This document provides an overview of HIV/AIDS, including transmission, pathogenesis, diagnosis, treatment, and psychiatric aspects. Key points include: - HIV is transmitted through bodily fluids and infects CD4 cells. Over time it can cause AIDS through opportunistic infections. - Testing detects HIV antibodies. Positive results mean infection but not immunity. Counseling addresses testing, results, and confidentiality. - A wide range of neurological and psychiatric syndromes can occur due to HIV, including dementia. - Treatment involves prevention, antiretroviral drugs, and psychotherapy to address issues like guilt, relationships, and end-of-life decisions. Partner notification is also discussed.

1. Neuropsychiatric Aspects of HIV
Infection and AIDS

2. 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.
• 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.

3. • HIV is present in blood, semen, cervical and vaginal
secretions, and, to a lesser extent, in 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 .

4. Pathogenesis
• 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 RNA into the infected
lymphocyte, where the RNA is transcribed into 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.

6. AIDS Safe-Sex Guidelines
Remember: Any activity that allows for the exchange of body
fluids of one person through the mouth, anus, vagina, bloodstream,
cuts, or sores of another person is considered unsafe at this time.
Safe-sex practices:
• Massage, hugging, body-to-body rubbing
• Dry social kissing
• Masturbation
• Acting out sexual fantasies (that do not include any unsafe-sex
practices)
• Using vibrators or other instruments (provided they are not shared)

7.  Low-risk sex practices:
• These activities are not considered completely safe:
– French (wet) kissing (without mouth sores)
– Mutual masturbation
– Vaginal and anal intercourse while using a condom
– Oral sex, male (fellatio), while using a condom
Oral sex,
– female (cunnilingus), while using a barrier
– External contact with semen or urine, provided there are
no breaks in the skin

8. Unsafe-sex practices:
• Vaginal or anal intercourse without a condom
• Semen, urine, or feces in the mouth or the
vagina
• Unprotected oral sex (fellatio or cunnilingus)
• Blood contact of any kind
• Sharing sex instruments or needles

9. • 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.

10. • 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 transmission worldwide.
• 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.

11. • 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 more than 95 percent of cases.
• Health workers are theoretically at risk because of
potential contact with bodily fluids from HIV-infected
patients.
• 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 .

12. Centers for Disease Control and Prevention (CDC)
Guidelines for the Prevention of HIV Transmission
from Infected to Uninfected Persons
Infected persons should be counseled to prevent the further transmission of HIV
by:
1. Informing prospective sex partners of their infection with HIV, so they can
take appropriate precautions. Abstention from sexual activity with another
person is one option that would eliminate any risk of sexually transmitted HIV
infection.
2. Protecting a partner during any sexual activity by taking appropriate
precautions to prevent that person's coming into contact with the infected
person's blood, semen, urine, feces, saliva, cervical secretions, or vaginal
secretions. Although the efficacy of using condoms to prevent infections with
HIV is still under study, the consistent use of condoms should reduce the
transmission of HIV by preventing exposure to semen and infected
lymphocytes.
3. Informing previous sex partners and any persons with whom needles were
shared of their potential exposure to HIV and encouraging them to seek
counseling and testing.

13. 4. For IV drug abusers, enrolling or continuing in programs to eliminate
the abuse of IV substances. Needles, other apparatus and drugs must
never be shared.
5. Never sharing toothbrushes, razors, or other items that could
become contaminated with blood.
6. Refraining from donating blood, plasma, body organs, other tissue,
or semen.
7. Avoiding pregnancy until more is known about the risks of
transmitting HIV from the mother to the fetus or newborn.
8. Cleaning and disinfecting surfaces on which blood or other body
fluids have spilled, in accordance with previous recommendations
9. Informing physicians, dentists, and other appropriate health
professionals of antibody status when seeking medical care, so that
the patient can be appropriately evaluated

14. Diagnosis
Serum Testing:
• Techniques are now 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.

15. 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.

16. Possible Indications for Human
Immunodeficiency Virus (HIV) Testing

17. Pretest HIV Counseling

18. Posttest HIV Counseling

19. 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, now 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 below.
• 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.

20. • 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.

21. Clinical Features
Nonneurological Factors:
• About 30 percent 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. Rarely, acute aseptic meningitis
develops shortly after infection, as does
encephalopathy or Guillain-Barr syndrome.

22. • The most common infection in persons infected
with HIV who have AIDS is Pneumocystis carinii
pneumonia, which is characterized by a chronic,
nonproductive cough, and dyspnea, sometimes
sufficiently severe to result in hypoxemia and its
resultant cognitive effects.
• The other disease that was initially associated
with the development of AIDS is Kaposi's
sarcoma, a previously rare, blue-purple-tinted
skin lesion

23. • The most common infections are from
protozoa such as Toxoplasma gondii; fungi
such as Cryptococcus neoformans and
Candida albicans; bacteria such as
Mycobacterium avium-intracellulare; and
viruses such as cytomegalovirus and herpes
simplex virus.

24. Neurological Factors
• An extensive array of disease processes can
affect the brain of a patient infected with HIV.
• The most important diseases for mental
health workers to be aware of are HIV mild
neurocognitive disorder and HIV-associated
dementia.

