Neuropsychiatric Aspects of HIV Infection and AIDS

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. Mental health professionals from nursing, social work, psychology, and psychiatry followed the plight of patients of the epidemic and helped to mobilize interest and galvanize a response. Initially, much of the work focused on grief and loss issues, as well as supportive psychotherapy, but it quickly broadened to recognize a number of specific psychiatric conditions, including acquired immune deficiency syndrome (AIDS) dementia, the associated AIDS mania, increased rates of major depression, and psychiatric consequences of CNS injuries.

The first case of AIDS was reported in 1981. Analysis of specimens retained from persons who died before 1981, however, has shown that HIV infections were present as early as 1959. This suggests that in the 1960s and 1970s, HIV-related disorders and AIDS were increasingly common but unrecognized, particularly in Africa and North America. According to the Centers for Disease Control and Prevention (CDC), as of 2005 almost 950,000 persons in North America had been diagnosed with full-blown AIDS since 1981. There were about 43,000 new infections in 2004, with about 15,000 deaths. The CDC estimates that approximately 460,000 persons are living with AIDS in the United States. The World Health Organization (WHO) estimates that, worldwide, 2.5 million adults and 1 million children have AIDS and about 30 million persons are infected with HIV.

OVERVIEW OF HIV TRANSMISSION

Human immunodeficiency virus is a retrovirus related to the human T-cell leukemia viruses (HTLV) and to retroviruses that infect animals, including nonhuman primates. At least two types of HIV have been identified, HIV-1 and HIV-2. HIV-1 is the causative agent for most HIV-related diseases; HIV-2, however, seems to be causing an increasing number of infections in Africa. Other subtypes of HIV may exist, which are now classified as HIV-O. 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. HIV is most often transmitted through sexual intercourse or the transfer of contaminated blood from one person to another. Unprotected anal and vaginal sex are the sexual activities most likely to transmit the virus. Oral sex has also been implicated, but rarely. Health providers should be aware of the guidelines for safe sexual practices and should advise their patients to practice safe sex.

The chance of becoming infected after a single exposure to an HIV-infected person is relatively low: 0.8 to 3.2 percent for unprotected receptive anal intercourse, 0.05 to 0.15 percent with unprotected vaginal sex, 0.32 percent after puncture with an HIV-contaminated needle, and 0.67 percent after using a contaminated needle to inject drugs. The probability of transmission, however, could be higher, depending on the viral load of the contact person (which tends to be higher at the beginning and end of the course of the illness) or other factors, such as the presence of other sexually transmitted diseases. The presence of sexually transmitted diseases, such as herpes or syphilis, or other lesions that compromise the integrity of skin or mucosa further increases the risk of transmission. 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.

Although male-to-male transmission has been the most common route of sexual transmission in North America, male-to-female and female-to-male transmissions are increasing, and they represent most transmissions worldwide. Some studies have shown that about 50 percent of the regular sex partners of persons with HIV infection become infected, a statistic suggesting that some persons do not yet understand immunity or resistance to HIV infection.

Transmission by contaminated blood most often occurs when those abusing a substance intravenously (IV) share hypodermic needles without proper sterilization techniques. Transmission of HIV through blood transfusions, organ transplantation, and artificial insemination is no longer a problem now that donors are tested for HIV infection. Many hemophilia patients, however, received transfusions of HIV-infected blood products before HIV was identified as the causative agent. The risk of infection of health care workers after a needlestick is rare, about 1 in 300 incidents.

Children can be infected in utero or through breast-feeding when their mothers are infected with HIV. Zidovudine (Retrovir) and protease inhibitors taken by the HIV-infected pregnant woman prevent perinatal transmission in greater than 95 percent of cases. Health workers are theoretically at risk because of potential contact with bodily fluids from HIV-infected patients. In practice, however, the incidence of such transmission is very low, and almost all reported cases have been traced to accidental needle punctures with contaminated hypodermic needles. No evidence has been found that HIV can be contracted through casual contact, such as by sharing a living space or a classroom with a person who is infected, although direct and indirect contact with an infected person’s bodily fluids, such as blood and semen, should be avoided.

