MUHIMBILI UNIVERSITY OF HEALTH

AND ALLIED SCIENCES

SCHOOL OF NURSING

FORENSIC AND COMMUNITY MENTAL

HEALTH NURSING
HIV&AIDS
GROUP No. 07
FACILITATOR: JOEL SEME
21/5/2019 1
 Learning Objectives
• Introduction
• Epidemiology
• Interlink between HIV/AIDS and Mental heath
• Psychiatric illness associated with HIV/AIDS
• HIV and substance use disorders
• Prevention challenges
• Medication related mental disorders
 Introduction
• HIV is a Human Immunodeficiency virus that
attacks the body immune system and if left
untreated it results to AIDS.

• AIDs is an Acquired Immune Deficiency

Syndrome that is caused by HIV.
 Introduction cont…..
• Mental health is defined as a state of well
being in which the individual realizes his/her
own potential, can copy with normal stress of
life, can work productively and fruitfully and
is able to make a contribution to his /her
community.
 Introduction cont…..
• Mental heath includes, emotional,
psychological, and social well being. It affect
how people think, feel and act. It also help to
determine how to handle stress, related to
others and make choices.
 Epidemiology
• Studies have demonstrated a high
seroprevalence of HIV infection in people with
serious mental illnesses.
• Some studies has reported behavioral risk
factors for transmission of HIV in between
30% and 60% of people with severe mental
illnesses.
 Epidemiology cont....
• People with HIV infection have higher rate of
HIV associated neurocognitive disorders,
although these disorders tend to be milder than
they were before effective antiretroviral
therapy.(OXFORD MEDICINE, 2022)
 INTERLINK BETWEEN HIV/AIDS AND
MENTAL HEALTH
• HIV increase risk for psychiatric illness
• Psychiatric illness increase risk for HIV
• Effective treatment of mental illness can
improve patient outcome
• Effective treatment of mental illness can
decrease HIV transmission
 Cont....
•The risks lead to HIV includes high rates of
sexual contact with multiple partners, injecting
drug users, sexual abuse.
•Besides the these behavioral risks, mental
disorders may interfere with the ability to
acquire and/or use information about HIV/AIDS
thus increase the likelihood of occurrence of risk
behaviors.
 Cont...
• The prevalence of mental illnesses in HIV-
infected individuals is substantially higher
than in general population.
• Studies in low and higher income countries
have reported higher rate of depression in
HIV-positive people compared with HIV-
negative control group.
• The level of distress often seems to be related
to severity of symptoms of HIV-infection.
 Psychiatric Illnesses Associated with
HIV

• HIV Associated Dementia

• HIV Associated depression.
• Psychotic Disorders
• Affective Disorders
• Anxiety Disorders
• Psychiatry side effects of ARVs
HIV Related Dementia
 Cont....

Definition
•HAD is acquired impairment of intellectual and cognit-
ive ability.
•In a sufficient degree of severity
– It interfere social or occupational functions
– where memory impairment is a pre dominant fea-
ture.

•Other cognitive function are also affected with behavi-

oural and personality changes that significantly affect
the individual quality of life
 Cont....
•It occurs in 20-30% of patients with CD4 T-
lymphocyte count less than 100 cells/mm 3

•Direct viral effects of HIV on the CNS

•If available brain imaging will show atrophy

(shrinking) and non-specific white matter
changes
 Cont....

Pathological changes
• HIV can be found in CSF and brain tissue,
hence the virus can cross BBB

• Virus then infect glia cells

• Glia cells secret neurotoxin lead to neuronal

damage and death
 Cont....

