Presentation is about psychiatric manifestations of hiv/aids.

1. PSYCHIATRIC MANIFESTATIONS OF HIV/AIDS
Presenter – Dr. D. Raj Kiran
Chairperson – Dr. Supriya Hegde
HIV does not make people dangerous to know, so you can shake their hands and give them a hug:
Heaven knows they need it - Princess Diana

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

3. HISTORY
• One of the earliest documented HIV infections was
discovered in a preserved blood sample taken in 1959
from a man from 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 or psychiatric
aspects of AIDS by Holtz & colleagues.
• First psychiatrist to address these issues was Stuart E.
Nichols in his article in Psychosomatics.

4. HIV IN INDIA
• It is estimated that India had approx
1.2 lakh new HIV infections in 2009
(2.7 lakh in 2000).
• The estimated adult HIV prevalence
in India was 0.31% in 2009.
• The adult prevalence is 0.25%
among women and 0.36% among
men in 2009.
• Manipur has shown the highest
estimated adult HIV prevalence
(1.40%) < Andhra Pradesh (0.90%)
< Mizoram (0.81%) < Nagaland
(0.78%) < Karnataka (0.63%) and
Maharashtra (0.55%).
http://www.nacoonline.org/upload/REPORTS/NACO%20Annual%20Report%202010-11.pdf

5. PATHOGENESIS OF NEUROPSYCHIATRIC
MANIFESTATIONS
• One of the mechanisms is ―TROJAN HORSE
HYPOTHESIS‖.
• HIV-1 enters the brain inside infected macrophages.
• These migrate into the brain parenchyma through BBB
disruption and establishment of a chemokine gradient.
• Virus buds into intra cytoplasmic vesicles in
macrophages with limited expression of viral proteins
on the cell surface and escapes from immune
surveillance.

6. HIV TESTING IN INDIA
• Testing for HIV requires specific and informed consent of the
person being tested.
• The confidentiality of the test result (both negative as well as
positive) should be strictly maintained.
• This is to respect the privacy and rights of the individuals and to
protect them from discrimination, victimization and
stigmatization.
• The test result, name of the individual, etc. must never be
discussed loosely.
• The test report must be placed in a sealed envelope and
submitted to the clinician who requisitioned the test.
http://nacoonline.org/upload/Policies%20&%20Guidelines/5-
GUILDELINES%20FOR%20HIV%20TESTING.pdf

7. PRE TEST COUNSELING
• Information about the HIV test - what it tests for, what it
might NOT tell (window period).
• Information about how HIV is transmitted and how
patient can protect from infection.
• Information about the confidentiality of test results.
• A clear, easy-to-understand explanation of meaning of
a positive and a negative test.
http://aids.gov/hiv-aids-basics/prevention/hiv-testing/pre-post-test-counseling/

8. POST TEST COUNSELING
• Clear communication about what the test result mean.
• If test is negative - HIV prevention counselling.
• If test is positive - A confirmatory test, Western blot test.
The results of that test should be available within 2 weeks.
• If confirmatory test is positive, then -
Patient will be given information about what HIV is &
how it effects health.
Patient will be informed about how the virus can affect &
how to protect others from becoming infected.
Patient will also be informed about resources &
treatments available.
http://aids.gov/hiv-aids-basics/prevention/hiv-testing/pre-post-test-counseling

9. MANIFESTATIONS OF HIV INFECTION
(i) Malignant course of HIV infection and the associated stigma.
(ii) Direct effects of HIV on brain.
1. Delirium
2. Mild cognitive and motor disorders
3. Dementia
(iii) Vulnerability of Persons with severe mental illness to HIV infection.
1. Mood disorders
2. Psychosis
3. PTSD
4. Personality disorders
5. Anxiety and phobic disorders
6. Adjustment disorders

10. (iv) Tumours & Opportunistic infections.
1. Toxoplasmosis
2. CMV infection
3. Progressive multifocal leukoencephalopathy
4. Cryptococcal meningitis
5. Metastatic tumours eg Kaposi's sarcoma
(v) Effects of drugs.
1. Anti Retroviral drugs
2. Acyclovir & Ganciclovir
3. Anti-tuberculosis drugs
4. Steroids
5. Chemotherapeutic agents
(vi) Substance abuse

11. STIGMA ATTACHED WITH HIV INFECTION
• HIV/AIDS stigma is perceived as an individual‘s
deviance from socially accepted standards of normality
and can include such deviances as
‗‗immorality, promiscuity, perversion, contagiousness
and death ‘‘.
• Stigma is socially constructed and is attributable to
cultural, social, historical and situational factors.
• Stigmatised individuals are subject to ‗‗feelings of
shame and guilt‘‘.
• Women are more vulnerable to the stigma.

