This document discusses the pathophysiology and management of HIV-related mental illness. It notes that psychiatric disorders are highly prevalent in people living with HIV, including substance use disorders, depression, and cognitive impairments. Risk factors include medical comorbidities, psychosocial stressors, and a history of mental illness. Treatment involves managing underlying medical conditions, treating psychiatric symptoms, and addressing psychosocial needs through counseling and support groups. Special populations like MSM, women, and the elderly are also at elevated risk and require tailored care.

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Riaz Rahman, MS3

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Pathophysiology of HIV
on the CNS
Initial Systemic
HIV Infection
Crosses BBB via
infected
macrophage
Viral Replication
in Infected
Astrocytes &
Monocytes
Low-Grade
Neuroinflamatory
Response
Neurotoxic Effect
on Brain
Parenchyma
Neurological &
Psychiatric
Sequelae

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 Prevalence: ~1.1 million people living with HIV by end of 2009
 Incidence: 50,007 new cases reported in 2011
Source: Centers for Disease Control, 2013
HIV Statistics in General Population

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HIV Prevalence in Psychiatric Populations
General
Population
HIV/AIDS
Population
Major Depression Anxiety DisordersSubstance Abuse
Source: BW Hospital, Harvard Medical School, 2012

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Risk Factors for Developing
HIV-Related Mental Illness
Medical Factors: Psychosocial Factors:
• Degree of CNS
Involvement
• Opportunistic infections
• Prognosis
• Other medical conditions
affecting brain
• Medication interactions
• History of Mental Illness
• Change in quality of life
• Stigma
• Social Support
• Substance Abuse

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HIV-Related Reactive Disorders
Substance Abuse Disorder
 Substance abuse is a primary vector
for the spread of HIV.
 Often demoralized, become hopeless
& are more likely to engage in high
risk behaviors.
 Patients with substance use disorders may not seek
health care or may be excluded from health care.
 Addiction and high-risk sexual behavior have been
linked across a wide range of settings.

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HIV-Related
Substance Abuse Disorder
 The accumulation of medical sequelae 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.

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HIV-Related
Substance Abuse Disorder

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HIV-Related
Substance Abuse Disorder
 The prevalence of this comorbidity is exceedingly high: about 50
percent of those in HIV care have a comorbid mental illness
 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 has HIV.
 The steps for the treatment of substance abuse disorder:
1. Role induction & motivation to change
2. Detoxification
3. Treatment of co-morbid conditions
4. Rehabilitation
5. Relapse prevention

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Minor Cognitive Motor Disorder
Dementia
Delirium

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HIV-Related Cognitive Disorders
Common Neurocognitive Symptoms
It is important to assess HIV/AIDS
patients for changes over time in:
 Memory
 Word finding/retrieval
 Concentration
 Slowing
 Motor concerns
 Perception of patient’s ability by others

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HIV-Related Cognitive Disorders
Minor Cognitive Motor Disorder
 Less severe cognitive disorder emergent in earlier HIV infection
 Prevalence data variable; up to ~60% by late-stage AIDS
 Symptoms are subtle & mild manifestations of HIV-associated
dementia: Cognitive and motor slowing.
 Mild impairments must be 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 remain stable with HAART, while others will
progress to frank dementia.

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 Generally seen in late stages of HIV illness (CD4+
count <200 cells/ml)
 Prevalence: reported to be 15%
 Risk factors: higher HIV RNA viral load, lower
educational level, older age, anaemia, illicit drug use &
female sex.
 Presentation (triad of symptoms): memory &
psychomotor speed impairments, depressive
symptoms, and movement disorders
HIV-Related Cognitive Disorders
Dementia

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

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 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.
HIV-Related Cognitive Disorders
Delirium

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 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.
HIV-Related Cognitive Disorders
Delirium

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Depression
Mania
Bipolar Disorder

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HIV-Related Mood Disorders
Depression
A Risk Factor For HIV: A Consequence of HIV:
 impact on behavior
 intensification of
substance abuse
 exacerbation of self-
destructive behaviors
 promotion of poor
partner choice in
relationships
 Caused by direct injury
to subcortical areas
 chronic stress
 social isolation
 intense demoralization
 HIV related medical
conditions &
medications

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HIV-Related Mood Disorders
Depression
 Most frequent 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.
 Nonspecific somatic symptoms (fatigue, insomnia)
 Medication plus psychotherapy (Interpersonal & CBT) -
more effective than either modality alone.

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HIV-Related Mood Disorders
Depression & HIV Relationship
Depression
Increase in Cortisol levels
Decrease in circulating
lymphocytes
Reduced ability of lymphocytes to
produce lymphokines
Increased expression of HIV by
Mononuclear cells

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HIV-Related Mood Disorders
Depression vs. Grief
 Grieving patients do not feel worthless, guilty, or
suicidal (they may have a passive wish for death)
 Grieving patients usually retain the capacity for
pleasure
 Grief comes in waves rather than being more
constant and unremitting
 Grieving patients can look forward to the future

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 Difficult to find out the incidence & prevalence
of bipolar illness among HIV because the
spectrum of bipolar illness is broad
 Bipolar disorder is as a risk factor for HIV/AIDS
 If early onset after HIV diagnosis: Bipolar I is
likely diagnosis
 If later onset after HIV diagnosis: likely
symptoms are secondary to AIDS mania
HIV-Related Mood Disorders
Bipolar Disorder

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HIV-Related Mood Disorders
AIDS Mania
 Associated with late-stage HIV infection.
 Consequences of brain involvement.
 Progressive cognitive decline prior to 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.

