Paper no.

II (Behavioral Medicine- Unit IX – HIV/AIDS)

By Riju Raj

M.phil 2nd year

Clinical psychology

Contents:
Brief introduction on HIV/AIDS
Model of HIV disease service program in India
Pre and Post test counseling
Psychosocial issues of HIV/AIDS
Psychological assessment and interventions
Highly active anti- retroviral treatment (HAART)
Neuropsychological problems of HIV/AIDS
Issues related to prevention/ spreading of awareness

1.Brief Introduction

HIV causes AIDS. HIV stands for Human Immunodeficiency Virus. It breaks down the
immune system which protects the body against disease. HIV causes people to become sick with
infections that normally wouldn’t affect them.

AIDS stands for Acquired Immune Deficiency Syndrome. It is the most advanced stage of
HIV disease. Some people develop HIV symptom shortly after being infected. But usually takes
more than 10 years. There are several stages of HIV disease. The first HIV symptoms may
include swollen glands in the throat, armpit or groin. Other early HIV symptoms include slight
fever, headaches, fatigue and muscle aches. These symptoms may last for only a few weeks.

Symptoms of HIV/AIDS:

AIDS symptoms appear in the most advanced stage of HIV disease. In addition to a badly
damaged immune system, a person with AIDS may also have thrush —

1. a thick, whitish coating of the tongue or mouth that is caused by a yeast infection and
sometimes accompanied by a sore throat severe or recurring vaginal yeast infections,

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 2. chronic pelvic inflammatory disease severe and frequent infections periods of extreme
and unexplained tiredness that may be combined with headaches, lightheadedness,
3. Dizziness, quick loss of more than 10 pounds of weight that is not due to increased
physical exercise or dieting but bruising more easily than normal long periods of
frequent diarrhea,
4. frequent fevers and/or night sweats swelling or hardening of glands located in the throat,
armpit, or groin periods of persistent, deep, dry coughing, increasing shortness of breath
5. appearance of discolored or purplish growths on the skin or inside the mouth
unexplained bleeding from growths on the skin, from the mouth, nose, anus, or vagina,
or from any opening in the body frequent or unusual skin rashes,
6. Severe numbness or pain in the hands or feet, the loss of muscle control and reflex,
paralysis, or loss of muscular strength confusion, personality change, or decreased
mental abilities.

Causes of HIV/AIDS:
The most common ways HIV is spread are by:
 Having sex with an HIV infected person
 sharing needles or syringes with someone who has HIV/AIDS
 being deeply punctured with a needle or surgical instrument contaminated with HIV
 getting HIV-infected blood, semen, or vaginal secretions into open wounds or sores
 Babies born to women with HIV/AIDS can get HIV from their mothers during birth or
from breastfeeding.
 Infected blood transfusion
However HIV is not transmitted by simple casual contact such as kissing, sharing drinking
glasses, or hugging.

2.Model of HIV disease service program in India:

Shortly after reporting the first AIDS case in 1986, the Government of India established a
National AIDS Control Program (NACP) which has become the Department of AIDS under
Ministry of Health and Family Welfare.
In 1991, the scope of NACP was expanded to focus on blood safety, prevention among high‐risk
populations, raising awareness in the general population, and improving surveillance. A

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semi‐autonomous body, the National AIDS Control Organization (NACO), was established
under the Ministry of Health and Family Welfare to implement this program. This “first phase”
of the National AIDS Control Program lasted from 1992 ‐1999. It focused on initiating a national
commitment, increasing awareness and addressing blood safety. It achieved some of its
objectives, notably increased awareness. Professional blood donations were banned by law.
Screening of donated blood became almost universal by the end of this phase. By 1999, the
program had also established a decentralized mechanism to facilitate effective state‐level
responses. States such as Tamil Nadu, Andhra Pradesh, and Manipur demonstrated a strong
response and high level of political commitment, many other states, such as Bihar and Uttar
Pradesh, have yet to reach these levels.

The second phase of the NACP began in 1999 and ended in March 2006. Under this phase, India
continued to expand the program at the state level. Greater emphasis was placed on targeted
interventions for the most at risk populations, preventive interventions among the general
population, and involvement of NGOs and other sectors and line departments, such as education,
transport and police. In order to induce a sense of urgency, the classification of states has focused
on the vulnerability of states, with states being classified as high and moderate prevalence (on
the basis of HIV prevalence among high risk and general population groups) and high and
moderate vulnerability (on the basis of demographic characteristics of the population).

