatment
regimes thus placing them at high risk of drug resistance,
high viral load, more morbidity & mortality.
▪ Patients with mental illness may also contribute to
spreading the epidemic due to high risk activities.
▪ People infected with HIV may develop various
psychiatric, psychological & psychosocial problems
either due to direct viral effect / by indirect
mechanisms.
STIGMA ATTACHED WITH HIV INFECTION :-

▪ HIV/AIDS stigma is perceived as an individual‘s

deviance from socially accepted standards of
normality & can include deviances such as
immorality, promiscuity, perversion,
contagiousness & death ‘‘.
▪ Stigma is socially constructed & is attributable
to cultural, social, historical & situational factors.
▪ Stigmatised individuals are subjected to feelings
of shame & guilt‘‘.
▪ Women are more vulnerable to the stigma.
▪ There are 3 broad types of HIV/AIDS-related
stigma.
1. Self stigma - occurs through self blame & 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.
▪ 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 & Action Against The HIV

Infection in India) - Chennai,
▪ ASHA Foundation - Bangalore,
▪ THE HUMSAFAR TRUST - Mumbai,
▪ Indian Network for People Living with
HIV/AIDS(INP+)- Chennai,
▪ Save the Children, Bal Raksha , Bharat - Delhi.
 DELIRIUM :-

▪ Prevalence of delirium in HIV-infected

populations has been reported to be b/w 43 &
65 %.
▪ Clinical presentation & significance of delirium
in HIV patients are characterized by inattention,
disorganized thinking / confusion, & fluctuations
in level of consciousness.
▪ Emotional changes are common & often
unpredictable, & hallucinations & delusions are
frequently seen.
▪ Acute / sub-acute onset.
▪ Risk factors include:
older age
multiple medical problems
multiple medications
impaired visual acuity &
previous episodes of delirium

▪ pts with HIV-associated dementia are at an

increased risk to develop delirium.
The differential diagnosis of delirium includes:
▪ HIV-associated dementia
▪ AIDS mania
▪ minor cognitive–motor disorder
▪ major depression, bipolar disorder
▪ panic disorder
▪ schizophrenia.
▪ Delirium can usually be differentiated from
the above conditions based on its rapid
onset, fluctuating level of consciousness, &
link to a medical etiology.
▪ History of illness, physical examination, relevant
investigations, review of all medications are
needed.
▪ A variety of causes may be found like toxins,
metabolic, infectious, cardiovascular,
endocrine, pulmonary, traumatic etc.
▪ EEG may show diffuse slowing of background
alpha rhythm which resolves as confusion
clears.
▪ Treatment consists of 3 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, & a view of the outside world, & active
engagement & reorientation by staff members,
family, & friends.
3. Management of behaviour / psychosis - low
doses of high-potency antipsychotic agents,
benzodiazepines should be used with caution.
 HIV-ASSOCIATED DEMENTIA

▪ In the ICD -10 classification Dementia in human

immunodeficiency virus disease is included
under Organic mental disorder (F02.4) &
prevalence is estimated at 15%.
▪ HIV itself is the causative factor behind the
dementia.
▪ Autopsy studies of demented AIDS patients
revealed characteristic white matter changes
& demyelinization , microglial nodules,
multinucleated giant cells, & perivascular
infiltrates but a marked absence of HIV within
neurons.
▪ Thus neuronal loss occurs through the action of
macrophages & microglial cells &/or the
through activation of cytokines & chemokines
that trigger abnormal neuronal pruning.
▪ Typical late findings show an approximate 40%
reduction in frontal and temporal neurons.
Risk factors:
▪ higher HIV RNA viral load
▪ lower educational level
▪ older age
▪ Anemia
▪ illicit drug use
▪ female sex.
▪ High CSF HIV RNA levels may be present in
patients with relatively low serum HIV RNA
levels & may correlate more directly with the
severity of neurological deficits.
▪ Clinically typical triad of symptoms —memory
& psychomotor speed impairments, depressive
symptoms, & movement disorders.
▪ Apathy is a common early symptom.
▪ A frank depressive syndrome also commonly
develops, typically with irritable mood &
anhedonia instead of sadness & crying spells.
▪ Sleep disturbances are common, as is weight
loss.
▪ Restlessness & anxiety may be complicating
factors.
▪ Psychosis develops in a significant number of
patients, typically with paranoid ideas,
although hallucinations are seen.
▪ In about 5 - 8 % of patients, a syndrome
known as AIDS mania.
▪ Modified HIV Dementia Scale is a very useful
bedside screen & can be administered serially
to document disease progression.
On examination:
▪ impaired saccadic eye movements
▪ Dysdiadochokinesia.
▪ Hyper-reflexia.
▪ frontal release signs (grasp, root, snout, &
glabellar reflexes).
▪ In late stages, motor symptoms may be quite
severe, with marked difficulty in smooth limb
movements, especially in the lower extremities.
▪ Treatment includes optimal HAART regimen &
treat associated symptoms aggressively.
▪ Depression-antidepressants
▪ Methylphenidate (Ritalin) / other stimulants may
be useful in the treatment of apathy.
 Minor Cognitive–Motor Disorder

