Monday 15 July 2013

PSYCHIATRIC AND PSYCHOSOCIAL PROBLEMS OF PATIENTS LIVING WITH HIV/AIDS


INTRODUCTION:
            HIV/AIDS is a topic that has been greatly discussed and researched due to its’ impact on human beings. Ever since the HIV/AIDS virus was identified, people have been trying to find ways of educating others about this virus. Many campaigns have been put into place, and people have been made aware of the various effects of the virus. We must remember that this virus has not only physiological effects, but also major psychological effects. Those living with HIV/AIDS will be referred to as infected, while the personal caregivers and family members will be referred to as affected. We define psychological effects as those thoughts, feelings, emotions that affect the mental state and well-being of the infected and affected persons. The psychological effects of HIV/AIDS, such as: fear, loss, grief, guilt, denial, anger, anxiety, low self-esteem, depression, suicidal behavior and thinking, and socio-economic issues9.
BACKGROUND OF THE GLOBAL AND INDIAN HIV EPIDEMIC
             Globally there were estimated 33million people infected with HIV in 2007 with 2.7 million new infections and 2 million HIV related deaths. Nearly an estimated 5 million people infected with HIV lived in Asia in 2007 and about 380 000 people were newly infected (UNAIDS Global Epidemic Update, 2008).In India, First HIV case in India was reported from Chennai in 1986,  First case of AIDS was reported from Mumbai in 1987 the estimated number of HIV infections as of 2008 is 2.47 million. The distribution of HIV infection and mode of transmission varies by state. Most HIV infections in India (86% of reported AIDS cases) are due to unprotected heterosexual transmission (UNAIDS, 2008). HIV prevalence tends to be higher in the industrialized, peninsular states. The six states with the highest HIV prevalence are: Maharashtra, Andhra Pradesh, Tamil Nadu, Karnataka, Manipur, and Nagaland. In India, more than 1, 88,000 people living with HIV/AIDS are accessing Anti Retroviral Therapy from public sector hospitals/clinics (NACO, 2008).4

HIV and AIDS
HIV- Human Immunodeficiency Virus. A person infected with HIV is known as an HIV positive person. HIV is a retrovirus. The genetic material of retroviruses is carried in the form of RNA rather than DNA.
AIDS- Acquired Immuno Deficiency Syndrome
            A loss of CD4 T lymphocytes such that CD4 count is in an HIV infected individual < 200. (However some patients with CD4 < 200 continue to display reasonably good health).  The appearance of opportunistic infections and/or cancers. PLHAs may be infected with HIV for many years before their immune system is damaged. Sufficiently (CD4<200) to cause opportunistic infections and hence AIDS.

HIV Epidemiology
Initially, HIV infection in India was restricted to high-risk populations: sex workers, trafficked women, or men having sex with men (MSM) and injection drug users.(IDUs)
HIV today is no longer restricted to any particular group. It has reached the general population - which includes married women, babies and children, youth, and men who have never had any high-risk behavior. Infected individuals can transmit HIV infection through unsafe contact (e.g. unprotected sex, needle sharing) to individuals who belong to the “bridge population”. Once a member of the bridge population (e.g. truck drivers, clients of sex workers, migrants, etc.) gets back to their home, they can infect their wives/partners, who in turn can infection to pass on their babies4.
Bridge Populations
Clients of sex workers
Partners of IDUS Migrant/
Mobile populations Truck
drivers Populations in
conflict situation

General Populations
Women. Infant, Children and Youth Men and Women
High-risk
Populations
Sex Workers, Trafficked
Women, Men who have
Sex with men,  Needle
Sharing drug users

 








Clinical Features
Non neurological Factors
Flulike syndrome(30%) 3 to 6 weeks after becoming infected; the flulike syndrome includes fever, Myalgia, headaches, fatigue, gastrointestinal symptoms, and sometimes a rash. The syndrome may be accompanied by splenomegaly and lymphadenopathy. The median duration of the asymptomatic stages is 10 years, although nonspecific symptoms ”lymphadenopathy, chronic diarrhea, weight loss, malaise, fatigue, fevers, night sweats may variably appear. During the asymptomatic period, however, the T4 cell count almost always declines from normal values (>1,000/mm3) to grossly abnormal values (<200/mm3).
The most common infection
1.    Pneumocystis carinii pneumonia,
2.    Kaposi's sarcoma,
3.    Protozoal infection such as Toxoplasma gondii;
4.    Fungal infections such as Cryptococcus neoformans and Candida albicans;
5.    Bacterial infections such as Mycobacterium avium-intracellulare; and
6.    Viral infections such as cytomegalovirus and herpes simplex virus.1

