NEW ORLEANS — The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.
HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, said Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.
Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.
Such dysfunction also can occur as a result of various treatments, such as antivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that without effective HIV treatment, long-standing adverse effects can occur as a result of subcortical and cortical insult.
The effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain—all of which are common in HIV patients and may contribute greatly to the cognitive problems.
Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain “a sense of disconnect between what's going on in the periphery and what's going on in the nervous system,” he said.
For example, findings in HIV, as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.
In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment.
“It may be a question of how much inflammation is in the brain itself,” he said.
As for psychiatric issues, many HIV patients experience depression, anxiety, and other psychiatric conditions. Mood disorders are the most common psychiatric complaint in those who have HIV, with studies suggesting that up to 60% have depression, half are substance abusers, and up to 25% have an anxiety disorder. Several factors are considered probable risk factors for depression in HIV (see box), such as a personal or family history of a mood disorder, and alcohol or drug use.
It may be that those at increased risk of HIV are also at increased risk of mood disorders, but in some cases the disorders can also be secondary to the disease, treatments, and/or physical manifestations of the disease, such as lipodystrophy, which can be a telltale sign of HIV infection.
Suicide also is a risk in HIV patients, and that risk is elevated across the trajectory of the disease; surviving into middle and older years has been associated with increased risk, and in the era of antiretroviral therapy, such survival is more common. However, few studies have evaluated suicide risk in this period.
Other psychiatric disorders common in HIV patients include adjustment disorders and psychotic disorders. Somatic problems such as sleep and pain disorders, fatigue, and sexual dysfunction also occur frequently and, like mood and other psychiatric disorders, should be addressed in these patients.
Depression Risk Factors in HIV
▸ Personal history of a mood disorder.
▸ Personal or family history of alcoholism, substance use, suicide attempt, and/or anxiety disorders.
▸ Current alcohol or drug use.
▸ An inadequate social support system.
▸ Nondisclosure of HIV-positive status.
▸ Multiple losses.
▸ Disease progression.
▸ Treatment failure and, in some cases, treatment success (for example, when a patient expects to die but is treated successfully and is subsequently haunted by fears that the treatment will fail and that he or she will be faced with preparing again for death).
In addition, women are twice as likely as men to develop depression regardless of HIV status, and women with HIV and depression are twice as likely to die as are women without signs or symptoms of depression, Dr. Forstein noted.