Psychological issues in HIV Dr Ramani Ratnaweera Consultant Psychiatrist TH Karapitiya
Most patients with serious, progressive illness confront a range of psychological challenges
HIV is infectious / potentially fatal Disease is unusual / extent of associated stigma Sexual behaviour, may not be easily modifiable Rapidly changing treatment developments and outlook Greatest psychological challenge / Continuing to maintain hope in the context of illness progression
Emotional responses to testing HIV-positive HIV is threatening a person’s existence Stress is natural and affects one’s emotions Shock, Disbelief, Panic, Fear, Guilt, Anger, Despair, Hopelessness, Numbness We can’t force people to be strong Whatever they are going through is a natural process Pre-test counselling about the significance of the procedure, and post-test counselling about its outcome, as well as risk-reduction counselling are important.
Grief of loosing one’s health Shock and disbelief, Realization of the exact situation, sadness, guilt, anger, fear, depression Acceptance and keep moving forward
• Provide enough information with regard to HIV • Learning about their condition, gaining confidence and making informed choices for their future • No matter how bad you’re feeling, keep one thing in mind. Testing HIV+ is not a death sentence.
Do I have to tell people I’m HIV+?
Do people really need to know? Do they need to know immediately? How to inform the family and friends…who will find out….. They don’t have to tell anyone until they are ready. But one must not underestimate the value of support in dealing with HIV. Be sure they are ready. Once you tell someone, they won’t forget you are HIVpositive. Anticipate and accept their reaction.
The shadow of HIV stigma • •
Despite advances in the prevention and treatment of HIV, Stigma still looms large. Historically, many of these groups are already stigmatized prior to being diagnosed. Knowledge of HIV transmission and transmission myths does not necessarily reduce stigmatizing attitudes
Living with HIV – an inspiring story “My name is Richard. My girlfriend and I are tested positive in 2008 when she was 7 months pregnant. Our children, daughter is now turning five years old while our son is turning one year old this year and are both negative. We are both on meds and doing fine and looking forward to see our grandchildren”
Breaking bad news “any news that drastically
and negatively alters the patient's view of her or his future.”
SPIKES protocol for breaking bad news – Robert Buckman S – Setting P – Perception of condition/seriousness Finding out how much the patient knows I – Invitation from the patient to give information how much the patient wants to know K – Knowledge: giving medical facts Give information in small chunks, treatment, prognosis Check whether the patient understood what you said E - Explore emotions, Prepare to give an empathetic response S – Strategy and summary Treatment plan, follow up
Types of mental disorders in people infected by HIV infection Abnormal psychological reactions - adjustment disorders, manifestations of personality disorder Mood and other disorders - major depression, suicidal behaviour, manic episodes, sexual dysfunction, anxiety disorders, obsessive compulsive disorder, eating disorders, association with child sexual abuse Substance use disorders Organic brain syndromes - acute and subacute brain syndromes, Delirium, HIV-associated dementia, HIV-associated minor cognitive impairment
Adjustment disorders one of the most common diagnoses in people referred to mental health services – about 30% in some reports.  Personality disorder is often an associated diagnosis, usually including avoidant, dependent, narcissistic or histrionic features and sometimes made worse by substance misuse. 
Severe depression /15% of referrals. Suicidal ideas / risk of both deliberate selfharm and suicide. Sexual dysfunction / organic and iatrogenic factors Risk for developing delirium - 30% to 40% of hospitalized HIV+ people with advanced illness (AIDS) HIV-associated dementia is prevalent up to 15% in advanced disease
Anxiety disorders, including phobias and panic attacks, and obsessive-compulsive disorders are occasionally seen. Eating disorders can complicate the management of HIV, and there are disturbing reports of rape and child sexual abuse leading to HIV infection.
Delirium in HIV+ people ď‚—
metabolic abnormalities, sepsis, hypoxemia, anemia, CNS infections and malignancies, almost all HIV-related drugs, opioids, and illicit substances. Initial HIV infection may also cause delirium. Relieve distress, control agitation, prevent exhaustion, Nursed in a quiet single room, Regular visits by relatives, Lighting at night to promote orientation, Reality orientation approach, reorientation by staff, Adequate hydration Medication – haloperidol 2-10mg/day, first dose can be given IM if necessary, atypicals/ olanzapine 2.5mg, risperidone 1mg, quetiapine 12.5mg
HIV-Associated Neurocognitive Disorder (HAND) HAND risk is correlated with the nadir (low point) of CD4 cell count and an HIV viral load in the cerebrospinal fluid at least as high as plasma viral loads. ď‚— With HAART ( highly active antiretroviral therapy) the incidence of HAD has fallen, although its prevalence has actually increased because HIV+ people are living longer. ď‚—
Mental disorders of family and relatives of people with HIV
Adapting to changing relationship, with increased dependency and decline in health. Fear of infection and concerns about sexual contact, and contraception and fertility in heterosexuals, may compound the difficulties. Anxiety and depression are common in partners of infected individuals, and the problems may be worse when both partners are infected. Similar findings apply to relatives and other care-givers. The problems of children infected or affected by HIV (uninfected children of HIV-infected parents or siblings) is a growing area of concern.
Abnormal beliefs in people seeking testing for HIV Some individuals who have undergone HIV testing with negative results remain concerned about the possibility of being infected, or have the conviction that they are seropositive. ď‚— The usual reassurance and explanation are not sufficient to put their minds at rest, and they may seek testing repeatedly, with little change in their anxiety or beliefs. ď‚— This may reflect neurotic disorders (obsessional disorder, somatisation or hypochondriasis), or may be delusional in nature. ď‚—
Management of mental disorders in HIV infection ď‚— Psychological
interventions
HIV seropositives - cognitive-behavioural interventions, psychoeducational techniques, supportive pychotherapy, interpersonal psychotherapy, and other specific Interventions, coping effectiveness training (CET)
Psychopharmacological interventions
Drugs with low side-effect profiles for depression SSRI Sedatives and tranquillizers are used symptomatically in acute and chronic brain syndromes and in mania and psychosis Zidovudine for HIV-associated cognitive disorders The new atypical antipsychotics seem to be well tolerated and effective Psychiatric hospitalization and respite/hospice care Benefits of multidisciplinary working
Maintaining a healthy life style good nutrition Exercise control of recreational substance use alterations in sexual risk behavior Community organizations and peer support
What it means to grow old with HIV Neurocognitive impairment has a significant impact on the person’s everyday functioning abilities. Severe HIV-associated dementia causes psychological and behavioural disturbances The risk of other neurocognitive conditions increases - Alzheimer disease,Vascular dementia and Parkinson disease-related dementia.
Legal issues with HIV infection ď‚—
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Physicians must make all efforts to convince HIV/AIDS patients to take action to notify all partners (sexual and/or injecting drugs/ sharing needles) about their exposure and potential infection. When all strategies to convince the patient to take such action have been exhausted, and if the physician knows the identity of the patient's partner(s), the physician is compelled, either by law or by moral obligation, to take action to notify the partner(s) of their potential infection.
It's about not being alone Sharing concerns and experiences with others is not only the first step to coping, Good social support and confiding relationships are the first step to normalizing HIV in one’s life.
Thank you