Risk factors
Old age
Level of immunodeficiency
High viral load
Low cd4 count (100-200 copies)
 Cont....
Clinical manifestation
•HAD presents with typical symptoms seen in
other sub-cortical dementias
•Following are early symptoms patients may
present with:
– Apathy
– Irritability
– Sometimes manic symptoms (new onset
psychosis)
 Cont....
Clinical manifestation
• Personality changes

• Social withdrawal

• Cognitive changes
• Visual –spatial memory (e.g. misplacing things)
• Poor visual – motor coordination
• Difficult with complex sequencing – unable to perform
previously learned tasks
• Impaired verbal memory – word findings
• Impaired attention and concentration
• Gait disturbances – slow steps
 Cont....
Management
• Continue with ART
• Treat opportunistic infections if present
• Initiate antipsychotic medications
• Initiate anticholinergic medications as well –
patients prone to EPSE
• Start with low dose of antipsychotic then in-
crease slowly with close monitoring treatment
response.
 Cont....
 Atypical such as olanzapine or resperidone can
be given
 Be careful with patients who are on ritonavir
(enhance liver enzymes)
 Avoid benzodiazepines ; increase confusion
and decrease concentration
 Involve family members
 Psychoeducation
HIV and Depression
 Introduction

 Depression is the state

of lowered mood, often
accompanied by
disturbances of sleep,
energy, appetite,
concentration, interest,
and sexual drive

22
 HIV and Depression

Studies suggest that there are higher rates of

HIV infection in depressed population due to
the following factors
 Increased risk taking behavior
 Social exclusion
 Substance misuse
 Cognitive deficits/ Impaired judgment
 HIV and Depression Cont….

• Mentally ill patient are less likely to attend for

HIV screening and to attend follow up. Also
have poor quality of life and increased
mortality
 HIV and Depression Cont….
 Studies suggest that depression is an
independent risk factor for poor prognosis for
those initiated on ARVs.
 HIV-positive have nearly twice the rate of
major depression as HIV-negative
 HIV and Depression Cont..
HIV with depressive disorders compared with
HIV alone was found that; HIV with
depressive disorder have poor prognosis due
to the followings;
delays in medical treatment
Worse adherence to medical treatment
 Depression and HIV Cont…
• Symptoms of Depression
 Depressed mood ( irritable mood )
 Loss of interest on pleasure in activities
(anhedonia)
 Decreased energy or easily fatigued
 Disturbed sleep
 Disturbed appetite
 Reduced concentration/attention
 Reduced self esteem and self confidence
 HIV And Substance Use

HIV can be a risk factor for substance use.

But also
Substance use can be a risk factor for HIV
transmission.
 HIV And Substance Use Cont...
 Alcohol and other drugs can affect a person’s
judgment and increase risk of getting or
transmitting HIV.
 In people living with HIV, substance use can
worsen the overall consequences of HIV.
 Social and structural factors make it difficult
to prevent HIV among people who use
substances.
 HIV And Substance Use Cont...
Commonly Used Substances and HIV Risk
 Alcohol. Excessive alcohol consumption, (binge
drinking) can be an important risk factor for HIV
because it is linked to risky sexual behaviors and,
among people living with HIV, can hurt treatment
outcomes.
 Opioids. Opioids, a class of drugs that reduce pain,
include both prescription drugs and heroin. They are
associated with HIV risk behaviors such as needle
sharing when injected and risky sex, and have been
linked to a recent HIV outbreak
 HIV And Substance Use Cont...
 Methamphetamine. Is linked to risky sexual
behavior that places people at greater HIV risk. It can
be injected, which also increases HIV risk if people
share needles and other injection equipment.
 Cocaine. Crack cocaine is a stimulant that can create
a cycle in which people quickly exhaust their
resources and turn to other ways to get the drug,
including trading sex for drugs or money, which
increases HIV risk.
 Inhalants. Has been linked to risky sexual
behaviors, illegal drug use, and sexually transmitted
diseases among gay and bisexual men
 Prevention Challenges
A number of behavioral, structural, and
environmental factors make it difficult to control
the spread of HIV among people who use or
misuse substances:
 Prevention Challenges Cont..
 Complex health and social needs.
People who are alcohol dependent or use drugs
often have other complex health and social
needs. Research shows that people who use
substances are more likely to be homeless, face
unemployment, live in poverty, and experience
multiple forms of violence, creating challenges
for HIV prevention efforts.
 Prevention Challenges Cont..
 Stigma and discrimination associated with
substance use.
Illicit drug use is viewed as a criminal activity
rather than a medical issue that requires
counseling and rehabilitation. Fear of arrest,
stigma, feelings of guilt, and low self-esteem
may prevent people who use illicit drugs from
seeking treatment services, which places them at
greater risk for HIV.
 Prevention Challenges Cont..
 Lack of access to the health care system.
Since HIV testing often involves questioning
about substance use histories, those who use
substances may feel uncomfortable getting
tested. As a result, it may be harder to reach
people who use substances with HIV
prevention services.
 Prevention Challenges Cont..
 Poor adherence to HIV treatment.
People living with HIV who use substances are
less likely to take antiretroviral therapy (ART) as
prescribed due to side effects from drug
interaction. Not taking ART as prescribed can
worsen the effects of HIV and increase the
likelihood of spreading HIV to sex and drug-
sharing partners.
 Medication-Related Mental Disorders