Neurological Factors
For psychiatrists, the importance of these non neurological, non psychiatric complications lies in their biological effects on patients' brain functions (e.g., hypoxia with Pneumocystis carinii pneumonia) and their psychological effects on patients' moods and anxiety states. An extensive array of disease processes can affect the brain of a patient infected with HIV .The most important diseases for mental health workers to be aware of are HIV mild Neurocognitive disorder and HIV-associated dementia.
Symptoms such as photophobia, headache, stiff neck, motor weakness, sensory loss, and changes in level of consciousness should alert a mental health worker that the patient should be examined for possible development of a CNS opportunistic infection or a CNS neoplasm. HIV infection can also result in a variety of peripheral neuropathies that should prompt mental health clinicians to reconsider the extent of CNS involvement.1
Neuropsychiatric Disorders in HIV-Infected Patients
Neuropsychiatric disorders are common in HIV-infected patients, and they can be either primary or secondary.
·         Primary complications are those that can be attributed directly to the infection of the central nervous system by the virus, or to immunopathological events precipitated by HIV infection. Primary HIV-related brain disorders include HIV-related dementia and minor cognitive disorder.
·         Immune suppression can lead to a variety of secondary complications affecting the brain, including opportunistic infections (e.g. cerebral toxoplasmosis and progressive multifocal leucoencephalopathy) and tumours (e.g. cerebral lymphoma). Secondary complications in the form of acute and sub-acute syndromes (e.g. delirium) often occur as a result of cerebrovascular complications and toxic states induced by various therapeutic agents.2,9
Neuro-Psychiatric Syndromes
1.    HIV-associated acute stress reaction: This transitory syndrome appears in some individuals after they are notified of their seropositivity. It is equally frequent among those who, after a period as an asymptomatic carrier, are informed that the infection has progressed towards full-blown AIDS. The appearance of these symptoms is closely linked in time to the stressful circumstance, generally remits in hours or days.
      Some patients suffer from intrusive thoughts or brooding related to their uncertainties regarding health, the future, the risk of contagion to others (especially loved ones), and the idea of death. The vegetative symptoms of panic attacks are also usually present (e.g. palpitations, dry mouth, hot flush, trembling, pressure in the chest, epigastric disturbance). In more severe cases, the patient may also present social isolation, verbal expressions of rage or feelings of desperation, and other forms of altered behavior. These symptoms tend to appear within a few minutes to a few hours after the subject is informed, and remit in 2 or 3 days.
2.    HIV-Associated Dementia: Dementia due to HIV disease in the presence of a dementia that is judged to be the direct pathophysiological consequence of human immunodeficiency virus (HIV) disease. The development of dementia is generally a poor prognostic sign, and 50 to 75 percent of patients with dementia die within 6 months.
3.    Mild Neurocognitive Disorder: A less severe form of brain involvement is called HIV-associated Neurocognitive disorder, also known as HIV encephalopathy. It is characterized by impaired cognitive functioning and reduced mental activity that interferes with work, homemaking, or social functioning. No laboratory findings are specific to the disorder, and it occurs independently of depression and anxiety. Progression to HIV-associated dementia usually occurs but may be prevented by early treatment.1
4.    Grief Reaction to HIV/AIDS: A four-stage grief reaction by clients diagnosed with AIDS has been described (Nichols, 1983). The reaction is similar to the pattern designated by Kabler-Ross in dying patients (Nichols, 1983).
First Stage- The initial stage consists of shock, numbness, and disbelief. The severity of the reaction may depend on existing support systems for the individual. During this period, clients report sleep problems and an experience of depersonalization and derealization. For some, the acknowledgment of the AIDS diagnosis causes severe emotional paralysis or regression.
Second Stage- The second stage is denial, in which the person may attempt to ignore the diagnosis of AIDS. Although it may serve a necessary psychic function, this denial can cause the client to engage in behaviors that are both self-destructive and potentially dangerous to others. Some clients begin to plunge into complete isolation, avoiding human contact as much as possible.
Third Stage- In the third stage, the individual begins to question why he or she contracted AIDS. Expressions of guilt and anger are frequent as the client seeks to understand the reason for his or her illness. Homosexual or bisexual men may experience feelings of homophobia (i.e., the unreasonable fear or hatred of homosexuals or homosexuality) and believe that God is punishing them for their homosexual preference.
Fourth or Final Stage- The fourth or final stage that of resolution and acceptance depends on the individual's personality and ego integration. This stage may be signified by the acceptance of the illness and its limitations, a sense of peace and dignity, and a preparation for dying. As the debilitating symptoms progress, however, other clients may become increasingly despondent and depressed, stop eating, express suicidal ideation, and develop almost-psychotic fixations and obsessions with their illness. A significant and growing number of AIDS clients make successful suicide attempts.3
5.    Delirium: Delirium can result from the same causes that lead to dementia in patients infected with HIV Clinicians have classified delirious states characterized by both increased and decreased activity. Delirium in patients infected with HIV is probably under diagnosed, but it should always precipitate a medical workup of a patient infected with HIV to determine whether a new CNS-related process has begun.
      Delirium is one of the organic mental disorders observed most frequently in hospitalized HIV-infected patients. The exact prevalence of delirium or acute organic brain syndrome in HIV is unknown. Patients with advanced systemic disease and dementia are at a high risk for delirium, the cause of which is often multifactorial.
      A conservative attitude has been recommended for the management of these conditions, with the use of low oral or intramuscular doses of Neuroleptic, and correction of the organic disorders responsible for the development of disturbances in the level of consciousness. However, others have postulated that patients suffering from delirium and agitation should be given high doses of Neuroleptics alone or in combination with lorazepam in cases where quick control of the symptoms is vital. The efficacy of pharmacological interventions in patients with delirium is heightened if treatment is begun as soon as the first symptoms appear.

