The prevalence of HIV in persons with untreated psychiatric illness may be 10 to 20 times that of the general population.1 The U.S. Preventive Services Task Force has recommended HIV screening of all persons age 15 to 65 because 20% to 25% of individuals with HIV infection are unaware that they are HIV-positive.2 Because >20% of new HIV infections in the United States are undiagnosed,3 it is crucial to educate patients with mental illness about HIV prevention, make condoms available, and offer HIV testing.
As psychiatrists, we have a unique role in caring for patients at risk for or infected with HIV because in addition to comprehensive medical and psychiatric histories, we routinely take histories of substance use, sexual activities, relationships, and trauma, including childhood neglect and emotional, physical, and sexual abuse. We develop long-term, trusting relationships and work with individuals to change behaviors and maximize life potential.
Increasing awareness of stigma, discrimination, and psychiatric factors involved with the HIV pandemic can lead to decreased transmission of HIV infection and early diagnosis and treatment. Compassionate medical and psychiatric care can mitigate suffering in persons at risk for, infected with, or affected by HIV.
Preventing HIV transmission
AIDS differs from other complex, severe illnesses in 2 ways that are relevant to psychiatrists:
• it is almost entirely preventable
• HIV and AIDS are associated with sex, drugs, and AIDS-associated stigma and discrimination (“AIDSism”).4-6
Unsafe exposure of mucosal surfaces to the virus—primarily from exchanging body fluids in unprotected sexual encounters—accounts for 80% of new HIV infections.7 HIV transmission via sexual encounters is preventable with condoms. Percutaneous or intravenous infection with HIV—primarily from sharing needles in injection drug use—accounts for 20% of new infections.7 Use of alcohol or other substances can lead to sexual coercion, unprotected sex, and exchange of sex for drugs or money. Hence, treating substance use disorders can prevent HIV transmission.
Early diagnosis of HIV can lead to appropriate medical care, quicker onset of antiretroviral (ARV) treatment, and better outcomes. Recent research has shown that pre-exposure prophylaxis with ARV treatment can prevent transmission of HIV8; therefore, becoming aware of risk behaviors and prevention can be lifesaving for serodiscordant couples.
One of the most important ways to prevent HIV’s impact on the brain and CNS is to diagnose HIV shortly after transmission at onset of acute infection. If HIV is diagnosed very early—preferably as soon as possible after inoculation with HIV or at onset of the first flu-like symptoms—and treated with ARVs, the brain has less of an opportunity to act as an independent reservoir for HIV-infected cells and therefore to develop HIV-associated neurocognitive disorders.9,10Table 1 outlines steps psychiatrists can take to help prevent HIV transmission.
Psychiatric disorders and HIV
Psychiatric disorders and distress play a significant role in transmission of, exposure to, and infection with HIV (Table 2).4-6,11 They are relevant for prevention, clinical care, and adherence throughout every aspect of illness.
Comprehensive, compassionate, nonjudgmental care of persons at risk for or infected with HIV begins with a thorough psychiatric evaluation designed to provide an ego-supportive, sensitive, and comprehensive assessment that can guide other clinicians in providing care.12 Setting the tone and demonstrating compassion and respect includes shaking hands, which takes on special relevance in the context of AIDSism and stigma. Assessing the impact of HIV seropositivity or AIDS is best done by asking about the individual’s understanding of his or her diagnosis or illness and its impact. For some persons with HIV, verbalizing this understanding can be relieving as well as revealing. It is a chance for the patient to reveal painful experiences encountered in the home, school, camp, workplace, or community and the anguish of AIDSism and stigma.
Pay attention to sensitive and sometimes painful issues related to sexual history and sexuality. Questions related to sexual history and sexuality in heterosexual men and women as well as gay, lesbian, bisexual, and transgender individuals—such as “What is your sexual function like since you have been ill?” “Do feelings about your sexual identity play a role in your current level of distress?” and “What kind of barrier contraception are you using?”—are included in the comprehensive assessment described by Cohen et al.12
Comprehensive psychiatric evaluations can provide diagnoses, inform treatment, and mitigate anguish, distress, depression, anxiety, and substance use in persons with HIV and AIDS.12 A thorough and comprehensive assessment is crucial because HIV has an affinity for brain and neural tissue and can cause CNS complications such as HIV-associated neurocognitive disorders (HAND), even in otherwise healthy HIV-seropositive individuals. See this article at CurrentPsychiatry.com for a discussion of HAND and delirium in patients with HIV.