▪ 26 % of pts on treatment for HIV had cognitive

impairment.
▪ The symptoms of MCMD are often overlooked
as they may be very subtle, but they are
essentially mild manifestations of the same
symptoms seen in HIV-associated dementia:
Cognitive & motor slowing.
▪ Patient complains taking longer to read a novel,
dysfunction when performing fine motor tasks
like playing the piano, an increased tendency
to stumble / trip, / more mistakes when
balancing the checkbook.
▪ The disorder is confirmed when mild
impairments are present in at least 2 of the
following domains:
Verbal/language, attention, memory (recall
/ new learning), abstraction, & motor skills.
▪ Prevalence data for MCMD are variable,
often suggesting up to 60 % prevalence by
late-stage AIDS.
▪ HAART may be of some benefit in slowing
progression.
Major Depression in Patients with HIV
Disease :-

▪ 4-40 % HIV infected patients meet criteria for

depressive disorder & a much higher % have
depressive symptoms.
▪ Depression is a risk factor for HIV due to it’s
impact on behaviour, intensification of
substance abuse, exacerbation of self
destructive acts & poor choice of partners in
relations.
▪ Conversely HIV increases the chances of
depression by direct injury to sub-cortical areas
of brain, chronic stress, worsening social
situation, demoralization etc.
▪ Some HIV related conditions can produce
depression- (toxoplasmosis, cryptococcus,
lymphoma) & patients with low testosterone
levels / patients getting interferon alpha for co-
morbid HCV treatment may have depression.
▪ Treatment involves both antidepressant
medications & psychotherapy.
▪ No single drug is found to be the ideal
antidepressant & must be tailored as per
patient’s need (Eg :- activating SSRI if patient is
having hypersomnia / mirtazepine if insomnia is
a problem).
▪ Generally a low starting dose with a gradual
hike is recommended to minimize early side
effects which may compromise adherence.
▪ The possibility of significant drug interactions
of psycho-tropics must be kept in mind with
anti HIV agents many of which increase
antidepressant levels & may precipitate
toxicity / side effects.
▪ Psychological management is vital & includes
counselling, cognitive behaviour therapy,
supportive psychotherapy & interpersonal
psychotherapy.
 SUICIDE IN HIV/AIDS :-
▪ Suicide is a significant risk both in early & late
stage of disease & suicidal ideas may affect
almost 30% of individuals at the time of testing &
attempts tend to cluster in the first 6 months
after a positive test result thus underlining
importance of pre & post test counselling.
▪ Later with symptomatic AIDS the % of
completed suicide rises to 36 times > non HIV
infected person.
▪ Risk factors for attempts include social stigma,
withdrawal of family support, loss of friends &
partners, long term dependency & prospect of
an incurable illness.
BIPOLAR ILLNESS IN PATIENTS WITH HIV DISEASE :-
▪ Pts may have this condition after developing
AIDS / already have pre-existing bipolarity prior
to developing AIDS.
▪ A spectrum of symptoms from hypomanic
features to frank mania may be encountered
with elevated / irritable mood, decreased
need for sleep, talkativeness, increased
activity & even delusions & hallucinations.
▪ Some patients may have a delusion that they
have discovered a cure for HIV & go into
euphoria.
▪ AIDS Mania- a slightly different condition with
onset in late stages of disease, lack of family
history / past episodes & presence of cognitive
impairment.
▪ Patients tend to have cognitive slowing /
dementia.
▪ In AIDS Mania, irritable mood is more typical
than euphoria & psychomotor slowing may be
observed.
▪ This type of mania is usually more severe & has
a chronic course with infrequent remissions &
tends to relapse after cessation of therapy.
▪ Treatment of classical mania early in AIDS is
with mood stabilizers Eg:- lithium, valproate,
carbamazepine , lamotrigine & antipsychotics
(esp. SGAs).
▪ AIDS mania patients typically respond to
treatment with antipsychotic agents alone.
▪ Late-stage patients are far more sensitive to
the therapeutic effects but even more so to
the toxic side effects of antipsychotic agents.
▪ In late-stage disease the dose of antipsychotic
needed may be much lower than normally.
Schizophrenia in Patients with HIV Disease :-
▪ Prevalence rates are b/w 4 & 19 % in both
inpatient & outpatient samples.
▪ Schizophrenia contributes to behaviours that may
lead to HIV infection.
▪ Patients with schizophrenia may have high rate of
unprotected sex, multiple sex partners, trading sex
for money & have sex while intoxicated.
▪ Patients with more positive symptoms & more
impulsive behaviours may be prone to high risk
sexual activities.
▪ Management employs antipsychotics for symptom