6.  Anxiety Disorders: Patients with HIV infection may have any of the anxiety disorders, but generalized anxiety disorder, posttraumatic stress disorder, and obsessive compulsive disorder are particularly common. Diagnosis of an anxiety disorder when a patient presents with common somatic symptoms, such as chest pain, diaphoresis, dizziness, gastrointestinal disturbances, and/or headache, for which no underlying medical etiology can be established. Management of Anxiety Disorders includes: Psychological/Supportive Intervention -Basic supportive and behavioral interventions are sufficient to alleviate anxiety in certain patients.
Pharmacologic Interventions includes Buspirone, benzodiazepines, selective serotonin reuptake inhibitors (SSRIs) are the treatment of choice because they effectively prevent panic attacks from recurring. 1,5

7.    Adjustment Disorder: Adjustment disorder with anxiety or depressed mood has been reported to occur in 5 to 20 percent of patients infected with HIV. The incidence of adjustment disorder in persons infected with HIV is higher than usual in some special populations, such as military recruits and prison inmates.

8.    Depressive Disorders: A range of 4 to 40 percent of those infected with HIV has been reported to meet the diagnostic criteria for depressive disorders. Depression is higher in women than in men.      There are several factors behind the increased morbidity for affective disorders found in this population. First of all, the patient's discovery of the infection has a dramatic psychological impact, as does the disease's relentless progression. Second, the neurotropism of the virus itself produces neuropathological changes in deep grey structures whose dysfunction is known to cause mood disturbances and changes in the neurotransmission systems, which may contribute to the development of depression. Finally, the groups that in Western countries are at the highest risk for HIV infection (intravenous drug users and male homosexuals/bisexuals) are also known to be at a high risk for depressive syndromes, independently of having the virus.
                  When severe physical disease is present the diagnosis of major depression can be difficult to make, because the disease itself may be the real source of many depressive symptoms, for example insomnia, loss of appetite and weight, fatigue, lack of energy, retardation, and concentration difficulties. To avoid misdiagnosing depression, it is important to focus on the more psychological, as opposed to somatic, symptoms associated with low mood. These include persistent low mood, loss of enjoyment of usually pleasurable activities, suicidal thoughts and marked feelings of hopelessness, guilt, and self-reproach. Suicidal ideation may not be expressed directly, but may be expressed more passively, for example poor adherence to medical treatment. Assessment of depressed mood also requires evaluation of the probable contributing factors.
9.     Mania: Mood disorder with manic features, with or without hallucinations, delusions, or a disorder of thought process, can complicate any stage of HIV infection, but most commonly occurs in late-stage disease complicated by Neurocognitive impairment. HIV seems to increase the risk of manic episodes, and mania is a frequent reason for psychiatric hospitalization among people with the virus.
      Mania has been found to be a side-effect of medication frequently used for HIV/AIDS, including Didanosine (DDI), Ganciclovir, Procarbazine, Estavudine (D4T), Steroids, and Zidovudine (AZT). Most cases of new-onset mania occur in advanced HIV disease and they are often associated with the presence of substantial cognitive impairment. New-onset mania in severe symptomatic disease is predictive of reduced survival1,2.

