FROM THE ACADEMY OF PSYCHOSOMATIC MEDICINE
Psychiatrists are uniquely positioned to provide both preventive and therapeutic interventions for children, adolescents, adults, and elderly persons who are vulnerable to, infected with, or affected by HIV. Psychiatrists routinely take patient histories that include substance use; sexual activities; relationships; and trauma, including childhood neglect and emotional, physical, and sexual abuse—as well as comprehensive medical, psychiatric, and social histories. Progress in preventing HIV infection has lagged far behind progress in the disease’s diagnosis and treatment. Stigma, discrimination, and fear may prevent persons with risk behaviors such as unprotected sex and injection drug use from getting tested, learning that they have HIV infection, or obtaining much needed care.
While there are similarities, HIV/AIDS differs from many complex and severe medical illnesses because it is an infectious and stigmatized disease that can lead to and is associated with other multimorbid medical illnesses. It is also associated with psychiatric illnesses because of the affinity of HIV for brain and neural tissue as well as its profound impact on persons who are infected.
Increasing awareness of stigma, discrimination, and psychiatric factors associated with the HIV pandemic can lead to decreased transmission as well as early diagnosis and treatment. Compassionate medical and psychiatric care can mitigate suffering in persons at risk for, infected with, and affected by HIV.
Prevention of HIV infection
Strategies have been developed for communicating, preventing HIV transmission, improving adherence to risk reduction and medical care, addressing health care disparities, and ameliorating stigma. These include the National AIDS Strategy Updated to 2020, the 2015 Blueprint to Eliminate AIDS in New York State, and the World Health Association Guidelines. Key prevention strategies for all patients are presented in Table 1.
Treatment as prevention
Persons who are thought to be the most substantially vulnerable to HIV infection include HIV-negative members of serodiscordant couples and HIV-negative injection drug users. An HIV-negative member of a serodiscordant couple may take pre-exposure prophylaxis (PrEP) to prevent infection. PrEP and postexposure prophylaxis (PEP) with antiretroviral medications such as tenofovir together with emtricitabine—in combination with safe sex, barrier contraception, and safe injection drug practices—can prevent HIV transmission in serodiscordant couples. The evidence for the use of PrEP and PEP in serodiscordant couples is strong.1
PrEP may also be an effective measure in persons with HIV infection who are injection drug users. In 2014 and 2015, both the Centers for Disease Control and the World Health Organization included injection drug users in their endorsement of PrEP as an HIV prevention method. Much of the evidence for the efficacy of PrEP in injection drug users was derived from the Bangkok Tenofovir Study, which showed a 48.9% reduction in HIV infections.2 Ongoing PrEP demonstration projects have included injection drug users in their participant pool, but data concerning overall awareness, uptake, and engagement in injection drug users are limited. A summary of recommendations for prevention and pre- and postexposure prophylaxis is provided in Table 2.
Psychiatric disorders and HIV infection
The comprehensive, compassionate, and nonjudgmental approach to the care of persons at risk for or infected with HIV begins with a thorough psychiatric evaluation. This evaluation is designed to provide an ego-supportive assessment.3 Shaking hands, while important with all initial patient encounters, takes on special relevance in the context of AIDSism, or HIV stigma and discrimination against gay persons, drug users, and those with infectious disease.4 Assessing the impact of HIV infection is best done by asking about the individual’s understanding of his or her illness. Special attention is needed to address sensitive issues related to sexual history, gender, and sexuality. See Table 3 for key issues related to neurocognitive disorders, delirium, and substance abuse in persons with HIV infection.
Depression and HIV infection. It can be challenging to determine the prevalence of depressive disorders in persons with HIV infection because of the overlap of the physiological changes associated with HIV illness and the somatic symptoms of depression, such as appetite changes, anergia, fatigue, loss of libido, sleep disturbances, and cognitive impairment. Overwhelming evidence indicates that depressive manifestations and disorders are highly prevalent in persons with HIV infection.5,6
Dr Cohen is Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai in New York. Dr Cozza is Associate Professor of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, MD. Dr Bourgeois is Clinical Professor and Vice Chair of Clinical Affairs in the Department of Psychiatry/Langley Porter Psychiatric Institute at the University of California, San Francisco. Dr Moghimi is Staff Psychiatrist at Whitman Walker Health and Clinical Instructor in the Department of Psychiatry and Behavioral Sciences at George Washington University in Washington, DC. Dr Douaihy is Professor of Psychiatry and Medicine and Medical Director, Addiction Medicine Services and Addiction Psychiatry Fellowship at the Western Psychiatric Institute and Clinic of the University of Pittsburgh School of Medicine in Pittsburgh, PA. Drs Cohen, Cozza, Bourgeois, and Moghimi report no conflicts of interest concerning the subject matter of this article. Dr Douaihy reports that he has received research grants from NIDA, NIMH, NIAAA, Orexo, and Alkermes; in addition, he receives royalties from Oxford University Press.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense.
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