Psychiatric symptoms in HIV-infected patient

may result from the use of prescription
medication. For example, high doses of AZT can
produce anxiety, insomnia, or hyperactivity.
Similarly, Efavirenz is associated with variety of
central nervous system symptoms, such as very
vivid dreams or nightmares
The use of steroids in HIV/AIDS treatment may
induce psychosis.
late-stage HIV disease, memory and other
cognitive functions may be worsened by certain
combinations of medications, particularly central
nervous system
ANTIRETROVIRAL DRUGS INTERACTION
WITH PSYCHOTROPIC DRUGS
 All protease inhibitors and non- nucleoside
reverse transcriptase inhibitors are metabolized
by the p450 system and posses enzyme
inhibiting or inducing properties.
 Psychotropic medications also possess similar
metabolic characteristics hence may interact
with antiretroviral drugs.
 Interaction cont...
Psychotropic medications including;
antidepressants, neuroleptics and anticonvulsants
are often prescribed for HIV/AIDS patients to
manage drug or disease related adverse effects,
mood stabilizing effect or for concurrent
psychiatric condition.
 Interaction cont...
Psychotropic drugs often have narrow
therapeutic indices and maybe susceptible to
interaction involving CYP 450 system.
Thus there is high potential for clinically
significant interaction between psychotropic
drugs and protease inhibitors or non-nucleoside
reverse transcriptase inhibitors (NNRTIs).
 Interaction cont...

Modification Interaction in drug selection,

dose, or dosing regimen maybe needed to
ensure adequate antiretroviral concentration,
thus minimizing the risk of incomplete viral
suppression or development of drug resistance
The initial dose of psychotropic could be
reduced or dose titration and monitoring for
toxicity.
 Interaction cont...
ANTIDEPRESSANTS
 Interaction with antiretroviral drugs are possible with
all SSRIs by means of their potential to inhibit
CYP450 enzymes.
 Because they are metabolized by CYP450 isozymes
there is potential for increased levels of SSRIs when
used in combination with enzyme inhibitors
 The combination of fluoxetine with ritonavir has
shown to increase the concentration of ritonavir
 Antidepressants Cont..
 Also when ritonavir used in combination with
fluoxetine may cause increase in fluoxetine
level
 Fluoxetine and paroxetine may cause toxicity
by increased level of protease inhibitors
 BENZODIAZEPINES.
 Alprazolam, midazolam and triazolam are
dependent on CYP3A4 for metabolism.
 Potent inhibitors of CYP isoform such as ritonavir
can decrease clearance of these drugs and result
into over sedation and possibly death.
 Oxazepam, lorazepam and temazepam are
metabolized by glucuronidation . Drugs that
increase the activities of glucuronidation e.g.
ritonavir and nelfinavir may lower level of these
drugs.
 Group members
• Michael K Patson
• Dereck A Majebeli
• Tednes A Kanubo
• Prisca Charles
• Machibya Paul
• Sauda Mbaga
• Michael Masunga
• Bertha Mashauri