10. Substance Abuse: Substance abuse is a problem both for IV substance abusers who contract HIV-related diseases and for other patients with HIV, who may have used illegal substances only occasionally in the past but may now be tempted to use them regularly to deal with depression or anxiety.

11. Suicide: Suicidal ideation and suicide attempts may increase in patients with HIV infection and AIDS. The risk factors for suicide among persons infected with HIV are having friends who died from AIDS, recent notification of HIV seropositivity, relapses, difficult social issues relating to homosexuality, inadequate social and financial support, and the presence of dementia or delirium.

12. Psychotic Disorder: Psychotic symptoms are usually later stage complications of HIV infection. They require immediate medical and neurological evaluation and often require management with antipsychotic medications. Prevalence is not high; such a development can lead to complicated diagnostic and management problems. When seropositive individuals present with psychotic symptoms, efforts should be made to clarify the clinical features and to establish their etiology, which could well be unrelated to HIV. While in some cases the psychotic symptoms may be the result of subtle or gross brain pathology associated with HIV infection, in others it may be iatrogenic or secondary to substance misuse. Recent publications have also indicated that psychiatric patients per se may be considered a group at risk for contracting HIV infection.

13. Worried Well: The so-called worried well are those in high-risk groups who, although they are seronegative and disease free, are anxious about contracting the virus. Some are reassured by repeated negative serum test results, but others cannot be reassured. Their worried well status can progress quickly to generalized anxiety disorder, panic attacks, obsessive compulsive disorder, and hypochondriasis.


Psychosocial Impact of AIDS:
Acquired immunodeficiency syndrome is frequently described as a tragic and complex phenomenon that provokes a shattering emotional and psychosocial impact on all who are involved with the illness. Certain population groups at risk for the psychosocial impact of AIDS, including:
·         clients in various stages of the illness
·         sexual partners and
·         family of individuals with AIDS individuals
Clients in various stages of the illness:  individuals with a mental disorder (e.g., substance abuse) who fear exposure but refuse to be tested. The most serious psychosocial problems occur for those clients who actually have the disease. Most people with AIDS are relatively young, were previously healthy, and had not experienced a major medical illness. The confirmation of this diagnosis can be catastrophic for the client, eliciting a series of emotional and social reactions.
Psychosocial problems- These problems include:
1.    Loss of self-esteem, fear of the loss of physical attractiveness and rapid changes in body image,
2.    Feelings of isolation, withdraw, not disclose their feelings, and become socially isolated.
3.    Stigmatization an overwhelming sense of hopelessness and helplessness,
4.    Loss of control over their lives
5.    Emotional crises due to universal stigma faced on a daily basis.
6.    Experience rejection and loss of support from all parts of society, including significant others, families, friends, social agencies, landlords, and health care workers.
7.    Constant rejection causes a re-living of the coming-out process, with a heightening of the associated anxiety, guilt, and internalized self-hatred. Sees themselves as undesirable by others who view them as “contagious”.
8.    The fear of spreading AIDS to others can lead to further isolation and abandonment. And to adjust to a new lifestyle.
9.    Intense anger and hostility.
10. Loss of job and home, forced changes in lifestyle, the perceived lack of response by the medical community, and the often crippling expense associated with the illness.
11. It is not easy to accept that one is infected and thus shock and disbelief, leading to denial,
12. Another destructive stressor is that of feeling dependent. The dependency occurs when the infected person must rely heavily on family and friends for emotional and financial support, particularly when they have to apply for social services assistance.
13.  Infected person is not granted an opportunity to gain access to life insurance policies. This also can be very frustrating and demoralizing. The final aspect of dependence is the fear of a protracted illness that will drain the family and friends both financially and emotionally.
14. In rural areas, HIV/AIDS also causes labour shortages for farm and domestic work by reducing the household’s workforce. Much livestock is lost when families are destroyed by HIV/AIDS because the remaining family members may not know how to care for the livestock, or plant and produce crops and fodder.
15. Additionally, in some of the more traditional cultures, livestock is taken away from the wife and children when the husband/father dies. Thus, a cycle of hunger, desperation, and poverty begins as a result of this disease.6