12. STIGMA
• There are three broad types of HIV/AIDS-related stigma.
1. Self stigma - occurs through ‗self blame and 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

13. STIGMA
• 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 and
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.

14. DELIRIUM
• It is a state of global derangement of cerebral function.
• Prevalence is reported to be between 43 – 65%.
• The clinical presentation in HIV patients is the same as
those in non-HIV-infected individuals.
• Patients with HIV associated dementia are at increased
risk of developing Delirium.
• In toxic/ metabolic causes, the EEG may show diffuse
slowing of the background alpha rhythm, which
resolves as confusion clears.

15. DELIRIUM
• The cause of delirium should be aggressively sought by
intensive medical examination.
• Treatment
1. Identification & removal of underlying cause.
2. Reorientation of the patient by maintaining diurnal
variation of light cycle, providing orienting stimuli such
as clocks, calendars & active engagement of family
members.
3. Management of behavior/psychosis by low dose of
high potency antipsychotic.

16. MINOR COGNITIVE MOTOR DISORDER
• It is a less severe neurocognitive disorder emergent in
earlier HIV infection.
• Prevalence data are variable, often up to 60% by late-
stage AIDS.
• The symptoms are subtle & mild manifestations of the
same symptoms seen in HIV-associated dementia:
Cognitive and motor slowing.

17. MINOR COGNITIVE MOTOR DISORDER
• The disorder is confirmed when mild impairments are
present in at least two of the following domains:
Verbal/language, attention, memory (recall or new
learning), abstraction, and motor skills.
• HAART may be of some benefit in slowing progression.
• Some patients may continue to have minor problems,
while another group will progress to frank dementia.

18. HIV ASSOCIATED DEMENTIA
• Prevalence of HIV dementia in infected adult is
reported to be 15%.
• It is generally seen in late stages of HIV illness, usually
when CD4+ count is below 200 cells per ml.
• Risk factors associated are higher HIV RNA viral
load, lower educational level, older age, anaemia, illicit
drug use & female sex.
• HIV itself is the causative factor, it acts through
activation of cytokines and chemokines that trigger
abnormal neuronal pruning.

19. HIV ASSOCIATED DEMENTIA
• Apathy is a common early symptom of HIV-associated
dementia.
• Clinically presents with triad of symptoms - memory
and psychomotor speed impairments, depressive
symptoms, and movement disorders.
• Early cases show impairments in timed trials such as a
timed oral trail making task or grooved
pegboard, occasional stumbling while walking or
running, slowing of fine repetitive movements.

20. HIV ASSOCIATED DEMENTIA
• Modified HIV Dementia Scale is a useful bedside
screen & for disease progression.
• In late stages patients develop more global dementia,
with marked impairments in naming, language, praxis,
marked difficulty in smooth limb movements.
• Overall, HIV-associated dementia is rapidly progressive
usually ending in death within two years.
• Treatment is to ensure an optimal HAART regimen and
treat associated symptoms aggressively.

21. DEPRESSION
• Most frequently occurring psychiatric disorder in HIV.
• Lifetime prevalence in HIV infected patients is 22–45%.
• The Multi centre AIDS Cohort Study (MACS) showed
that there is a two & half fold increase in rates of
depression as patient CD4 < 200.
• Up to 15–20% of all patients with recurrent depressive
episodes end up in suicide.
Vinita Jagannath, B. Unnikrishnan, Supriya Hegde, John T. Ramapuram, S.Rao, B. Achappa, D.
Madi, M.S. Kotian. Association of depression with social support and self-esteem among HIV
positives. Asian J Psy 2011:4, 288-292.

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

23. Depression
↓
Increase in Cortisol levels
↓
Decrease in circulating lymphocytes
Reduce the ability of lymphocytes to produce lymphokines
Increase expression of HIV by Mononuclear cells

24. DEPRESSION
• Nonspecific somatic symptoms (fatigue, insomnia) are
the result of depression.
• Drugs causing depression → withdrawal of the
offending drug, if no response then treated as major
depression.
• Medication plus psychotherapy (Interpersonal & CBT) -
more effective than either modality alone.

