30 - Psychiatry and Reproductive Medicine

Authors: Sadock, Benjamin James; Sadock, Virginia Alcott

Title: Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition

Copyright ©2007 Lippincott Williams & Wilkins

> Table of Contents > 11 - Neuropsychiatric Aspects of HIV Infection and AIDS

11

Neuropsychiatric Aspects of HIV Infection and AIDS

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

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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

  • 35% were white
  • 43% were black
  • 20% were Hispanic
  • 1% was of other race/ethnicity
Of the adults and adolescents with AIDS, 77% were men. Of these men,
  • 58% were men who had sex with men (MSM)
  • 21% were injection drug users (IDU)
  • 11% were exposed through heterosexual contact
  • 8% were both MSM and IDU.
Of the 93,566 adult and adolescent women with AIDS,
  • 64% were exposed through heterosexual contact
  • 34% were exposed through injection drug use
An estimated 3,927 children were living with AIDS at the end of 2004, of whom 97% probably acquired the infection from their mothers.
People with AIDS are surviving longer and are contributing to a steady increase in the number of people living with AIDS. This trend will continue as long as the number of new diagnoses exceeds the number of people dying each year.

Table 11-2 AIDS Safe-Sex Guidelines

Remember: Any activity that allows for the exchange of body fluids of one person through the mouth, anus, vagina, bloodstream, cuts, or sores of another person is considered unsafe at this time.
Safe-sex practices
   Massage, hugging, body-to-body rubbing
   Dry social kissing
   Masturbation
   Acting out sexual fantasies (that do not include any unsafe-sex practices)
   Using vibrators or other instruments (provided they are not shared)
Low-risk sex practices
These activities are not considered completely safe:
   French (wet) kissing (without mouth sores)
   Mutual masturbation
   Vaginal and anal intercourse while using a condom
   Oral sex, male (fellatio), while using a condom
   Oral sex, female (cunnilingus), while using a barrier
   External contact with semen or urine, provided there are no breaks in the skin
Unsafe-sex practices
   Vaginal or anal intercourse without a condom
   Semen, urine, or feces in the mouth or the vagina
   Unprotected oral sex (fellatio or cunnilingus)
   Blood contact of any kind
   Sharing sex instruments or needles
AIDS, acquired immunodeficiency syndrome.
(From Moffatt B, Spiegel J, Parrish S, Helquist M. AIDS: A Self-Care Manual. Santa Monica, CA: IBS Press; 1987:125, with permission.)

Table 11-3 Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of HIV Transmission from Infected to Uninfected Persons

Infected persons should be counseled to prevent the further transmission of HIV by:
  1. Informing prospective sex partners of their infection with HIV, so they can take appropriate precautions. Abstention from sexual activity with another person is one option that would eliminate any risk of sexually transmitted HIV infection.
  2. Protecting a partner during any sexual activity by taking appropriate precautions to prevent that person's coming into contact with the infected person's blood, semen, urine, feces, saliva, cervical secretions, or vaginal secretions. Although the efficacy of using condoms to prevent infections with HIV is still under study, the consistent use of condoms should reduce the transmission of HIV by preventing exposure to semen and infected lymphocytes.
  3. Informing previous sex partners and any persons with whom needles were shared of their potential exposure to HIV and encouraging them to seek counseling and testing.
  4. For IV drug abusers, enrolling or continuing in programs to eliminate the abuse of IV substances. Needles, other apparatus and drugs must never be shared.
  5. Never sharing toothbrushes, razors, or other items that could become contaminated with blood.
  6. Refraining from donating blood, plasma, body organs, other tissue, or semen.
  7. Avoiding pregnancy until more is known about the risks of transmitting HIV from the mother to the fetus or newborn.
  8. Cleaning and disinfecting surfaces on which blood or other body fluids have spilled, in accordance with previous recommendations.
  9. Informing physicians, dentists, and other appropriate health professionals of antibody status when seeking medical care, so that the patient can be appropriately evaluated.
HIV, human immunodeficiency virus; IV, intravenous.
(From MMWR Morb Mortal Wkly Rep. 1986;35:152, with permission.)

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

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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

  1. Patients who belong to a high-risk group: (1) men who have had sex with another man since 1977; (2) intravenous drug abusers since 1977; (3) hemophiliacs and other patients who have received since 1977 blood or blood product transfusions not screened for HIV; (4) sexual partners of people from any of those groups; (5) sexual partners of people with known HIV exposure—people with cuts, wounds, sores, or needlesticks whose lesions have had direct contact with HIV-infected blood.
  2. Patients who request testing. Not all patients admit to the presence of risk factors (e.g., because of shame, fear).
  3. Patients with symptoms or acquired immunodeficiency syndrome (AIDS).
  4. Women belonging to a high-risk group who are planning pregnancy or who are pregnant.
  5. Blood, semen, or organ donors.
(Adapted from Rosse RB, Giese AA, Deutsch S, Morihisa JM. Laboratory and Diagnostic Testing in Psychiatry. Washington, DC: American Psychiatric Press; 1989:54, with permission.)

