Assessment and treatment of psychosis in people living with HIV/AIDS

The pathophysiology of psychosis and other forms of severe mental illness in HIV infection is complex, and multifactorial causation is likely in most instances. Severe mental illness has been identified as a risk factor for the acquisition of HIV infection and occurs as both a manifestation of opportunistic infections and a result of the neurotropic effects of the virus.1 A full psychiatric assessment in people living with HIV/AIDS (PLWHA) presentingwith psychosis is important but may prove difficult in many parts of South Africa. This paper presents a variety of algorithms to simplify the assessment and management of an HIV-infected patient with psychosi

The behaviourally disturbed patient with HIV/AIDS

While HIV invades the brain early in the course of HIV infection,1 severe mental illness probably only occurs later in the disease.2 In many instances this may be the first presentation of a psychiatric illness in a younger person.In addition, the clinical syndrome may include manic and/or psychotic  features, together with neurocognitive disturbance. These patients are at risk of secondary opportunistic infections or other features of systemic  immunocompromise which may cause or confound the clinical picture

Needs and services at an in-patient psychotherapy unit

Objective: To describe the impact of services provided, during an admission,on unmet needs and correlates of unmet needs. Method: The study used a modified version of The Camberwell Assessment of Need (CAN) to assess the perceived needs of 100 patients on admission to a psychotherapy unit, Valkenberg Hospital, Cape Town. At discharge, the study documented the extent to which the patients had perceived services and interventions to be useful. Results: The mean number of needs on admission was 8.6. At discharge, help received was highest for psychiatric needs. The services most often regarded as useful were organised group activities and therapies. Regression analysis suggests that a lower level of education and the presence of borderline personality traits contribute significantly to unmet need on discharge. Conclusion: The in-patient program is effective in meeting psychiatric needs, but less useful for addressing psycho-social needs. These needs may exacerbate psychiatric problems and should be managed more actively before, during and after an in-patient stay. Keywords: Mental health services; Camberwell assessment of Need; Unmet need African Journal of Psychiatry Vol. 10 (3) 2007: pp. 149-15

Needs and services at an in-patient psychotherapy unit

Objective: To describe the impact of services provided, during an admission, on unmet needs and correlates of unmet needs. Method: The study used a modified version of The Camberwell Assessment of Need (CAN) to assess the perceived needs of 100 patients on admission to a psychotherapy unit, Valkenberg Hospital, Cape Town. At discharge, the study documented the extent to which the patients had perceived services and interventions to be useful. Results: The mean number of needs on admission was 8.6. At discharge, help received was highest for psychiatric needs. The services most often regarded as useful were organised group activities and therapies. Regression analysis suggests that a lower level of education and the presence of borderline personality traits contribute significantly to unmet need on discharge. Conclusion: The in-patient program is effective in meeting psychiatric needs, but less useful for addressing psycho-social needs. These needs may exacerbate psychiatric problems and should be managed more actively before, during and after an in-patient sta

HIV/AIDS and psychiatry: Towards the establishment of a pilot programme for detection and treatment of common mental disorders in people living with HIV/AIDS in Cape Town

As the roll-out of antiretrovirals (ARVs) to people living with HIV / AIDS (PLWHA) continues to increase in South Africa, so too does the need to integrate mental health services into HIV care. In this editorial, we argue that the role of mental health in ARV programmes is central. The prevalence of mental disorders in PLWHA is higher than in the general population, and the impact of these conditions is substantial. Screening tools for mental disorders are both available and feasible. These should be incorporated into routine ARV care, with support from dedicated HIV mental health services

Forum: Psychotropic prescribing in HIV

Psychiatric disorders frequently co-occur with HIV, as preceding conditions or consequent to HIV infection. This potentially compromises HIV diagnosis and antiretroviral (ARV) treatment adherence. We provide a brief guide to the diagnosis and treatment of common mental disorders in people living with HIV/AIDS, including: prescribing psychotropics in HIV; neuropsychiatric side-effects of ARVs and other medications commonly prescribed in HIV; and the diagnosis and treatment of depression, anxiety, psychosis, agitation, sleep disturbance, pain, and mania. Psychotropic treatments recommended were drawn primarily from those available in the public sector of South Africa