control & psychological support & rehabilitation.
 Personality in Patients Infected with HIV :-
▪ Personality disorder prevalence among HIV
infected is 19-36% & the most common is
antisocial personality disorder which itself is a
risk factor for HIV infection.
▪ Knowledge of HIV & its transmission is
insufficient to deter these individuals from
engaging in HIV risk behaviours, suggesting
that certain personality characteristics may
enhance their vulnerability to practice such
behaviours.
▪ Unstable extroverts are more prone to
engage in HIV risk behaviour despite having
knowledge of the consequences, for them
the immediate removal of pain/ obtaining of
pleasure assumes paramount importance.
▪ 2ND most common (25%) type is the stable
extrovert.
▪ Their emotional condition generates a kind of
indifference to HIV risk more than an
immediate need for pleasure.
▪ Unstable introverts (14%) consist of the next
most common group, who are anxious, moody
& pessimistic; they seek drugs / sex not for
pleasure but for relief from pain.
▪ They are concerned about the future &
consequences but think they have little control
over their fate.
▪ Stable introvert (1%) they are controlled &
even-tempered persons who are least likely to
engage in risky behaviour.
▪ Personality factors may have significant
implications for treatment like non adherence
to medication regimes, engaging in high risk
behaviours etc. & they have to be addressed
during management of such patients.
▪ Personality traits were not directly related to
HAART adherence. However, clinical
experience suggests that non-adherence is
more common among extroverted / unstable
patients.
▪ A cognitive-behavioural approach is most
effective in treating patients.
▪ 5 principles guide standard care :
1. Focus on thoughts, not feelings.
2. Use a behavioural contract.
3. Emphasize constructive rewards.
4. Use relapse prevention techniques.
5. Coordinate with medical care providers.
 Worried Well :-
▪ The so-called worried well are those high-risk
groups who, although they are sero-negative
& 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 &
hypochondriasis.
Substance Abuse & Addiction in HIV Disease :-
▪ Substance abuse is a primary vector for the
spread of HIV.
▪ This impact is directed not only at those who
use intravenous drugs & their sexual partners
but also at those who are disinhibited /
cognitively impaired by intoxication & are
driven by addiction to impulsive behaviours
and unsafe sexual practices.
▪ Diagnosis of substance dependence may be
difficult to make because physical symptoms
of HIV infection overlap with those of
substance abuse / dependence.
▪ Neurological symptoms can overlap b/w HIV
infection & substance abuse.
▪ Double diagnosis refers to Substance abuse &
Psychiatric illness.
▪ Triple diagnosis refers to a dual diagnosis patient
who also has HIV.
▪ Most HIV-positive substance abusers would be
classified as “unstable extroverts.”
▪ These can be found in as many as 49% of all
substance abusers.
▪ The clinician must be especially mindful of
interactions b/w these medications & the abused
substances. Eg :- (Stavudine can cause
neuropathy as a side effect which can be
exacerbated by alcohol).
▪ Treatment of Substance Use Disorders in
Patients Infected with HIV
1. Role induction & motivation
2. Detoxification
3. Treatment of co-morbid conditions
4. Rehabilitation
5. Relapse prevention
Psychological Problems in Patients Infected with HIV:-
▪ 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 &
high risk sexual behaviour.
▪ Adjustment disorder may occur in 5-20 % of
patients.
▪ Risk factors include past history of psychiatric
problem, poor support, lack of social acceptance.
▪ Obsessive compulsive disorder may occur with /
without depressed mood involving repeated
bodily scrutiny for evidence of disease
progression.
▪ Repeated ruminations may occur about death
& dying & thoughts of having spread of the virus
to others may be present.
▪ Other anxiety disorder like GAD, panic disorder
may occur. HIV diagnosis can lead to PTSD in
some patients.
▪ Psychological difficulties of everyday life in AIDS
pts are very complex & include grief, social
isolation, family problems, workplace difficulty,
peer rejection, stigma & many others & they
need to be managed appropriately.
 Special Issues in HIV :-
Fatigue :-
▪ Fatigue is a common symptom in HIV-infected
patients.
▪ It may have multiple causes:
direct effect of virus
medical causes like anaemia
Infection
side effect of medications Eg:- ART
medicine.
due to psychiatric disorder such as
depression, substance withdrawal, / as a result
of demoralization.
▪ Testosterone has been used to treat fatigue in
HIV infected men.
▪ Depression may be treated by activating
antidepressants (fluoxetine).
Dextro-amphetamine may be useful in treating