Effects of AIDS on Family Dynamics
The family of an AIDS client experiences severe psychological stress and trauma. The pressure on the family system causes members to;
·         Fear of infection,
·         Anticipatory grief,
·         Shame and  Helplessness,
·         Discrimination
·         Respond with quiet anger, confusion, and frustration
·         Possible rejection of the AIDS client
·         Blame the client's partner for the condition.
·         Fragile balance of roles in the family system Coleman (1988).
·         An adult child needs parental support to meet daily self-care needs.
·         Forced to assume financial responsibility.
·         uncertainty about the future
            Some families are able to achieve resolution of their own painful psychological conflicts and provide the necessary physical and emotional support to the AIDS client. A significant number of families, however, become fixed in their rejection, grief, and anger and are never able to resolve the distance and estrangement from the family member with AIDS. These burdens are usually placed on the shoulders of elderly caregivers, family members, partners and sometimes even friends.
            In response to this familial abandonment, the individual with AIDS often develops an alternate family that assumes the support and caretaker role. This new family may include a gay partner and close gay and straight friends who significantly alter their lifestyles to care for the client. These friends experience the same sense of loss, isolation, and bereavement as the more traditional family, but are denied the customary social support systems and public recognition for their role.6

Psychological Impact on Affected Children
HIV/AIDS has no age-appropriateness and not even children are spared. There are a number of psychological impacts affecting children of HIV/AIDS parents they are;
·         A parent who is HIV infected may show less interest in the child due to the dramatic mood swings associated with the pressure of being infected. The child is likely to react with fear and anxiety and sometimes will blame themselves    (Mallmann,  2002).
·         Children don’t like to see their parents sick, and so the pressure begins in a child when he or she realizes that the parent is always sick.
·         The older children are expected to take up responsibilities which are much beyond their capabilities and can be overwhelming.
·          Anger and neglect are other concerns.
·         Stress, grief, avoidance and teasing by other children, social isolation and discrimination can lead to behavioral disturbances, fatalism, self stigmatization, and increased opportunities for abuse (Claudia, 2002). And thoughts of suicide
·         Children tend to worry about parents. This fear results in children often opting to not attend school, or being hyperactive and inattentive while in school.
·         Children are much more vulnerable to economic and social hardships such as malnutrition, poverty, child labour, homelessness and reduced access to education and healthcare (AIDS brief, 2004).
·         Children are also infected with the virus, impairs normal emotional and psychological functioning.6