While the government’s response has been scaled up markedly over the last decade, major
challenges remain in raising the overall effectiveness of state‐level programs, expanding the
participation of other sectors, and increasing safe behavior and reducing stigma associated with
HIV‐positive people among the population.

The Third Phase of NACP program has dramatically scaling up targeted interventions in order to
achieve a very high coverage of the most at risk groups. Under this phase, surveillance and
strategic information management also receive a big boost. A partnership with civil society
organizations was at paramount in the implementation of the program with special focus on
involvement of community in the program planning and implementation.

On completion of NACP III, government of India has realized their strengthens and with the help
of development partners and donor agencies, NACO has conducted consultations with all the
stakeholders including the representatives from civil societies, community representatives, non-
health departments and experts from public health and designed the program activities for NACP

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IV. In future the focus of this phase will be primarily on scaling up prevention through NGOs
and sustaining the efforts and results gained in last 3 phases and integration with the health
systems response to the epidemic e.g. through provision of ART, STI services, and treatment of
opportunistic infections through the National Rural Health Mission.

3.Pre and post test counseling:

Both pre- and post-test counseling are essential because it is important to have a clear
understanding of what the test is and what its implications may be, in order to be able to make
informed choices.

Pre test counseling:

In the pre test, the client:

 Are informed about the test.

 Made aware of the reason why HIV testing is being recommended

 Informed about the current contact of the plan and how the client will obtain the result
 Supported till the result is obtained in reducing his/her stress where he/she is has
experienced an event that is associated with a higher likelihood that subsequent infection
may have occurred.
 Answer to the client’s queries and needs
Post test counseling:
In case of HIV test negative result:
 The client must interpreted the test result that shows no infection
 The client must be recommended for further test so that to be in safe side
 The client must be reeducated once again regarding the ways he/she can be further
infected.
In case of HIV test positive result:
 The result must be shared to the client in a straight forward and simple manner.
 The client must be provided time to consider the result
 Ensuring that the client understands the result
 Providing support and empathy for emotions that the client might express in response to
the test result.

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  Discussing immediate concerns that the client may have such as partner, families, impact
of results, and disclosure of results.
 Describing follow-up services available including treatment, care, counseling and other
community-based services.
 Discussing ways to prevent forward transmission of HIV.
 Client’s and their family member’s doubt must be clarified.

4.Psychosocial issues of HIV/AIDS:

Following are the psychosocial issues related to HIV and HIV affected people:
 Stigmatization
 Discrimination
 Social isolation
Psychological issues of HIV/AIDS:
 Sense of grief and loss
 Alteration of personality
 Anxiety
 Depression
 Substance abuse
 Suicide
Psychosocial intervention:
Psycho social intervention mainly focuses on Practical Support and Assistance that ensure:
 Increasing social network
 Spending time with friends & family
 No discrimination in work settings and other community setting

5.Psychological assessment and interventions:

 Personal interviews are carried out to assess or to reveal patient’s current feeling
regarding the disease, his outlook and his approach to deal with this and his opinion
regarding his family and other social associates.
 Family counseling: In this each member of the family is included in the sessions both
individually and in group to discuss their attitude towards HIV/AID and there feeling
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 towards the current situation of the infected member. Further the level of psychological
stress the family members are going through is also assessed.
 Professional counseling that includes Individual Therapy and Support Groups and CBT
 Anger and anxiety management, problem solving, Solution Focused Therapy.
 Education that includes learning to manage the disease and still enjoy life

6.Highly active anti- retroviral treatment (HAART):