fatigue and depression in HIV.
HIV/HCV Co-infection :-
▪ Hepatitis C virus (HCV) is a blood-borne
pathogen that is currently most commonly
transmitted by injection drug use.
▪ 50 % of HIV-infected patients are also infected
with HCV.
▪ HIV infection is likely to make individuals more
susceptible to contract HCV if exposed, likely
due to immuno-suppression, & also to cause
more rapid progression of liver disease.
▪ Interferon-alpha has been associated with
depressive syndromes, suicide, &, on rare
occasions, mania.
▪ Depressive symptoms associated with
interferon-alpha have been successfully treated
with both SSRIs & tricyclic antidepressants.
ANTI RETROVIRAL DRUGS WITH
NEUROPSYCHIATRIC SIDE EFFECTS
HIV-SPECIFIC PSYCHOTHERAPEUTIC ISSUES :-
▪ Pretest , test, & posttest counseling issues;
▪ Risk behaviour reduction in patients at risk /
infected with HIV;
▪ Partner notification in patients infected with
HIV;
▪ Impaired patients with issues of capacity &
competence;
▪ HAART adherence issues.
▪ Major psychodynamic themes for patients
infected with HIV involve self-blame, self-
esteem, & issues regarding death.
▪ The psychiatrist can help patients deal with
feelings of guilt regarding behaviours that
contribute to HIV infection / AIDS.
▪ Individual therapy may be either short term /
long term & may be supportive, cognitive,
behavioural, / psychodynamic.
▪ Group therapy techniques can range from
psychodynamic to completely supportive in
nature.
Possible Indications for Human
Immunodeficiency Virus (HIV) Testing
Pre test HIV Counseling
Post test HIV Counseling
 Confidentiality :-
▪ Confidentiality is a key issue in serum testing.
No one should be given an HIV test without
prior knowledge & consent, although various
jurisdictions & organizations, such as the
military, now require HIV testing for all
inhabitants / 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; as
the information could result in discrimination in
employment, housing, & insurance.
▪ The major exception to restriction of disclosure
is the need to notify potential & past sexual / 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) / to notify the potential
victim.
RISK BEHAVIOR REDUCTION IN PATIENTS AT RISK /
INFECTED WITH HIV
▪ Interventions include:
stress management & relaxation techniques
Education
cognitive self-management training
Negotiation skills training
Psychotherapy directed at emotional distress
reduction
Relapse prevention models for high-risk behaviour
reduction
Education directed at eroticizing safer sex
Assertiveness training
Peer education in bars.
 PARTNER NOTIFICATION
▪ Partners should be notified of exposure risk &
potential infection as well.
▪ Physicians / health department officials to
notify partners of HIV-infected patients of their
risk.
▪ Sex workers & their clients can make their own
decisions & should be responsible for their own
behaviour all the way to the sentiment that
HIV infected sex workers should be arrested &
jailed for attempted murder.
CAPACITY TO CONSENT/COMPETENCE
▪ Patient must understand that there is a
decision before him / her regarding some
aspect of care & must understand the
consequences not only of each option but
also of refusal to make a choice.
▪ The patient must be able to manipulate the
information involved in a rational way.
▪ Patterns of prior behaviour, severity of illness,
poor judgment, & psychiatric vulnerabilities
complicate these decisions & play an
important role in tempering the way in which
patients are managed.
 HAART ADHERENCE
▪ Intervention such as cognitive-behavioural
psychotherapy, structured psycho-educational
psychotherapy, supportive psychotherapy, &
group interventions have all been used to
improve patient adherence to office visits &
medication regimens.
▪ HIV medication adherence focuses on
technical interventions such as pill box & timer
reminders, less complex pharmacological
interventions, decreased pill burdens, &
increased access to care.
▪ Psychotherapy has been shown to improve
clinic visit adherence, the best indirect predictor
of medication adherence.
DRUG-DRUG INTERACTIONS :-
▪ HIV-infected patients, like other patients with
chronic medical conditions taking many
medications, are at high risk for drug
interactions.
▪ They often require smaller doses of medication,
and their medication can become toxic quickly.
▪ All protease inhibitors and non-nucleoside
reverse transcriptase inhibitors (NNRTIs) are
metabolized by the P450 system and possess
enzyme-inhibiting or enzyme inducing properties.
▪ Ritonavir may be associated with the most
significant interactions.
DRUG METABOLISM :-
Anti-Retrovirals
▪ P450 Substrates - All Protease inhibitors
▪ P450 Inhibitors -
strong- ritonavir
moderate- indinavir, nelfinavir
weak- saquinavir

