Once in the body, the human immunodeficiency virus (HIV) multiplies and invades almost all body tissues. Billions of viral particles are made each day and cause the infected person's immune system, which is the defense against all germs, to fail, threatening the person's health. HIV infects specific cells, especially lymphocytes, which are a type of white blood cell. HIV also invades the cells of the central nervous system—the brain and the spinal cord—early in the course of the infection.
When a person becomes infected with HIV, the immune system mounts a long and difficult battle to contain the infection. It may take years before the virus overwhelms the body's defense system and causes the illness complex known as acquired immunodeficiency syndrome, or AIDS. Some people may be infected for ten years or more before they show signs of illness, and others may get sick quickly, especially if they have other illnesses that weaken the immune system. Although a person infected with HIV may not feel or look sick, he or she can give the virus to others. Even people with HIV who are being treated with medications that fight the infection can pass on the virus.
HIV is transmitted through body fluids. The risk of transmission is related to the amount of virus present in the fluid. Blood, semen, vaginal secretions, and breast milk have high viral concentrations, and the risk of transmission through these fluids is high. HIV is spread primarily by unprotected sex—that is, sexual activity in which no condom is used—and by needle sharing among intravenous drug users. It can also be transmitted from an infected mother to an infant during pregnancy, at the time of delivery, and through breast-feeding. Because saliva, tears, and urine have such a low concentration of virus in infected individuals, transmission through these fluids is unlikely.
Infected individuals may develop psychiatric problems that can be diagnosed and treated. The principal disorders afflicting people with HIV and AIDS that can benefit from psychiatric interventions are dementia, delirium, mood disorders such as depression and mania, psychotic disorders (losing touch with reality, hearing voices, and feeling paranoid), substance use disorders, anxiety, and sleep disorders.
People with HIV and AIDS frequently complain of cognitive deficits—problems in thinking. Dementia is a condition characterized by severe cognitive deficits that worsen over time. Dementia impairs short-term memory and concentration and interferes with a person's ability to manage several things at once. Cognitive deficits are more likely to worsen during the later stages of AIDS, although they can appear at any time during the course of HIV infection. Cognitive deficits can be evaluated and diagnosed properly, and their severity and change over time can be measured.
Treatments for cognitive problems may include a variety of components. A combination of medications may be used to fight the virus and reduce its ability to reproduce. Several psychiatric medications, including stimulants and antidepressants, may also improve cognitive function for a while, as can drugs that decrease inflammation in the brain. Psychotherapy can help patients understand and adapt to the changes they are experiencing.
Delirium is a temporary state of impaired mental functioning, often the result of direct effects on brain tissue from illness or medication. Diagnostic evaluation is essential to determine the underlying problem and correct it as well as to control symptoms of delirium, such as agitation and hallucinations.
Depression, anxiety, mania, and psychotic disorders among HIV-infected people are diagnosed and treated in much the same way as they are for other patients with these disorders. However, medical problems and drug interactions often complicate diagnosis and treatment. Psychiatric medications may be helpful in decreasing symptoms of anxiety and depression. Psychotherapy can play an important role in helping people cope with the emotional effects of infection and illness and with making difficult decisions.
Many people with HIV and AIDS also have substance use disorders. These people require help not only to enter treatment for their HIV infection but also to reduce high-risk behaviors associated with drug use that could result in transmission of the virus.
Control over the viral infection is difficult in an environment of ongoing drug use, and access to substance abuse treatment is a necessary part of the overall treatment of HIV infection. An infected person must take the anti-HIV medications at least 95 percent of the time to prevent the virus from adapting to and outsmarting the medications. Many infected people who have substance use disorders must postpone taking the medications until they are stable enough to adhere to a schedule. Adherence to a medication regimen—the ability to take medications exactly as needed—is a big problem for people with HIV even in the absence of drug use. Clinicians and patients must work together to establish how and when medications are taken in order to improve patients' adherence and the medications' effectiveness.
Sleep complaints are also common among people with AIDS. Sleep disturbances may result from the effects of the virus on the brain, from a coexisting psychiatric illness such as depression or anxiety, or from pain or other symptoms of HIV infection. Patients with sleeping problems should ask their doctors for help, because poor sleep makes it more difficult to function with illness and may interfere with taking medications properly.
A trusting working relationship between patient and doctor is at the heart of effective care for people with HIV. The patient is facing a life-threatening illness that also carries great stigma and shame. Because treating people with HIV and AIDS typically requires the efforts of a group of health professionals, communication and collaboration among them are necessary for optimal care. It is important for patients and their families to appreciate that communication among these professionals does not represent a breach of confidentiality but an effort to work together.
Because of the many psychiatric complications of HIV infection, good care involves ongoing attention to the patient's mental state so that problems in thinking and mood can be recognized and treated early. People with HIV should report to their clinicians any change in how they feel, think, or behave.
Mental health professionals have an obligation to assess the risk that a patient with HIV will transmit the infection to others and to work with the patient to reduce that risk. Clinicians and patients must work together to contain sexual and drug use behaviors that transmit HIV. Ongoing efforts to decrease or stop drug use should also be a clear goal of treatment.
Psychotherapy offers a private setting in which the patient can explore feelings and motivations that prompt risky behavior and develop alternative coping strategies. People with HIV need to be able to trust their psychiatric clinicians and feel that they can be truthful even when they feel embarrassed or ashamed about their behaviors.
Effective care for HIV-infected people, like that for people with any chronic illness, emphasizes personal and social functioning. Self-esteem is enhanced when a person can take responsibility and make his or her own decisions about what to do. However, HIV infection is not an illness that can be managed alone. Support from family, friends, and community is critical. Many people will find spirituality and religion a haven that gives them strength in coping with this chronic and frightening disease. Patients may need to confront issues of disability, dying, and death, and they will need the help and strength of others to face these matters.
Significant others in the lives of people with HIV and AIDS, including partners, family, friends, and other people in the community, should be enlisted to provide care and support. Research shows that HIV-infected people who have others who care and help them take medications and get to medical appointments do better. In advanced stages of AIDS, significant others often must assume an important role in day-to-day care. Caring for a person with an advanced disease can be highly stressful. Significant others may benefit from referral to specialized educational and support groups.