The neurobiology of HIV dementia: implications for practice in South Africa

In this review, the neuropathogenesis of HIV dementia (HIV-D) is discussed in the context of the local epidemic. HIV-D continues to be prevalent in the era of highly active anti-retroviral therapy. HIV neuro-invasion into the central nervous system may result in the development of separate HIV genotypes in an individual through compartmentalisation. The blood brain barrier continues to limit penetration of anti-retroviral drugs into the cerebrospinal fluid. Individuals with active neuro-inflammation appear to respond well to HAART. In some cases low grade neuro-degeneration persists with consequent clinical deterioration. In South Africa, the emergence of a sub-epidemic of HIV-D is being driven by various factors, including the incomplete coverage of HAART to all who need it, the late stage presentation of people living with HIV/AIDS (PLWHA) and a co-occurring methamphetamine epidemic. Differences in viral subtype do not appear to confer protection against HIV-D. Implications for PLWHA who are at risk for HIV-D in South Africa are explored, with a view to providing suggestions for improving practice and research into this area.Key words: Dementia; HIV; HAART; South Afric

The neurobiology of HIV dementia: implications for practice in South Africa

In this review, the neuropathogenesis of HIV dementia (HIV-D) is discussed in the context of the local epidemic. HIV-D continues to be prevalent in the era of highly active anti-retroviral therapy. HIV neuro-invasion into the central nervous system may result in the development of separate HIV genotypes in an individual through compartmentalisation. The blood brain barrier continues to limit penetration of anti-retroviral drugs into the cerebrospinal fluid. Individuals with active neuro-inflammation appear to respond well to HAART. In some cases low grade neuro-degeneration persists with consequent clinical deterioration. In South Africa, the emergence of a sub-epidemic of HIV-D is being driven by various factors, including the incomplete coverage of HAART to all who need it, the late stage presentation of people living with HIV/AIDS (PLWHA) and a co-occurring methamphetamine epidemic. Differences in viral subtype do not appear to confer protection against HIV-D. Implications for PLWHA who are at risk for HIV-D in South Africa are explored, with a view to providing suggestions for improving practice and research into this area

Patients with severe mental illness: A new approach to testing for HIV

Background. The prevalence of HIV infection in South Africa is approaching 20% of young adults. In severely mentally ill people it is probably higher. Testing for infection is subject to stringent ethical principles. Undiagnosed HIV infection in people with severe mental illness increases costs and morbidity. Since effective treatments are available, it is imperative to diagnose HIV infection early in this high-risk population. Methods. A literature review established the prevalence of HIV infection in inpatient populations with HIV infection. The pattern of testing for HIV over 3 years at a major psychiatric hospital was investigated. We surveyed public sector psychiatrists in the Western Cape to establish their attitudes to HIV in their patients. Results. The reported HIV seroprevalence in psychiatric inpatients ranges from 0 to 59.3%, with a mean of 10%. Data show a clear trend towards an increase in prevalence: before 1996 the mean HIV seroprevalence was 7.4%, while after 1996 the mean was 15%. State psychiatrists in the Western Cape do not test routinely for HIV infection, mainly owing to ethical constraints: 14.6% of patients at Lentegeur Hospital were tested in 2006. Conclusions. The high prevalence of HIV infection in South Africa, which is probably higher in patients with severe mental illness (most of whom are not competent to provide informed consent), and the availability of effective treatment require debate and a clear policy regarding testing for HIV infection to be implemented. We recommend a new approach to HIV testing in these patients. South African Medical Journal Vol. 98 (3) 2008: pp. 213-21

Understanding the experience and manifestation of depression in people living with HIV/AIDS in South Africa

Understanding the experience of depression in people living with HIV/AIDS (PLWH) could aid in the detection and treatment of the disorder. Yet, there is limited knowledge of the subjective experience of depression amongst PLWH in low- and middle-income countries despite high rates of this disorder in this population. In the current study, semi-structured interviews were conducted with depressed adults living with HIV attending a primary infectious disease clinic in South Africa. Interview transcripts were thematically analyzed. The construct of depression was consistent with DSM-IV criteria; however, the symptom presentation was distinctive. Somatic symptoms were most prominent in participants' initial presentations because participants perceived them as medically relevant. Affective, cognitive, and behavioral symptoms were not readily reported as participants did not perceive these symptoms as pertinent to their medical treatment. We identified several idioms of distress that could assist in screening for depression in this population. A valid, contextually developed screener for depression in PLWH awaits further investigation. Such a measure could play a key role in formulating a logistically feasible method of detection and treatment for depression in this population