1. HIV/AIDS AND MENTAL ILLNESS: TODAY’S CHALLENGE Prof SegganeMusisi MD, FRCP (C) Department Of Psychiatry Makerere University Global Mental Health and Africa: Opportunities, Challenges And Collaborations Mbarara University Of Science And Technology: Aug. 15th - 16th , 2011

2. ACKNOWLEDGEMENTS MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES ACADEMIC ALLIANCE FOR AIDS CARE AND PREVENTION IN AFRICA (IDI) UGANDAN MENTAL HEALTH ASSOCIATIONS: UPA, APRO, MHRC RESEARCH GRANTS: ARCH, ROGERS FOUNDATION, SIDA/SAREC, USHS, FULBRIGHT COMMISSION, NIH. MY STUDENTS AND RESEARCH COLLEAGUES

4. Progression Of The Epidemic

5. Nature & Extent Of The Mental Health Problems

6. Etiological Factors

7. The Mental Health Problems Themselves

8. Mental Health Problems Of HIV/AIDS In Children

9. Orphans & Caregivers

10. HIV/AIDS Among The Elderly

11. The Challenge

13. PROGRESSION OF THE EPIDEMIC STARTED IN EARLY 1980s MOST ADVANCED & SERIOUS IN SUB-SAHARAN AFRICA LINKED TO POVERTY & LOW EDUCATION 70% OF PLWHA ARE IN SUB-SAHARAN AFRICA RAN ITS COURSE, PEAKED & HAS SHOWN DIFFERENT WAVES.

14. OBSERVATIONS :THE AIDS WAVES EARLY 1980s – FIRST AIDS CASES INFECTION WAVE Very physically ill – Wasted : SLIM Disease Early death Ran mad : Bewitched (From Tanzania) DEATH WAVE Widows Orphans ORPHAN WAVE COTOs HIV-positive Adolescents THE ELDERLY HIV- POSITIVE WAVE Effect of HAART Effect Of Ageing

15. IK Missoula 2003

16. IK Missoula 2003

19. FAMILY DISCORD

20. STIGMA (Cultural, Religious & Disease Factors)

21. INFECTIOUS

22. FATAL

23. CHRONIC

24. DISFIGURING

25. INVOLVES CNS

26. OPPORTUNISTIC INFECTIONS

28. PERSONALITY DISTURBENCES PREMORBID ADJUSTMENT PERSONALITY CHANGES Antisocial behaviour Irresponsibility Giving up Irresponsible Sexuality

30. Bipolar Disorder

31. Depression

32. Schizophrenia

33. MR

34. SUBSTANCE ABUSE

35. Alcohol

36. Marijuana, Mayirungi

37. IV Drug use

38. HIGH HIV RISK POPULATIONS

39. 4H Club

40. Prostitutes & Truck drivers

41. Professionals

43. ADJUSTMENT AND REACTIVE DISORDERS ACUTE STRESS DISORDER SUICIDALITY ADJUSTMENT DISORDERS: WITH ANXIOUS MOOD WITH DEPRESSED MOOD WITH DISTURBENCE OF CONDUCT WITH MIXED FEATURES

45. Kuganda S. (2011): M.Med (Psychiatry)Thesis, MakCHS

46. 6% Psychological Distress

47. 27% Panic Attacks & 27% Generalised Anxiety Disorder

48. Factors associated with Anxiety Disorder:

49. Unemployment

50. Poor Social Support

51. Oral Thrush

53. PSYCHOTIC DISORDERS HIV-RELATED PSYCHOSIS: SCHIZOPHRENIA-LIKE PARANOID MIXED PRE-EXISTING SCHIZOPHRENIA Maling’s et al: (2011). AIDS Care, Vol. 23, No. 2, 171-178 18.4% Prevalence in First Episode Psychosis F>M; Older age of onset (41 years). More auditory, visual & tactile hallucinations. More likely to remit.

55. The IHDS can screen for Dementia in Uganda/Africa

56. 31% prevalence Of Dementia: Cognitive impairment ↓ with HAART

57. Question: When can we start HAART with CD4>200?

58. Nakasujja N et al(2010): BMC Psychiatry 10:44Depressive & cognitive symptoms are common in HIV/AIDS Cognitive deficits persist despite adequate treatment for depression

60. About 60% reported having lived in visiting unions at one point

61. Conclusion: Considerable flexibility, variability and volatility of marital unions & conjugal practices among the HIV-positive TASO clients.DISCORDANT COUPLES: 10% WIDOWS: 30%

62. DISCLOSURE OF HIV STATUS TO PARTNERLwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.

63. CONDOM USELwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.

64. PARTNER VIOLENCELwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.

65. HIV/AIDS AND CHILDREN(Wakhweya et al, 2000)  ORPHANS >2 million orphans in Uganda, >14 million orphans in Africa Types of Orphans: Paternal orphans (50%) Double orphans (30%) Maternal Orphans (20%) Classification Of AIDS orphans: HIV-positive orphans Have all the neuropsychiatric disorders, many physical illnesses associated with HIV + psychosocial problems HIV-negative orphans Have only psychosocial problems but no major disorders Elderly caretakers (30%), Child-headed households Poverty , Prostitution, Destitution Mother to Child Transmission (25%) >90% of infected children are orphans >60% are in stage III of illness by 10 yrs

66. Impact Of HIV/AIDS-related Parental Death On Children’s Home Life Increased: . Poverty . Household responsibility . Psychosocial distress . Vulnerability to sexual & labor abuse, . Stigma and isolation . Hunger and malnutrition Reduced: - Access to food - Access to health services - Access to school - Material goods : clothes, supplies - Guidance, protection, and love

68. >60% are in stage III of illness by 10 yrs

70. HPE (4.9%) Seizures(8.5%)

71. Suicide, (20%) , Substance Abuse(4.8%).

72. Somatoform Disorders (18.3%)

74. Shelter: To build and/or repair houses

75. Psycosocial Interventions: Care, Protection, Schooling

76. School fees, scholastic materials and LUNCH

77. Contributing to a better future…

78. ELDERLY HIV-POSITIVES NEW WAVE & INCREASING ↑ STIGMA, ↑ SECRECY, with ↓ACCESS TO CARE MULTIPLE PHYSICAL & MENTAL PROBLEMS HAD Vs OTHER DEMENTIAs SEXUALLY ACTIVE, SOME HAD >1 PARTNER. FEW USED CONDOMS ↓ SOCIAL SUPPORT, ARV TREATMENT & CLINIC ATTENDANCE NO SPECIFICALLY TARGETTED PREVENTION PROGRAMS LAXITY OF CARE ON THE PART OF THE STAFF

79. Elderly HIV-Positive Age Distribution (N=118)

80. The Elderly Sexual Behavior (last 3 months)

82. Problems In Scaling Up HIV care

83. Adherence, Resistance: The role of mental health

84. Substance Abuse

85. Unreached Pockets Of Infection : The marginalised (Trauma , mentally ill, elderly, orphans, disabled)

87. LETS MOVE FORWARD IN PARTNERSHIP