Evidence-Based Reviews

Using psychotropics safely in patients with HIV/AIDS: Watch for drug-drug interactions with antiretrovirals

Current Psychiatry. 2004 August;3(8):44-58

References

1. American Psychiatric Association. Practice guideline for the treatment of patients with HIV/AIDS. Am J Psychiatry. 2000 157 11(suppl). Also available at: www.psych.org/psych_pract/treatg/pg/hivaids_revisebook_index.cfm

2. Centers for Disease Control and Prevention National Center for HIV, STD, and TB Prevention. HIV AIDS Surveill Rep December 2001. Available at: http://www.cdc.gov/hiv/stats/hasr1302.htm

3. Centers for Disease Control and Prevention. HIV AIDS Surveill Rep 2002;14:148. Also available at: http://www.cdc.gov/hiv/stats/hasr1402/2002SurveillanceReport.pdf

4. Risk reduction: sex without condoms. HIV Counselor Perspectives [newsletter] 2001;10(2, March).

5. Cournos F, McKinnon K. HIV seroprevalence among people with severe mental illness in the United States: a critical review. Clin Psychol Rev 1997;17:259-69.

6. Steele FR. A moving target: CDC still trying to estimate HIV-1 prevalence. J NIH Res 1994;6:25-6.

7. Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med 2000;133:21-30.

8. Grant I, Atkinson JH, Jr. Neuropsychiatric aspects of HIV infection and AIDS. In: Sadock BJ, Sadock VA (eds). Kaplan and Sadock’s comprehensive textbook of psychiatry. Philadelphia: Lippincott Williams & Wilkins, 1999;308-36.

9. Ayuso JL. Use of psychotropic drugs in patients with HIV infection. Drugs 1994;47:599-610.

10. Mirken B. Danger: possibly fatal interactions between ritonavir and “ecstasy,” some other psychoactive drugs. AIDS Treat News 1997;Feb 21(No 265):5.-

11. Miller KD, Jones E, Yanovski JA, et al. Visceral abdominal-fat accumulation associated with use of indinavir. Lancet 1998;351(9106):871-5.

12. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47(No. RR-19):1-39.

13. Kraus MR, Schafer A, Faller H, et al. Paroxetine for the treatment of interferon-alpha-induced depression in chronic hepatitis C. Aliment Pharmacol Ther 2002;16(6):1091-9.

14. Nomenclature and research case definitions for neurologic manifestations of human immunodeficiency virus-type 1 (HIV-1) infection: report of a working group of the American Academy of Neurology AIDS Task Force. Neurology 1991;41:778-85.

15. Power C, Selnes OA, Grim JA, McArthur JC. HIV Dementia Scale: a rapid screening test. J Acquir Immune Defic Syndr Hum Retrovirol 1995 Mar 1;8(3):273-8.

16. Silberstein CH, McKegney FP, O'Dowd MA, et al. A prospective longitudinal study of neuropsychological and psychosocial factors in asymptomatic individuals at risk for HTLV-III/LAV infection in a methadone program: preliminary findings. Int J Neurosci 1987;32(3-4):669-76.

17. Reitan RM. Validity of the trail making test as an indicator of organic brain damage. Percept Mot Skills 1958;8:271-6.

18. Price RW, Yiannoutsos CT, Clifford DB, et al. Neurological outcomes in late HIV infection: adverse impact of neurological impairment on survival and protective effect of antiviral therapy. AIDS Clinical Trial Group and Neurological AIDS Research Consortium study team. AIDS 1999;13(13):1677-85.

19. Perry SW. Organic mental disorders caused by HIV: update on early diagnosis and treatment. Am J Psychiatry 1990;147(6):696-710.

20. Wilt SG, Milward E, Zhou JM, et al. In vitro evidence for a dual role of tumor necrosis factor-alpha in human immunodeficiency virus type 1 encephalopathy. Ann Neurol 1995;37(3):381-94.

21. Boven LA, Gomes L, Hery C, et al. Increased peroxynitrite activity in AIDS dementia complex: implications for the neuropathogenesis of HIV-1 infection. J Immunol 1999;162(7):4319-27.

22. Centers for Disease Control and Prevention. Revised guidelines for HIV counseling, testing, and referral. MMWR Nov. 9, 2001;50(RR19):1-58.

23. Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of persons living with HIV. MMWR July 18, 2003;52(RR12):1-24. Also available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm

24. Food and Drug Administration. Home Access HIV-1 Test System: Summary of safety and effectiveness. Available at: http://www.fda.gov/cber/PMAsumm/P950002S.pdf

25. Perry SW, Jacobsberg LB, Fishman B. Psychological responses to serological testing for HIV. AIDS 1990;4(2):145-52.

26. Opravil M, Ledergerber B, Furrer H. et al and the Swiss HIV Cohort Study Clinical benefit of early initiation of HAART in patients with asymptomatic HIV and CD4 counts >350/mm 3 . Abstract LB-6. Chicago, IL: 8th Conference on Retroviruses and Opportunistic Infections, 2001.

