Neuropsychiatric Aspects of HIV and AIDS

I. Introduction

The human immunodeficiency virus (HIV) epidemic was identified in the 1980s, and neurologists described several HIV-related central nervous system (CNS) syndromes within the first several years of the epidemic. These include acquired immunodeficiency syndrome (AIDS) dementia, the associated AIDS mania, increased rates of major depression, and psychiatric consequences of CNS injuries. More than 50% of infected persons have neuropsychiatric manifestations, which is often the first presenting complaint. Neuropathological changes have been found in up to 90% of AIDS patients at autopsy.

II. HIV Transmission

HIV is a retrovirus related to the human T-cell leukemia virus (HTLV) and to retroviruses that infect animals, including nonhuman primates. HIV-1 is the primary causative agent for most HIV-related disorders. HIV is present in blood, semen, cervical and vaginal secretions, and, to a lesser extent, saliva, tears, breast milk, and the cerebrospinal fluid of those who are infected. The modes of transmission include heterosexual and homosexual intercourse, needles, blood products, and medical accidents. Children can be infected in utero. Oral sex has been rarely implicated. Transmission also occurs through exposure to contaminated needles, thus accounting for the high incidence of HIV infection among drug users. HIV is also transmitted by infusions of whole blood, plasma, and clotting factors, but not immune serum globulin or hepatitis B vaccine. The risk for transmission is higher with higher viral loads and with the coexistence of sexually transmitted diseases that compromise skin or mucosal integrity.

AIDS develops 8 to 11 years after infection. This time has been increased by early intervention with antiretroviral drugs. The virus binds to the CD4 receptor on T4 (also called CD4) lymphocytes. The virus injects ribonucleic acid (RNA) into the lymphocyte. HIV pathophysiological mechanisms gradually disable all T4 lymphocytes and destroy cell-mediated immunity, and opportunistic infections develop.

III. Epidemiology

It is estimated that 33 million people have been infected with HIV worldwide, with more than 12 million deaths as a result. In the United States, an estimated 1.1 million persons are infected with the virus, and another 320,000 have full-blown AIDS. According to the Centers for Disease Control and Prevention (CDC), over 800,000 people in the United States are living with HIV infection or AIDS. The chance of becoming infected after a single exposure to an HIV-infected person is relatively low: 0.8% to 3.2% for unprotected receptive anal
intercourse, 0.05% to 0.15% with unprotected vaginal sex, 0.32% after puncture with an HIV-contaminated needle, and 0.67% after using a contaminated needle to inject drugs. The risk of infection of health care workers after a needlestick is rare, about 1 in 300 incidents. The proportion of African Americans and Hispanics with AIDS has increased. Worldwide, the vast majority (>95%) of AIDS cases and deaths occur in developing countries, mostly in young adults, with an increasing proportion of cases in women.

IV. Diagnosis and Clinical Picture

A. Serum testing.

Techniques are widely available to detect the presence of anti-HIV antibodies in human serum. The conventional test uses blood (time to result, 3 to 10 days), and the rapid test uses an oral swab (time to result, 20 minutes). Two available techniques for detection of antibodies to HIV are the enzyme-linked immunosorbent assay (ELISA) and the Western blot. The ELISA is the initial screen. The Western blot is more specific and is used to confirm positive ELISA results. Seroconversion is the change after HIV infection from a negative HIV antibody test result to a positive HIV antibody test result. Seroconversion usually occurs 6 to 12 weeks after infection but may take 6 to 12 months. Possible indications for HIV testing are outlined in Tables 10-1.

Some of the issues involved in pretest and posttest counseling are described in Tables 10-2 and 10-3.

B. Nonneurological clinical manifestations.

About 30% of persons infected with HIV experience a flulike syndrome 3 to 6 weeks after becoming infected; most never notice any symptoms immediately or shortly after their infection. When symptoms do appear, the flulike syndrome includes fever, myalgia, headaches, fatigue, gastrointestinal symptoms, and sometimes a rash. The syndrome may be accompanied by splenomegaly and lymphadenopathy. Rare neurological manifestations include Guillain-Barré syndrome, encephalopathy, and meningitis. An asymptomatic stage follows that lasts a median of 10 years. During this time, the number of CD4+ cells declines from a normal of more than 1,000/mm³ to fewer than 200/mm³.
Patients are at high risk for AIDS-defining complications when CD4+ cells drop to below 200. The two most common coinfections in persons infected with HIV who have AIDS are Pneumocystis carinii pneumonia and Kaposi’s sarcoma.

Table 10-1 Possible Indications for HIV Testing

Patients who belong to a high-risk group: (1) men who have had sex with another man since 1977, (2) intravenous drug abusers since 1977, (3) hemophiliacs or other patients who have received blood or blood product transfusions not screened for HIV since 1977, (4) sexual partners of people from any of these groups, (5) sexual partners of people with known HIV exposure—people with cuts, wounds, sores, or needlesticks whose lesions have had direct contact with HIV-infected blood.
Patients who request testing; not all patients will admit to the presence of risk factors (e.g., because of shame, fear).
Patients with symptoms of AIDS or HIV infection.
Women belonging to a high-risk group who are planning pregnancy or who are pregnant.
Blood, semen, or organ donors.
Patients with dementia in a high-risk group.

Adapted from Rosse RB, Giese AA, Deutsch SI, Morihisa JM. Laboratory & Diagnostic Testing in Psychiatry. Washington, DC: American Psychiatric Press; 1989:54, with permission.

Table 10-2 Pretest HIV Counseling

Discuss meaning of a positive result and clarify distortions (e.g., the test detects exposure to the AIDS virus; it is not a test for AIDS).
Discuss the meaning of a negative result (e.g., seroconversion requires time; recent high-risk behavior might require follow-up testing).
Be available to discuss the patient’s fears and concerns (unrealistic fears might require appropriate psychological intervention).
Discuss why the test is necessary (not all patients will admit to high-risk behaviors).
Explore the patient’s potential reactions to a positive result (e.g., “I’ll kill myself if I’m positive”). Take appropriate necessary steps to intervene in a potentially catastrophic reaction.
Explore past reactions to severe stresses.
Discuss the confidentiality issues relevant to the testing situation (e.g., whether it is an anonymous or a nonanonymous setting). Inform the patient of other possible testing options wherein the counseling and testing can be done completely anonymously (e.g., where the result would not be made a permanent part of a hospital chart). Discuss who might have access to the test results.
Discuss with the patient how being seropositive can potentially affect social status (e.g., health and the insurance coverage, employment, housing).
Explore high-risk behaviors and recommend risk-reducing interventions.
Document discussions in chart.
Allow the patient time to ask questions.

From Rosse RB, Giese AA, Deutsch SI, Morihisa JM. Laboratory & Diagnostic Testing in Psychiatry. Washington, DC: American Psychiatry Press; 1989:55, with permission.

C. Classification.

The CDC classifies AIDS based on CD4+ counts and the presence or absence of HIV-associated clinical conditions. Category A represents primarily asymptomatic patients; category B includes patients with AIDS-defining conditions, such a Pneumocystis pneumonia.

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