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

  1. Discuss meaning of a positive result and clarify distortions (e.g., the test detects exposure to the AIDS virus; it is not a test for AIDS).
  2. Discuss the meaning of a negative result (e.g., seroconversion requires time, recent high-risk behavior may require follow-up testing).
  3. Be available to discuss the patient's fears and concerns (unrealistic fears may require appropriate psychological intervention).
  4. Discuss why the test is necessary. (Not all patients will admit to high-risk behaviors.)
  5. Explore the patient's potential reactions to a positive result (e.g. “I'll kill myself if I'm positive”). Take appropriate necessary steps to intervene in a potentially catastrophic reaction.
  6. Explore past reactions to severe stresses.
  7. Discuss the confidentiality issues relevant to the testing situation (e.g., is it an anonymous or nonanonymous setting?). Inform the patient of other possible testing options where the counseling and testing can be done completely anonymously (e.g., where the result is not made a permanent part of a hospital chart). Discuss who has access to the test results.
  8. Discuss with the patient how being seropositive can potentially affect social status (e.g., health and life insurance coverage, employment, housing).
  9. Explore high-risk behaviors and recommend risk-reducing interventions.
  10. Document discussions in chart.
  11. Allow the patient time to ask questions.
HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome.
(Reprinted with permission from Rosse RB, Giese AA, Deutsch SI, Morihisa JM. Laboratory and Diagnostic Testing in Psychiatry. Washington, DC: American Psychiatric Press; 1989:55, with permission.)

Table 11-6 Posttest HIV Counseling

  1. Interpretation of test result:
    Clarify distortion (e.g., “a negative test still means you could contract the virus at a future time; it does not mean you are immune from AIDS”).
    Ask questions about the patient's understanding and emotional reaction to the test result.
  2. Recommendations for prevention of transmission (careful discussion of high-risk behaviors and guidelines for prevention of transmission).
  3. Recommendations on the follow-up of sexual partners and needle contacts.
  4. If test result is positive, recommendations against donating blood, sperm, or organs and against sharing razors, toothbrushes, and anything else that may have blood on it.
  5. Referral for appropriate psychological support: HIV-positive patients often need access to a mental health team (assess need for inpatient versus outpatient care; consider individual or group supportive therapy). Common themes include the shock of the diagnosis, the fear of death, and social consequences, grief over potential losses, and dashed hopes for good news.
    Also look for depression, hopelessness, anger, frustration, guilt, and obsessional themes. Activate supports available to patient (e.g., family, friends, community services).
HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome.
(From Rosse RB, Giese AA, Deutsch SI, Morihisa JM. Laboratory and Diagnostic Testing in Psychiatry. Washington, DC: American Psychiatric Press; 1989:58, with permission.)

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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

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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.

Table 11-7 Conditions Associated with Human Immunodeficiency Virus (HIV) Infection

Bacterial infections, multiple or recurrenta
Candidiasis of bronchi, trachea, or lungs
Candidiasis, esophageal
Cervical cancer, invasiveb
Coccidioidomycosis, disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic intestinal (>1 month's duration)
Cytomegalovirus disease (other than liver, spleen, or nodes)
Cytomegalovirus retinitis (with loss of vision)
Encephalopathy, HIV-related
Herpes simplex, chronic ulcers (>1 month's duration); or bronchitis, pulmonitis, or esophagitis
Histoplasmosis, disseminated or extrapulmonary
Isosporiasis, chronic intestinal (>1 month's duration)
Kaposi's sarcoma
Lymphoid interstitial pneumonia and/or pulmonary lymphoid hyperplasiaa
Lymphoma, Burkitt's (or equivalent term)
Lymphoma, immunoblastic (or equivalent term)
Lymphoma, primary, of brain
Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary
Mycobacterium tuberculosis, any site (pulmonaryb or extrapulmonary)
Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
Pneumocystis carinii pneumonia
Pneumonia, recurrentb
Progressive multifocal leukoencephalopathy
Salmonella septicemia, recurrent
Toxoplasmosis of brain
Wasting syndrome due to HIV
aChildren <13 years old.
bAdded in the 1993 expansion of the AIDS surveillance case definition for adolescents and adults.
(Adapted from 1993 revised classification system for HIV infection and expanded surveillance, case definition for AIDS among adolescents and adults. MMWR Morb Mortal Wkly Rep. 1992:41, with permission.)

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

Generic Name Trade Name Usual Abbreviation
Nucleoside reverse transcriptase inhibitors
   Zidovudine Retrovir AZT or ZDV
   Didanosine Videx ddI
   Zalcitabine Hivid ddC
   Stavudine Zerit d4T
   Lamivudine Epivir 3TC
   Abacavir Ziagen
Nonnucleoside reverse transcriptase inhibitors
   Nevirapine Viramune
   Delavirdine Rescriptor
   Efavirenz Sustiva
Protease inhibitors
   Saquinavir Invirase
   Ritonavir Norvir
   Indinavir Crixivan
   Nelfinavir Viracept
Fusion inhibitors
   Enfurvitide Fuzeon

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

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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.

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