After infection with HIV, AIDS is estimated to develop in 8 to 11 years, although this time is gradually increasing because of early treatment. Once a person is infected with HIV, the virus primarily targets T4 (helper) lymphocytes, also called CD4⁺
lymphocytes, to which the virus binds because a glycoprotein (gp120) on the viral surface has a high affinity for the CD4 receptor on T4 lymphocytes. After binding, the virus can inject its ribonucleic acid (RNA) into the infected lymphocyte, where the RNA is transcribed into deoxyribonucleic acid (DNA) by the action of reverse transcriptase. The resultant DNA can then be incorporated into the host cell’s genome and translated and eventually transcribed once the lymphocyte is stimulated to divide. After viral proteins have been produced by lymphocytes, the various components of the virus assemble, and new mature viruses bud off from the host cell. Although the process of budding may cause lysis of the lymphocyte, other HIV pathophysiological mechanisms can gradually disable a patient’s entire complement of T4 lymphocytes.

Diagnosis

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). Both tests are 99.9 percent sensitive and specific. Health care workers and their patients must understand that the presence of HIV antibodies indicates infection, not immunity to infection. Those with a positive finding on an HIV test have been exposed to the virus, have the virus within their bodies, have the potential to transmit the virus to another person, and will almost certainly eventually develop AIDS. Those with a negative HIV test result have either not been exposed to the HIV virus and are not infected or were exposed to the HIV virus but have not yet developed antibodies, a possibility if the exposure occurred less than a year before the testing. Seroconversion most commonly occurs 6 to 12 weeks after infection, although in rare cases seroconversion can take 6 to 12 months.

Counseling.

The major issues in counseling persons about HIV serum testing are who should be tested; why a particular person should or should not be tested; what the test results signify; and what the implications are. Although specific groups of persons are at high risk for contracting HIV and should be tested, any person who wants to be tested should probably be tested. The reasons for requesting a test should be ascertained to detect unspoken concerns and motivations that may merit psychotherapeutic intervention.

Past practices that may have put the testee at risk for HIV infection and safe sexual practices should be discussed. During posttest counseling, counselors should explain that a negative test finding implies that safe sexual behavior and the avoidance of shared hypodermic needles are recommended for the person to remain free of HIV infection. A positive test result indicates that the person is infected with HIV and can spread the disease. Those with positive results must receive counseling about safe practices and potential treatment options. They may need additional psychotherapeutic interventions if anxiety or depressive disorders develop after they discover that they are infected. Common issues and concerns are fear of disclosure, relationships with friends and family, employment and financial security, medical condition, and such psychological issues as self-esteem and self-blame. A person may react to a positive HIV test finding with a syndrome similar to posttraumatic stress disorder. Concern about minor physical symptoms, insomnia, and dependence on health care workers commonly arise. Adjustment disorder with anxiety or depressed mood may develop in as many as 25 percent of those informed of a positive HIV test result. Clinical interactions with patients should emphasize the meaning of a positive test result and should encourage reestablishment of emotional and functional stability.

Couples who are considering taking the HIV antibody test must decide who will be tested and whether to go alone or together. The therapist should ask why they are considering taking the test; partners often for the first time discuss issues of commitment, honesty, and trust, such as sexual contacts outside the relationship. They need to be prepared for the possibility that one or both are infected and must discuss what effect this will have on their relationship.

Confidentiality.

Confidentiality is a key issue in serum testing. No one should be given an HIV test without previous knowledge and consent, although various jurisdictions and organizations, such as the military, require HIV testing for all inhabitants or members. The results of an HIV test can be shared with other members of a medical team, although the information should be provided to no one else except in the special circumstances discussed in the next paragraph. The patient should be advised against disclosing the results of HIV testing too readily to employers, friends, and family members; the information could result in discrimination in employment, housing, and insurance.

The major exception to restriction of disclosure is the need to notify potential and past sexual or IV substance use partners. Most patients who are HIV positive act responsibly. If, however, a treating physician knows that a patient who is HIV infected is putting another person at risk of becoming infected, the physician may try either to hospitalize the infected person involuntarily (to prevent danger to others) or to notify the potential victim. Clinicians should be aware of the laws about such issues, which vary among the states. These guidelines also apply to inpatient psychiatric wards when an HIV-infected patient is believed to be sexually active with other patients.

CLINICAL FEATURES

Nonneurological Factors

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