Management

Prevention is the primary approach to HIV infection: Primary prevention involves protecting persons from getting the disease; secondary prevention involves modification of the disease's course. All persons with any risk of HIV infection should be informed about safe-sex practices and about the necessity to avoid sharing contaminated hypodermic needles.
Preventive strategies: Preventive strategies however, are complicated by the complex societal values surrounding sexual acts, sexual orientation, birth control, and substance abuse. Many public health officials have advocated condom distribution in schools and the distribution of clean needles to drug addicts. These issues remain controversial, although condom use has been shown to be a fairly (although not completely) safe and effective preventive strategy against HIV infection. Those who are conservative and religious argue that the educational message should be sexual abstinence. Many university laboratories and pharmaceutical companies are attempting to develop a vaccine to protect persons from infection by HIV. The development of such a vaccine, however, is probably at least a decade away4.
Assessment:
The assessment of patients infected with HIV should include;
·         Complete Sexual and Substance-Abuse History,
·         Psychiatric History and an Evaluation of the Support Systems available to them.
Nurse must understand a patient's history with regard to sexual orientation and substance abuse, and the patient must feel that the therapist is not judging past or present behaviors. A therapist can often encourage a sense of trust and empathy in the patient by asking specific, well-informed, straightforward questions about the homosexual or substance-using culture. The therapist must also determine the patient's knowledge about HIV and AIDS.
            The homosexual community has provided a significant support system for those infected with HIV, particularly for persons who are gay and bisexual. Public education campaigns within this community have resulted in significant (more than 50 percent) reductions in the highest risk sexual practices, although some gay men still practice high-risk sex. Homosexual men are likely to practice safe sex if they know the safe-sex guidelines, have access to a support group, are in a steady relationship, and have a close relationship with a person with AIDS. Partly because of the many biases against them, IV substance users with AIDS have received little support, and little progress has been made in educating these persons who are a major reservoir for spread of the virus to women, heterosexual men, and children1.
Pharmacotherapy:
            The active agents were in two general classes: reverse transcriptase inhibitors and protease inhibitors. The antiretroviral agents have many adverse effects. Of importance to nurses is that protease inhibitors are metabolized by the hepatic cytochromes P450 oxidase system and, therefore, can increase levels of certain psychotropic drugs that are similarly metabolized. These include Bupropion (Wellbutrin), meperidine (Demerol), various benzodiazepines, and selective serotonin reuptake inhibitors (SSRIs). Therefore, caution must be exercised in prescribing psychotropic drugs to persons taking protease inhibitors.
            Beyond treatment directed specifically against HIV, many interventions are available to prevent and treat various complications of immunodeficiency caused by opportunistic viral, bacterial, fungal, and protozoan infections. Both survival and quality of life have improved substantially because of early diagnosis and treatment of these opportunistic conditions.
The remaining forms of treatment are principally supportive. The most important step is to exclude other potentially treatable conditions, such as secondary infections or neoplasia, metabolic abnormalities with low-grade delirium, or other psychiatric disorders (e.g., major depressive disorder)1.
            Antidepressants are the treatment of choice in major depression, as well as in less severe depressive syndromes that are unresponsive to psychological and social intervention. Tricyclic antidepressants have been shown to be effective in treating depressed HIV-positive patients. AIDS patients can respond to lower dosages of tricyclics (25–100 mg), but they may also suffer severe Anticholinergic effects at reduced dosages. Therefore, the choice of an antidepressant for these patients should be guided by its side-effect profile. Several studies have been published showing therapeutic response to selective serotonin re-uptake inhibitors in seropositive patients with major depression.2
            In case of mania Standard Pharmacotherapy with Neuroleptic and lithium are effective, but the usefulness of these drugs may be restricted by the development of severe adverse effects. Immunosuppressed HIV-infected patients tolerate Neuroleptic and lithium poorly. Anticonvulsant medication (carbamazepine, sodium valproate) can adequately control the acute symptoms of a manic episode when standard agents are not tolerated. The administration of carbamazepine should include strict control of these patients' haemopoietic function, above all because they are frequently taking other medications, such as AZT, which can also trigger toxic effects in the bone marrow.1,2
                  Neuroleptics are the treatment of choice for controlling psychotic symptoms. The risk of developing antipsychotic-induced extrapyramidal symptoms is higher in psychotic patients with AIDS than in psychotic patients without AIDS. AIDS patients may have an increased risk of developing tardive dyskinesia, Neuroleptic malignant syndrome, and severe dystonic reactions. The presence of organic cerebral deterioration, in particular HIV-associated dementia, is a risk factor for the development of Neuroleptic malignant syndrome. The new antipsychotic Risperidone has been associated with fewer extrapyramidal side-effects and used successfully in this group of patients1.
            Psychosocial intervention:
Once the diagnosis is clear, then the usual supportive measures for neurocognitively impaired persons should be used. This includes;
·         Identifying areas of cognitive strength and deficit,
·         Reducing emphasis on areas that are now impaired (e.g., divided attention, speeded processing),
·         Emphasizing efforts to maintain good orientation and reality testing, and
·         Avoiding medications that might further compromise cognitive function, in particular, benzodiazepine drugs. If they must be used, such medications should be given at lower than usual doses. Antidepressant and antipsychotic agents, if indicated, may also have to be prescribed in much lower dosages
Psychotherapy:
Approaches- Major psychodynamic themes for patients infected with HIV involve self-blame, self-esteem, and issues regarding death.
·         The therapist can help patients deal with feelings of guilt regarding behaviors that contributed to infection or AIDS. Some patients with HIV and AIDS feel that they are being punished.
·         Difficult health care decisions, such as whether to initiate or continue taking antiretroviral medication and terminal care and life-support systems, should be explored, and here denial of illness may be evident. Major practical themes involve employment, medical benefits, life insurance, career plans, dating and sex, and relationships with families and friends.
·         Both individual and group therapy can be effective. Individual therapy may be either short term or long term and may be supportive, cognitive, behavioral, or psychodynamic. Group therapy techniques can range from psychodynamic to completely supportive in nature.
·         In deciding whether or not to tell others, patients must also address their sense of betrayal if they are not told. The same issues apply to the person's work environment, similarly, parents must decide when or whether to tell their children.
·         The question of custody of children after the parent's death must be considered.
·         The therapist may have a special role regarding HIV treatment. The psychiatrist may be the only person to whom the patient can express discouragement, weariness, fear of treatment failure, and fury or guilt for not being able to tolerate successful therapy or for not responding to regimens that have benefited others.
·         Direct counseling regarding substance use and its potential adverse effects on health of the patient who is HIV infected is indicated. Specific treatments for particular substance-related disorders should be initiated if necessary for the total well-being of the patient1,2.
Therapist-Related Issues- Counter transference issues and burnout of therapists who treat many patients infected with HIV must be evaluated regularly.
Involvement of Significant Others- The patient's family, lover, and close friends are often important allies in treatment. The patient's spouse or lover may have guilt feelings about possibly having infected the patient or may experience anger at the patient for possibly infecting him or her. The involvement of members of the patient's support group can help the therapist assess the patient's cognitive function and can also aid in planning financial and living arrangements for the patient. The patient's significant others may themselves benefit from the attention of the therapist in helping them cope with the illness and the impending loss of a friend or family member.
Partner Notification- Although no clear consensus has been reached, recommendations are that patients who are sexually active and infected with HIV should be counseled about potential risk to their sexual partners. Additionally, known partners should be notified of exposure risk and potential infection as well. Partner notification has been an extremely hotly debated topic; however, many states have developed legislation requiring or allowing either physicians or health department officials to notify partners of patients who are HIV infected of their risk. The current standard, despite the controversy, appears to be an obligation on the part of health care professionals to notify anyone who could be construed as clearly at risk and clearly identifiable and who may be unaware of their risk.1,2

