HIV and Mental Health

Dr.John Parker
Jsparker@pgwc.gov.za
 “The Ultimate Biopsychosocial
Disorder”
• High prevalence
• Vulnerable groups
• Long asymptomatic period, chronic,
stigmatized
• Neuroinvasion
• Commonest in adults 20-35
• Perinatal Transmission
 HIV Ethical Considerations
• Confidentiality critical… but not simple…
• High levels of stigma
• High levels of denial
• Common
• Easily identifiable clinics and medications
• Changing sociopolitical landscape
 Epidemiology
• DOH Antenatal Clinic Survey (2007): SA –
28% and W Cape – 12,6% (2005: SA 30,2;
W Cape 15,7)
• 2008 Gen Pop Survey (15000 respondents,
64% tested): SA 10, 9%; M= 7,9%
F=13,6% (2002: 10,8%)
• 2007 WHO estimate: 18,1% of 15-49y-olds
 Mental Illness in HIV- Adults
• Substance abuse
• Adjustment and Anxiety Disorders
• Depression
• Psychotic Disorders
• Neurocognitive Disorders
• Treatment-Induced Disorders
 Substance Use Disorders
• Estimates of > 15%
• Alcohol, cannabis, methamphetamine, IV
• To some degree reflect vulnerable
populations
• Associated with avoidance; denial and non-
adherence; may accelerate decline
 Adjustment and Anxiety
Disorders
• Adjustment disorder to diagnosis: 30%
• PTSD: 15-30%
• GAD: 15%
• Panic Disorder
 Depressive Disorders
• Estimates of up to 60% of HIV positive
patients
• Generally accepted figures of at least 35%
• More common in females
• Easily missed – under diagnosed
• Symptoms highly affected by cultural
context: PAIN; fatigue; non-specific
somatic complaints
 Depressive Disorders in HIV
Cont.
• Hopelessness, pessimism and poor
concentration affect adherence
• HIV progresses more rapidly
• 36x suicide rate
• May be mistaken for HAD/HND
• Respond well to treatment with improved
QOL and overall outcome
 HIV and Severe Mental Illness
• Increased incidence of HIV in those with
pre-existing, severe mental illness
• Evidence for deterioration, treatment-
resistance, increased side-effects to
medication
• “double stigma”
 HIV- Associated Psychosis
• Up to 10% of late-stage, usually in
association with dementia
• Small percentage occurring earlier
• Fluctuating level of consciousness; multiple
hallucinations; mixed mood
• Manic picture also common
• Very sensitive to medication
• Usually do well on ART
Neurocognitive disorders in HIV
• Neurocognition” describes brain processes
such as attention, language, learning and
perceptual motor integration- as well the
speed and efficiency of these processes
• Extremely common in HIV
• Indicate early invasion and neuropathology
in the brain
 Neurocognitive Impairment
• May occur early in the asymptomatic phase
• Possible consequence of early CNS
invasion
• Does not interfere with function
• Impairment on testing: verbal; attention;
working memory; executive function;
recall, sensory/perception; motor skills
 HIV-Associated Mild
Neurocognitive Disorder (MND)
• Previously known as Minor Cognitive Motor
Disorder (MCMD)
• Interferes with ADL but does not meet criteria for
dementia
• Usual complaints include mild impairment in
concentration, attention or memory; mild
coordination difficulties
• NB to exclude co-morbid infection and depression
 HIV-Associated Dementia
(HAD)
• Usually presents late in HIV,but may be the
first stage 4 defining illness
• Essential to exclude other opportunistic
CNS disorders eg. TBM; CNS lymphoma;
cryptococcal meningitis
• Subcortical dementia
• Triad of motor, cognitive and behavioural
signs
 HAD –Motor Sx
• Slowing and bradykinesia
• Apathy
• Tremor and highly sensitive to EPSE’s
• Postural abnormalities
• Gait abnormalities
• Associated peripheral neuropathies and eye
movement changes
 HAD - Cognitive
• Memory loss
• Mental slowing
• Reading difficulties
• Comprehension problems
• Impaired ability to use acquired knowledge
• Apathy and personality change
 HAD - Behavioural
• Mood disturbance: mixed; manic or
depressed
• Hallucinations (multiple)
• Disorientation
• Disinhibition
• Sleep changes
• Impaired judgement
 HAART in HIV/AIDS cognitive
impairment
• HAART improves cognitive performance
• HAART has been shown to improve cognition in Africa
• HAART has reduced the incidence of HAD by 50%,but
may delay rather than totally prevent HAD
• Impact of HAART affected by:
-Timing
-CNS penetration
– Viral clade (C in SA)
– Secondary infection/tumour
– Substance abuse, head injury
– Adherence and viral suppression
– Age, education and other demographic factors
 HIV in Children - Psychiatry
• Approximately 2,1mil HIV+ children
worldwide with 12mil AIDS orphans in
Africa
• Most infection vertical, but some via
transfusions and sexual abuse
Issues:
• Contextual
• Psychological
• neuropsychiatric
 Contextual Issues:
AIDS Orphans
• Poverty
• Care by relatives; especially grandmothers;
siblings
• Illness and death issues faced at an early age
• Bereavement: difficult, complicated by blaming,
shame and secrecy, disruption of bonding
• Need to express fears and fantasies
• Children with major life events have generally
poorer health measures; greater symptom
distress,more behavior problems
 Psychological Issues
• Stigma; isolation
• Hospitalisations may disrupt social development
• Pain; medication and side effects
• Facing mortality issues
• Loneliness,anger, confusion, fear,numbness and
guilt
• Cope through numbing, distraction, self-calming,
self-blame, risk-taking, drugs
• Depression, anxiety, disruptive behaviours
 Neuropsychiatry
• Bimodal presentation: seriously ill perinatally or
delayed presentation (“asymptomativ HIV” or
“slow progressors”)
• Up to 30% of late stage HIV in children
• Progressive encephalopathy characterized by a
triad of symptoms including impaired brain
growth, progressive motor dysfunction and loss or
arrest of developmental milestones
• Static encephalopathy with fixed deficits and
delayed milestones but no deterioration
 Neuropsychiatry cont.
• visual perception
• expressive language
• attention with ADHD Sx
• adaptive function
• executive function
• processing speed
• motor function
• memory
 Treatment
• Containment, counseling and support :
including care system
• Disclosure
• Destigmatization
• Specific medications
• ART: shown to stop or slow decline
• No evidence for denial of ART