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
    • 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
  • 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

Author: Armin

Created: 2022-09-22 Thu 00:28