25. DEPRESSION
• No single antidepressant has been found superior.
• SSRIs 1st choice, then TCAs.
• Start at low doses of any medication, titrate up to a
―full‖ dose slowly.
• Partial response to antidepressant medication should
be offered an augmentation strategy
(Li, Triiodothyronine, Olanzapine, Risperidone).

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

27. SUICIDE & HIV INFECTION
• Risk assessment.
• Treatment of underlying depression.
• Treatment of physical complaints.
• Crisis intervention.
• Supportive therapy or CBT.

28. BIPOLAR ILLNESS
• Difficult to find out the incidence & prevalence of
bipolar illness among HIV because the spectrum of
bipolar illness is broad.
• Bipolar disorder act as a risk factor.

29. AIDS MANIA
• Associated with late-stage HIV infection.
• Consequences of brain involvement.
• Progressive cognitive decline prior to the onset of mania.
• Irritable mood is more characteristic than euphoria.
• Psychomotor slowing with cognitive slowing of AIDS
dementia will replace the expected hyperactivity of mania
• Lack of previous episodes or family history.
• Has chronic course rather than episodic.

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

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

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

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

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

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

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

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

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

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

40. AIDS PHOBIA
• It is the fear of contracting HIV infection, despite the
negative test results.
• In addition to distinct AIDS related fears, somatization
disorders have been reported among men with risky
behaviour who tested negative for HIV.
• They have been associated with an anxious
temperament, are more among those with health anxiety.
• Often associated with misinformation and inadequate
knowledge.
• Treatment – Psychotherapy & Antidepressants.

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

42. SUBSTANCE ABUSE
• The accumulation of medical sequale from chronic
substance abuse can accelerate the process of
immunocompromise & amplify the progressive burdens
of the HIV infection itself.
• They become vulnerable to pneumonia, sepsis, soft
tissue infections, endocarditis, tuberculosis, STDs, viral
hepatitis infection & coinfection with human CD4 cell
lymphotrophic virus, lymphomas.
• Neurological symptoms can overlap between HIV
infection and substance abuse.

43. SUBSTANCE ABUSE
• Dual diagnosis - refers to a patient who has both a drug use
disorder and another psychiatric disorder.
• Triple diagnosis - refers to a dual diagnosis patient who
also has HIV.
• The steps for the treatment of substance in a simple way -
1. Role induction & motivation to change
2. Detoxification
3. Treatment of co-morbid conditions
4. Rehabilitation
5. Relapse prevention

44. OPPORTUNISTIC INFECTIONS
Toxoplasmosis:
• When CD4 < 200 cells per microliter.
• most common reason for intracranial masses.
• Ring-enhancing lesions in the basal ganglia or at the
gray–white matter junction.
• Acute focal or diffuse meningoencephalitis -
headache, fever, altered consciousness and focal
neurological signs.

45. OPPORTUNISTIC INFECTIONS
Cytomegalovirus:
• CD4 < 50 cells per microliter.
• Two distinct syndromes of CMV CNS infection.
Encephalitis with dementia  subacute onset, periods
of delirium, confusion, apathy & focal neurological
deficits.
Ventriculoencephalitis  infects the ependymal
cells, causing a rapid progression from delirium to
death.
• Treatment supportive, gancyclovir, foscarnet

46. OPPORTUNISTIC INFECTIONS
Cryptococal meningitis:
• 8 -10%.
• Present with fever and delirium.
• Treatment amphotericin B and flucytosine.
Progressive multifocal leukoencephalopathy:
• Demyelinating disease of white matter.
• Polyoma virus, named JC virus.
• CD4 < 100 cells per ml.
• Treatment supportive , HAART