P450 Inducers - ritonavir, nelfinavir, nevirapine

Psychiatric Medications :-
▪ P450 Inhibitors :-
Strong- fluoxetine, fluvoxamine
Moderate- paroxetine , sertraline , TCAs
Weak- venlafaxine , mirtazepine

▪ P450 Inducers :-
nicotine/ cigarette smoking
carbamazepine
alcohol
▪ The nucleoside reverse transcriptase inhibitors
(NRTIs) are not metabolized significantly by the
P450 system, making them less vulnerable to
interactions with psychotropic medications.
▪ Zidovudine plasma levels, however, can be
increased by concurrent use of methadone/
valproic acid.
Antidepressants :-
▪ Interactions with anti-retrovirals are possible
with all selective serotonin reuptake inhibitors
by means of their potential to inhibit
cytochrome P450 enzymes.
▪ Because they are all metabolized by CYP
isoenzymes, there is the potential for increased
levels of selective serotonin reuptake inhibitors
when used in combination with enzyme
inhibitors.
▪ The combination of fluoxetine & ritonavir has
been shown to increase the concentration of
ritonavir.
▪ In a series of 5 cases of serotonin syndrome in
patients taking fluoxetine & antiretrovirals, the
most common culprit was ritonavir, which was
believed to increase fluoxetine levels.
▪ Fluvoxetine & paroxetine may cause toxicity
by increasing levels of protease inhibitors.
▪ Fluvoxamine may also cause toxicity through
increased levels of protease inhibitors.
▪ The role of TCAs in treating HIV-infected
patients is based on long-term experience
with them & the potential for capitalizing on
their side effects.
▪ For instance, a patient with AIDS who has
stomach distress from HAART, chronic
diarrhoea, & depression may benefit from
treatment with a TCA.
Benzodiazepines :-
▪ Of the benzodiazepines, alprazolam,
midazolam, & triazolam are dependent on CYP
3A4 for metabolism.
▪ Potent inhibitors of this CYP isoform , such as
ritonavir , can decrease clearance of these
drugs and result in over-sedation and possibly
death.
▪ The benzodiazepines oxazepam, lorazepam,
and temazepam are metabolized by
glucuronidation.
▪ Drugs that increase the activity of
glucuronidatioan, such as ritonavir or nelfinavir,
may lower the levels of these drugs.
▪ Additionally, the use of midazolam, along with
delavirdine (as well as protease inhibitors) may
increase its effect and lead to over-sedation.
Antipsychotics :-
▪ CYP inhibitors have the potential to
increase the concentration of the
antipsychotics, clozapine, & pimozide.
▪ For this reason, these drugs have been
contraindicated with anti-retrovirals with
CYP inhibition, such as ritonavir .
▪ In addition, the potential for toxicity
increase by CYP inhibitors exists in other
antipsychotics, including
chlorpromazine, haloperidol, olanzapine,
& risperidone .
CONCLUSION :-
▪ HIV & AIDS are closely related to
psychiatry with the infection giving rise to
many psychiatric problems & psychiatric
illnesses leading to risk of acquiring HIV.
▪ Hence the approach to such a situation
must be holistic with good coordination
b/w medical specialists & psychiatrists,
psychologists to bring maximum possible
benefit to people with such a difficult
illness.
References :-

▪ CTP-10th Edition.
▪ Lishman’s Organic Psychiatry 4th
Edition.
▪ Internet Articles.