Antiretroviral agents have greatly improved the prognosis of patients infected with HIV. There
has also been a dramatic decrease in the complications of HIV infection. The development of
drug resistance is reduced by using a combination of drugs. The standard treatment for HIV
infection is called HAART- Highly Active Antiretroviral Therapy which usually includes two
nucleoside reverse transcriptase inhibitors (NRTIs) with either a non-nucleoside reverse
transcriptase inhibitor (NNRTI) or one or two protease inhibitors (PIs).
Following are the combinations of drugs that are used:
Nucleoside Reverse Transcriptase Inhibitors
 These inhibit the RNA-dependent DNA polymerase (reverse transcriptase) which HIV
uses to convert viral RNA into DNA before its incorporation into the cell genome.
 NRTIs should be used with caution in patients with chronic hepatitis B or hepatitis C
(there is greater risk of hepatic side-effects), in hepatic impairment, renal impairment and
in pregnancy.
 Side-effects include gastro-intestinal disturbances, headaches and blood disorders
(including anaemia, neutropenia, and thrombocytopenia).
Protease Inhibitors:
 These inhibit HIV enzyme required to produce mature infectious viral particles by
cleaving structural proteins and enzymes from their precursors. They are potent
inhibitors of HIV replication and work synergistically with nucleoside drugs.
 They reduce HIV viral load and increase CD4 counts more effectively than
nucleoside analogues, especially when used in triple therapy.
 PIs are associated with gastro-intestinal disturbances, headaches, hyperglycaemia
(caution in diabetes), increased risk of bleeding (especially in haemophilia), hepatic
impairment, lipodystrophy and metabolic effects.

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Fusion Inhibitors

 Enfuvirtide, which inhibits HIV from fusing to the host cell, is licensed for managing
infection that has failed to respond to a regimen of other antiretroviral drugs. It is used with
other antiretroviral drugs and is administered by subcutaneous injection twice daily
 Other Antiretrovirals like Maraviroc is the first CCR5 receptor antagonist licensed for the
treatment of HIV infection. Raltegravir is an integrase inhibitor and is indicated in
combination with other antiretroviral drugs for HIV infection resistant to first-line HAART.
Eviplera® is a new one-tablet formulation, used in antiretroviral-naïve patients with HIV-1.

7.Neuropsychological problems of HIV/AIDS:

Types of Central Nervous System Disorder:
a. Dementia
b. Cerebral Toxoplasmosis, also known simply as toxoplasmosis, is the most common central
nervous system infection in HIV patients. It is caused by protozoa called Toxoplasma
gondii, which lives in the soil and in animal feces. In HIV patients and other people with
suppressed immune systems, however, the bacteria can cause brain abscess (tissue damage
and the accumulation of pus)—the symptoms of which vary depending on the location of
the infection in the brain. Usual symptoms of toxoplasmosis include speech difficulties,
seizures, confusion, and lethargy, which develop over the course of days to weeks.
c. Cryptococcal Meningitis is a type of infection that is caused by a fungus. The course of the
illness is usually slow and may develop over days or months.
d. Progressive Multifocal Leukencephaly is an infection caused by a rare virus. A patient with
PML may suffer from dementia (a broad range of cognitive problems, including memory
loss, poor judgement, etc.), facial weakness, visual problems, and a loss of coordination.
The symptoms vary from person to person and generally reflect which area of the brain is
affected.
e. Central Nervous System Lymphoma is the second most common nervous system
abnormality in HIV patients. Primary lymphoma generally only develops in the central
nervous system when the immune system is suppressed. Primary lymphoma—as opposed to
metastatic lymphoma—is cancer that originates in the lymphatic system and has not spread
from some other part of the body.

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Types of Peripheral Nervous System Disorder:

a. Neuropathy
Neuropathy, also known as peripheral neuropathy, is disease in the peripheral nerves—the nerves
that lead to and from the spinal cord and connect with all the various parts of the body. It is very
common in HIV patients, usually in the later stages of HIV disease. It can manifest itself in
several different ways.
Distal symmetric neuropathy is the most common form of HIV-related neuropathy. It affects the
feet first and then the hands and it affects both sides of the body equally. Patients often feel a
strange tingling and painful burning sensation that can spread up the legs and arms. Some
patients feel numbness or weakening in the arms and legs.
Acute Inflammatory Demyelinating Neuropathy involves the nerve root (where the root connects
with the spinal cord) and the myelin sheath that surrounds and protects the nerves. The onset of
this kind of neuropathy is usually very rapid, sometimes developing within hours to days.
b. Myopathies are neurological disorders that involve the skeletal muscles—muscles that
are connected to bones, like the biceps in the upper arm and quadriceps in the thigh. There are
many different types of myopathies (including, for example, the muscular dystrophies), but the
most common type in people with HIV is polymyositis (PM). Its symptoms are in the form of
muscular aches, cramping, and tenderness, and extreme muscle weakness. Weakness primarily
affects the neck, arms, and upper portion of the legs—making it difficult to stand up from a
sitting position. Many patients also experience fever, malaise (general bodily discomfort), and
loss of appetite.
Treatment:
Central Nervous System Disorders:
Some neurological problems can be treated with medication(s). Anti-dementia drugs can be
prescribed to relieve confusion and slow the progression of mental decline. Neurological
infections can be treated with antibiotics. There is no known treatment for PML till today. If
there is an AIDS-related tumor in the brain or spinal cord, radiation therapy or steroids may be
helpful, although the prognosis is poor.
Peripheral nervous system:
Treatment of the various peripheral nervous system disorders usually focuses on relieving the
pain and other symptoms. Drug therapy is often used to treat neuropathic pain. Typical