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

48. REFERENCES
1. Anthony S.F, Clifford H.L. Chapter 188 & 189, HIV disease: AIDS & related disorders. Harrison‘s Principles of internal medicine. 17 th
edition. Pg 1500 & 1506.
2. Samir L et al. HIV infection in India: Epidemiology, molecular epidemiology and pathogenesis. J Biosci 33(4), November 2008, 515–525.
3. http://www.avert.org/hiv.htm.
4. http://en.wikipedia.org/wiki/HIV.
5. Zink WE, Zheng J, Persidsky Y, et al. ―The neuropathogenesis of HIV-1 infection. FEMS Immunol Med Microbiol‖. 1999, 26(3-4): 233-241.
6. Zhu, T., Korber, B. T., Nahmias, A. J., Hooper, E., Sharp, P. M. and Ho, D. D. . "An African HIV-1 Sequence from 1959 and Implications for
the Origin of the Epidemic" .1998, Nature 391 (6667): 594–7.
7. Centers for Disease Control (CDC). "Pneumocystis pneumonia—Los Angeles" . MMWR Morb. Mortal. Wkly. Rep.1981, 30 (21): 250–2.
8. Holtz et al. Psychosocial impact of AIDS—ostracism, the ‗‗sheet sign,‘‘ and the need for psychiatric literature about AIDS. Psychosoma tics.
9. http://www.unaids.org/en/dataanalysis/knowyourepidemic/countryreportsonhivestimates/india_hiv_estimates_report_ 2006_en.pdf.
10. Prabha S.Chandra, Geetha Desai & Sanjeev Ranjan. HIV & Psychiatric disorders. Indian j med res, april 2005.
11. Ramananda S, Murali K.N, Ashok B, Vijaygopal M. A study of Psychiatric manifestations of physically asymptomatic HIV-1 individuals. Ind
j Psy, 2000. 42(4), 427-433.
12. Thomas, F. Stigma, fatigue and social breakdown: exploring the impacts of HIV/AIDS on patient and carer well -being in the Caprivi
Region, Namibia.Social Science & Medicine,2006. 63, 3174–3187.

49. 13. Liamputtong, P., et al., HIV and AIDS, stigma and AIDS support groups: Perspectives from women living with HIV and..., Social
Science & Medicine (2009) doi:10.1016/j.socscimed. 2009.05.040.
14. Robertson KR, Smurzynski M, Parsons TD, Wu K, Bosch RJ: The prevalence and incidence of neurocognitive impairment in
the HAART era. AIDS. 2007;21:1915.
15. Davis HF, Skolasky RL Jr, Selnes OA, Burgess DM, McArthur JC: Assessing HIV-associated dementia: Modified HIV dementia
scale versus the grooved pegboard. AIDS Read. 2002;12:29.
16. Vinita Jagannath, B. Unnikrishnan, Supriya Hegde, John T. Ramapuram, S.Rao, B. Achappa, D. Madic, M.S. Kotian.
Association of depression with social support and self-esteem among HIV positives. Asian J Psy 2011:4, 288-292.
17. Ciesla JA, Roberts JE: Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J
Psychiatry. 2001;158:725.
18. Treisman G, Fishman M, Schwartz J, Hutton H, Lyketsos C: Mood disorders in HIV infection. Depress Anxiety. 1998;7:178.
19. Lyketsos CG, Schwartz J, Fishman M, Treisman G: AIDS mania. J Neuropsychiatry Clin Neurosci. 1997;9:277.
20. Himelhoch S, Powe NR, Breakey W, Gebo KA: Schizophrenia, AIDS and the decision to prescribe HAART: Results of a
national survey of HIV clinicians. J Prev Interv Community. 2007;33:109.
21. Sameer M. HIV Phobia: An issue of concern. Indian J Psy. April 2011. Supplement S73.
22. Cottler LB, Nishith P, Compton WM 3rd: Gender differences in risk factors for trauma exposure and post -traumatic stress
disorder among inner-city drug abusers in and out of treatment. Compr Psychiatry. 2001;42:111.
23. Trobst KK, Wiggins JS, Costa Jr PT, Herbst JH, McCrae RR: Personality psychology and problem behaviors: HIV risk and the
Five-Factor Model. J Pers. 2000;68:1232.
24. Spire B, Lucas GM, Carrieri MP: Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST).
Int J Drug Policy. 2007;18 (4):262.
25. Miguez MJ, Shor-Posner G, Morales G, Rodriguez A, Burbano X: HIV treatment in drug abusers: Impact of alcohol use. Addict
Biol. 2003;8:33.
26. Repetto MJ, Petitto JM: Psychopharmacology in HIV-infected patients. Psychosom Med. 2008;70(5):585–592.