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Suicidality
Adjustment Disorder
Post-Traumatic Stress Disorder

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Adjustment & Reactive Disorders
Suicide
 Epidemiology
 16 – 17 times higher than general
population
 Accounts for 0.8% of all AIDS death
 Risk factors
 manner in which news revealed
 Inadequate pre & post test
counseling
 Stage of disease
 Psychosocial factors – stress,
isolation, denial, drug abuse, social
support
 Management
 Risk assessment
 Treatment of underlying
depression
 Treatment of physical
complaints
 Crisis intervention
 Supportive therapy or CBT

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HIV-Related Reactive Disorders
Post-Traumatic Stress Disorder
 Symptoms associated with risk behaviors and markers of
HIV progression
 Endangers or exacerbates HIV risk behaviors and
worsens health outcomes.
 PTSD as a result of sexual abuse
 43% of women (Zirler et al. 1996) and 35% of MSM
(Lenderking et al. 1997) who were either HIV+ or at
risk had a history of sexual abuse
 Sexually abused adolescents are less likely to use
condoms

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HIV-Related Reactive Disorders
Post-Traumatic Stress Disorder
 Screening for PTSD:
 Trauma History Questionnaire
 PTSD Checklist
 Treatment
 Typically involves behavioural exposure and
flooding.
 Address comorbid depression or substance
abuse

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Psychosis
Schizophrenia

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HIV-Related Psychotic Disorders
Psychosis
 Early in the course of HIV infection: may be the
initial manifestation of HIV but more likely to
be from another cause (often substance
intoxication/withdrawal)
 Later onset: direct damage of the CNS from the
HIV virus or herald of an underlying secondary
CNS disorder
 Patients with psychosis have a higher mortality
rate

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Stigma
Pre-Test Counseling
Post-Test Counseling

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HIV-Related Stigma
Three Broad Types: Causes:
1. Self Stigma - self blame
and self-deprecation
2. Perceived Stigma - fear
of others’ reactions after
disclosing HIV positive
status
3. Enacted stigma - active
discrimination against
seropositive individuals
 Ignorance
 Lack of accurate
information about
HIV/AIDS
 Misunderstanding
about HIV
transmission
 Inadequate Pre/Post
Test Counselling

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HIV-Related Stigma
Support groups decrease stigma:
1. Provide more knowledge about the illness
2. Teach how to deal with and manage it
3. Allows seropositive individuals to learn more
about others who are in the same situation as
themselves
4. Gives seropositive individuals perspective that
they are not alone in the lonely world of life
with HIV/AIDS.

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Pre-Test Counseling
Pre-Test Counselling should have:
 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.

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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. Results 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 others & how to protect others from becoming
infected.
 Patient will also be informed about resources &
treatments available

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Differential
Assessment & Screening

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Differential for Complications
 Delirium
 Dementia (HAND)
 AIDS-Mania
 Metabolic
Disturbances
 Social factors
 Drug side-effects
 Other disorders
 Sexual
 Anxiety
 Mood
 Sleep
 Substance

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Assessment and Screening
Common mental illnesses among individuals with
HIV and substance abuse:
 Adjustment disorders
 Sleep disorders
 Depressive disorders
 Mania
 Dementia
 Delirium
 Psychosis
 Personality disorder

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Assessment and Screening
Mental disorders of concern in HIV-infected
substance abusers:
 Substance-induced mental disorders
 Intoxication
 Withdrawal
 HIV or HCV-related mental disorders
 Effects of HIV or HCV
 Drugs used to treat HIV or HCV
 Mental disorders related to opportunistic
illnesses

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MSM
Women
Children & Adolescents
Elderly & Aging

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Special Populations
 MSM
 Highest at-risk group
 Consensual v. forced sexual experiences
 Women
 Maternal mortality 10x higher in HIV+ women
not on HAART
 Past trauma creates greater risk

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Special Populations
 Children and Adolescents
 Higher rates of ADD/ADHD, depression, & anxiety
 Substance abuse disorders increased
 Cognitive impairment with perinatal infection
 Elderly and Aging
 70% of age 50+ HIV+ New Yorkers live alone
(compared to 39% of HIV-) and thus are likely feeling
separate, alone, rejected
 Greater susceptibility to negative emotional and
medical outcomes
 Depression, bereavement, poor mental health, SUDs

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HAART
Antipsychotics

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HAART Medications
 Efavirenz
 SE include mood and psychotic disorders
 Ritonavir
 Most powerful inhibitor of CYP3A4
 Raises serum levels of anticonvulsants,
sildenafil
 Clozapine and pimozide contraindicated

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Antipsychotic Medications
 Higher incidence of extrapyramidal side effects
in this population
 both high and low potency medications
 Newer antipsychotic medications are associated
with fewer serious side effects
 Benzodiazepines
 Generally use with caution
 Avoid in SUD
 Lorazepam worsens delirium symptoms

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Antipsychotic Medications
 Lithium useful with mania secondary to ZDV
 Monitor levels and blood chemistry
 Intolerable in advanced disease
 Valproic Acid
 Caution: may increase HIV replication
 Atypical antipsychotics
 Metabolic effects

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