Table of Contents
1. Overview
- thought to have originated in africa
- hiv1 and hiv2, single stranded RNA retrovirus
- belief that hiv was a result of oral polio vaccine trials contaminated by infected chimpanzee kidney cells in the belgian congo is discredited by most virologists
- CD4 targets, diminishes count of T4 helper cells ~100/m3/year, over 10 years cell-mediated immunity is lost
- high error rate during transcription
- HAART/CART
- even a few missed doses were shown to be associated with viral production and thus emergence of mutations
- concept of treatment as prevention (of spread)
- psychiatric conditions are associated with increased risk behaviour, decreased access to care, and increased medical comorbidities
- stages of HIV 1-4 depending on clinical severity (WHO classification)
2. Epidemiology
- 2012 UN AIDS: 35.2m in the world, most in sub-saharan africa
- US 1.2m infected
- transfusion-related risk: 1/1.5m
- highest risk: homosexual men, IV drug users and their female partners, and sex workers
- mother-to-fetus transmission 25-30% of live-births
- <2% with treatment
3. Delirium
- 43-65% prevalence
- same as non-HIV
- HIV increased risk
3.1. treatment
-same treatment as non-HIV
4. HIV dementia
- CMV encephalitis, PML, toxoplasmosis, meningitis, CNS lymphoma, HIV itselfl
- subcortical dementia: attention and concentration, motor slowing
- generally death in less than 1 year
- uncommon, especially with CART
- cognitive impairment more subtle and unpredictable course with HIV
- 52% HIV-associated neurocog disorder: 33% asymptomatic, 12% mild, 2% major
- risk: associated with degree of medical comorbidity, severity of hiv
4.1. treatment
- aggressive tx with CART
- safety assessment, antidep for dep, ritalin for apathy
- no clear effective treatment
5. MDD
- affects behaviour: risk factor for hiv, and affects treatment compliance
- increased risk of disease progression and mortality
- HIV increases risk for MDD through direct injury to subcortical areas of brain, chronic stress, social isolation, demoralization
- 2.5x increase in rate of depression as CD4 falls <200
5.1. treatment
- no single superior antidep
- some papers have noted SSRI as first line
- data don't show that, patient-centered approach
- some papers have noted SSRI as first line
- slow titration to minimize side effects
- worry about adherence
- 1 week at low dose, after that full dose
- interactions
- table 2.8-2 in kaplan textbook, pg 1530
- risk/benefit: depression can lead to CART non-adherence: more important than interaction
- risk/benefit: no clinical significance to interactions and no dose adjustments for either HAART or antidep
- psychotherapy
- CBT, IPT, and supportive psychotherapy
6. Bipolar
- AIDS mania: associated with cognitive impairment and lack of previous episode and family history
- manic symptoms happen after onset of AIDS, higher rates as well
- 8% of AIDS patients
- clinical picture different from bipolar mania: +cognitive slowing +irritable mood +psychomotor slowing (complicates dx)
- generally AIDS mania is severe and malignant
6.1. treatment
- standard treatment
7. Schizophrenia
- 4-19% prevalence
- no evidence that HIV causes schizophrenia, but schizophrenia contributes to risky behaviours resulting in HIV infection
- practitioners should use Risk Behaviours Questionnaire (RBQ)
7.1. treatment
- same as normal schizophrenia
- co-management
8. Hep C
- 50% co-infection rate
- increased rate of depression
- treatment with interferon-ribavirin combo increase MDD and can produce mania
- interferon-alphaa has been associated with depressive symptoms, suicide, and rarely mania
- successfully treated with SSRIs and TCAs
- 90% cure rate for newer agents, interferon-based agents likely won't be used
- interferon-alphaa has been associated with depressive symptoms, suicide, and rarely mania