27. Marzuk P, Tierney H, Tardiff K, et al. Increased risk of suicide in persons with AIDS. JAMA 1988;259:1333-7.

28. Marzuk PM, Tardiff K, Leon AC, et al. HIV seroprevalence among suicide victims in New York City, 1991-93. Am J Psychiatry 1997;154(6):1720-5.

To incorporate HIV-prevention messages and brief behavioral interventions into clinical visits:

speak with patients about sexual and drug use behaviors in simple, everyday language
learn about interventions shown to be effective
become familiar with community resources that address HIV risk reduction.²³

Training. The CDC and Health Resources and Services Administration of the U.S. Department of Health and Human Services offer free training on risk screening and prevention, as well as opportunities for continuing medical education (see Related Resources).

Table 4

Diagnostic criteria for HIV-associated dementia

Acquired abnormality in at least two of the following cognitive abilities (present for 1 month) At least one of the following: Absence of clouding of consciousness during a period long enough to establish the presence of criterion 1 Exclusion of another etiology
Source: Reprinted with permission from reference 14

Advances in antibody testing

Psychiatrists play an important supportive role in encouraging HIV screening of at-risk patients of unknown serostatus and in counseling such patients before, during, and after test results are known.

Rapid lab tests. In 2002, the FDA approved a rapid, highly accurate HIV-1 screening test for serum specimens and in March 2004 approved the same test for screening oral fluid specimens. Test results with serum or an oral swab are available from a laboratory in approximately 20 minutes. In clinical studies submitted to the FDA, the OraQuick oral fluid test correctly identified 99.3% of persons infected with HIV-1 (sensitivity) and 99.9% of those not infected (specificity).

CDC guidelines for HIV counseling and testing have been revised to include rapid testing. Screening tests are most accurate at least 3 months after an HIV exposure—the time required for antibodies to develop. When counseling patients after a reactive test result, emphasize that the result is preliminary and further testing is needed to confirm the result. Counsel patients who have a negative result within 3 months of possible infection to be retested to guard against a possible false-negative result.

Home test kits. An FDA-approved consumer-controlled test kit—Home Access HIV-1 Test System²⁴ —is sold at drug stores without a prescription. The customer pricks a finger with a special device, places drops of blood on a specially treated card, and mails the card to a licensed laboratory. Anonymous identification numbers are used when phoning for the results.

Customers may speak to a counselor before taking the test, while awaiting results, and when results are given. All individuals with a reactive test result are referred for a more-specific test and receive information and resources on treatment and support services.

Counseling the HIV patient

The psychological impact of positive HIV antibody test results on psychiatric patients has not been studied. Persons without psychiatric disorders commonly experience anxiety and depression immediately after learning of a positive result. Unless the patient has HIV-related physical symptoms, these psychological sequelae often return to baseline—similar to when the blood sample was drawn—within 2 weeks.²⁵

Patients need to know that a positive HIV test result is no longer associated with death within 2 to 3 years. During a 2-year period, for example, disease progression from HIV infection to AIDS decreased 7-fold among patients who started antiretroviral therapy with a CD4+ T-cell count >350 cells/mm3, compared with others who were monitored without therapy.²⁶ This may be especially important to reinforce with newly-diagnosed patients unfamiliar with advances in HAART.

Medication adherence. To increase patients’ adherence to antiretroviral therapy:

express interest that they are taking their medications
use psychotherapy to help them solve problems that interfere with adherence.

Suicide risk. In the 1980s, significantly increased suicide rates were reported among HIV-infected persons. For example, the suicide rate in 1985 for New York City men ages 20 to 59 living with an AIDS diagnosis was 36 times higher than that of similar men without AIDS.²⁷ A later study of HIV infection in New York male suicide victims from 1991 to 1993 suggested that HIV serostatus was associated with a modest increase—at most—in suicide risk. That study considered the interplay of other suicide risk factors, such as substance abuse.²⁸

Related resources

Guidelines for HIV counseling, testing, and referral. Centers for Disease Control and Prevention. www.cdc.gov/mmwr/preview/mmwrhtml/rr5019a1.htm
Training in HIV prevention and counseling. National Network of STD/HIV Prevention Training Centers (http://depts.washington.edu/nnptc) and AIDS Education and Training Centers National Resource Center (http://www.aids-ed.org)
Rapid HIV testing. Centers for Disease Control and Prevention. http://www.cdc.gov/hiv/rapid_testing/
Cytochrome P450 drug interaction table. Indiana University School of Medicine. Division of Clinical Pharmacology. www.drug-interactions.com

Drug brand names

Buspirone • BuSpar
Carbamazepine • Carbatrol
Citalopram • Celexa
Clomipramine • Anafranil
Fluoxetine • Prozac
Fluvoxamine • Luvox
Imipramine • Tofranil
Mirtazapine • Remeron
Paroxetine • Paxil
Sertraline • Zoloft
Trazodone • Desyrel
Venlafaxine • Effexor