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medications include tricyclic antidepressants such as amitriptyline (Elavil), anticonvulsants such
as gabapentin (Neurontin), and analgesics such as tramadol (Ultram).
Acute inflammatory demyelinating syndrome often requires immunotherapy or plasmaphoresis
as part of its treatment. Immunotherapy involves injecting a specific protein into the blood to
stop the abnormal immune response that is causing the neuropathy. Plasmaphoresis involves
removing some of the blood, separating the cells from the plasma, and then re-injecting the cells
back into the body.

8.Issues related to prevention/ spreading of awareness:

Although global attention to HIV and AIDS remains strong, particularly regarding treatment
initiatives, until recently HIV-prevention has garnered scant attention. Treatment alone will not
reverse the epidemic, and current prevention efforts have not been successful in halting HIV
transmission.

Issues:
 lack of capacity, such as health human resources and infrastructure;
 disjointed programs, such as prevention programs not integrated into institutions or other
health-related services;
 reliance on ineffective interventions, such as abstinence-based programs inadequate
implementation of interventions and approaches proven to be effective, such as
harmreduction;
 lack of coordination among stakeholders;
 and the challenge of stigma; the ethical challenges involved in research;
 the difficulty of sustaining political support for prevention programs, compared with
interventions with shorter time frames and faster results, such as treatment.

Improving HIV prevention issues:

 It is critical that countries understand how the epidemic is affecting them specifically to
ensure prevention interventions are appropriate and cost-effective. This includes
gathering information about HIV infection rates among different population groups
within a given country. Ongoing country-level surveillance of the epidemic is essential
for countries to plan and adjust their prevention strategies accordingly.

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 As part of “knowing the epidemic” there is a need to increase HIV testing. It is
estimated that just 11% of the world's population is aware of their HIV status. Research
has shown that people who are aware that they are HIV positive decrease their risk
behaviors. It is essential that there be widespread and easy access for HIV-testing as part
of comprehensive HIV prevention programming. It must also be emphasized that support
for testing should not negate the need for privacy, confidentiality, and consent—
safeguards must be in place to ensure that these rights are respected.
 Developing effective preventive models that includes features like adequate human
resource and institutional Capacity; a focus on interventions that are locally relevant,
evidence-based, and targeted to the appropriate population; a comprehensive approach,
including mass media campaigns to increase awareness and programs that build self-
esteem and life skills such as safer sex negotiation; the involvement of multiple sectors,
including communities which are affected by HIV/AIDS; initiatives to address stigma.
 Comprehensive preventive measures should be included to encompass structural
interventions, successful prevention efforts that require a diversity of biomedical and
behavioral methods that will provide individuals with a range of options, and have the
potential to further decrease the risk of HIV infection if used in combination. Such
measures should focus on interventions to prevent sexual transmission, interventions to
prevent blood-borne transmission, interventions to prevent mother-to-child transmission.

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Reference:

Consultation draft Addendum to BHIVA Treatment Guidelines, British HIV Association,

2009

HIV post-exposure prophylaxis - guidance from the UK Chief Medical Officers' Expert
Advisory Group on AIDS; Dept of Health (2008)

Gilleece Y, Chadwick DR, Breuer J, et al; British HIV Association guidelines for
antiretroviral treatment of HIV-2-positive HIV Med. 2010 Nov;11(10):611-9. doi:
10.1111/j.1468-1293.2010.00889.x.

Guidelines for the treatment of HIV-infected adults with antiretroviral therapy, The British
HIV Association (2008)

Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure;
British Association for Sexual Health and HIV (2011)

Links:

http://www.plannedparenthood.org/health-info/stds-hiv-safer-sex/hiv-aids

http://www.healthcommunities.com/infectious-diseases/hiv.shtml

http://www.patient.co.uk/doctor/antiretroviral-agents

http://www.worldbank.org/en/news/feature/2012/07/10/hiv-aids-india

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