25. Conditions Associated with Human Immunodeficiency Virus
(HIV) Infection

26. Psychiatric Syndromes
• HIV-Associated Dementia:
• Mild Neurocognitive Disorder
• Delirium
• Anxiety Disorders
• Adjustment Disorder
• Depressive Disorders
• Mania
• Substance Abuse
• Psychotic Disorder
• Worried Well

27. Treatment
• Primary prevention involves protecting persons
from getting the disease; secondary prevention
involves modification of the disease's course.
• All persons with any risk of HIV infection should
be informed about safe-sex practices and about
the necessity to avoid sharing contaminated
hypodermic needles.
• Many public health officials have advocated
condom distribution in schools and the
distribution of clean needles to drug addicts.

28. • These issues remain controversial, although condom
use has been shown to be a fairly (although not
completely) safe and effective preventive strategy
against HIV infection.
• Those who are conservative and religious argue that
the educational message should be sexual abstinence.
• Many university laboratories and pharmaceutical
companies are attempting to develop a vaccine to
protect persons from infection by HIV. The
development of such a vaccine, however, is probably at
least a decade away.

29. Pharmacotherapy
• A growing list of agents that act at different points in viral
replication has raised for the first time the hope that HIV might be
permanently suppressed or actually eradicated from the body.
• At the time of this writing, the active agents were in two general
classes: reverse transcriptase inhibitors and protease inhibitors.
• The reverse transcriptase inhibitors are further subdivided into the
nucleoside reverse transcriptase inhibitor group and the
nonnucleoside reverse transcriptase inhibitors. I
• n addition to the new nucleoside reverse transcriptase inhibitors,
nonnucleoside reverse transcriptase inhibitors, and protease
inhibitors, other classes of drugs are under investigation.
• These include agents that interfere with HIV cell binding and fusion
inhibitors (e.g., enfurvitide [Fuzeon]), the action of HIV integrase,
and certain HIV genes such as gag, among others.

30. Antiretroviral Agents

32. Psychotherapy
Approaches:
• Major psychodynamic themes for patients infected with HIV involve self-blame,
self-esteem, and issues regarding death.
• The psychiatrist can help patients deal with feelings of guilt regarding behaviors
that contributed to infection or AIDS. Some patients with HIV and AIDS feel that
they are being punished.
• Difficult health care decisions, such as whether to initiate or continue taking
antiretroviral medication and terminal care and life-support systems, should be
explored, and here denial of illness may be evident.
• Major practical themes involve employment, medical benefits, life insurance,
career plans, dating and sex, and relationships with families and friends.
• The entire range of psychotherapeutic approaches may be appropriate for patients
with HIV-related disorders. Both individual and group therapy can be effective.
• Individual therapy may be either short term or long term and may be supportive,
cognitive, behavioral, or psychodynamic.
• Group therapy techniques can range from psychodynamic to completely
supportive in nature.

33. Therapist-Related Issues:
• Countertransference issues and burnout of therapists
who treat many patients infected with HIV must be
evaluated regularly.
• Therapists must acknowledge to themselves their
predetermined attitudes toward sexual orientation and
substance use so that those attitudes do not interfere
with the treatment of the patient.
• Issues regarding the therapist's own sexual identity,
past behaviors, and eventual death may also give rise
to countertransference issues.

34. • Psychotherapists who have practices with
many patients infected with HIV can begin to
have their effectiveness impaired by
professional burnout.
• Some studies have found that seeing many
such patients in a short time seems to be
more stressful to therapists than seeing a
smaller number of those infected with HIV
over a longer period.

35. Involvement of Significant Others:
• The patient's family, lover, and close friends are often important
allies in treatment.
• The patient's spouse or lover may have guilt feelings about possibly
having infected the patient or may experience anger at the patient
for possibly infecting him or her.
• The involvement of members of the patient's support group can
help the therapist assess the patient's cognitive function and can
also aid in planning financial and living arrangements for the
patient.
• The patient's significant others may themselves benefit from the
attention of the therapist in helping them cope with the illness and
the impending loss of a friend or family member.

36. Partner Notification:
• Although no clear consensus has been reached, recommendations
are that patients who are sexually active and infected with HIV
should be counseled about potential risk to their sexual partners.
• Additionally, known partners should be notified of exposure risk
and potential infection as well.
• Partner notification has been an extremely hotly debated topic;
however, many states have developed legislation requiring or
allowing either physicians or health department officials to notify
partners of patients who are HIV infected of their risk.
• The current standard, despite the controversy, appears to be an
obligation on the part of health care professionals to notify anyone
who could be construed as clearly at risk and clearly identifiable
and who may be unaware of their risk.

37. • A particularly difficult situation is that of sex-industry
workers known to be HIV infected and known to be working
actively as prostitutes.
• Public health issues exist that pose a risk both for these
patients and, depending on the politics of the
circumstances, for their potential partners, clients,
customers, victims, or victimizers.
• The response to this problem has ranged from a sense that
sex-industry workers and their clients can make their own
decisions and should be responsible for their own behavior
all the way to the sentiment that such people should be
arrested and jailed for attempted murder.

38. • It has additionally been noted that some sex-industry
workers are impaired by a variety of psychiatric conditions,
including cognitive impairment, major mental illness,
personality disorder, and substance abuse disorders.
• These may further contribute to the sense that some sex-
industry workers may be less than fully responsible for their
behavior.
• Recommendations have been made for voluntary and
involuntary interventions regarding these patients.
• Specific psychiatric interventions regarding competency,
ability to consent, capacity, and, most importantly,
treatment for the conditions that impair such people are
critical to the mental health needs of patients with HIV.

39. Thank you…………….