Cultural Beliefs and Myths
Psychiatric mental health nurse needs to be aware of cultural beliefs and myths that may be expressed by the client in an attempt to justify HIV infection or AIDS. Although research has identified the etiology of AIDS, several cultural myths explain the cause inaccurately (Mortensen, 2001). For example, some cultural myths state that AIDS: Is a form of punishment for wrongdoing Has occurred as a message to teach people to get along with each other; Is the result of a sick world; Is the result of a government germ-warfare experiment; Another myth is that the cause of AIDS has been fabricated to allow Pharmaceutical companies and the health care system to profit financially from the sale of expensive drugs and use of specific treatment protocols. It is important to recognize that such myths exist. Be sure to assess the client for beliefs in such myths. The psychiatric mental health must be prepared to discuss them if the client or a family member introduces the subject.3

Ethnic Issues of Homophobia and Stigmatization
The nurse be aware the ethnic issues of homophobia and stigmatization (ie, to set a mark of disgrace or shame upon an individual) may also need to be addressed during the initial assessment. Norman (1996) discusses the problems of homophobia and stigmatization of men having sex with men in ethnic communities of color as well as in the society at large. Social and emotional isolation, disapproval, prejudice, judgments of shame and immorality, and even violence may occur. Attitudes of various ethnic communities may be influenced by organized religion, conceptualizations of men having sex with men, and the value placed on civil liberties. Dual standards for men and women extend to cultural attitudes toward monogamy, expression of sexuality, talking about sexuality, condom use, who may initiate sexual intercourse, and reproduction. A client may be reluctant to seek treatment unless he or she knows that the health care providers will respect his or her individuality and alternative lifestyle3.

Recommendations
It is most important to create a positive mind-set in those people who are living with the disease. This includes;
·         The stigma about dying can be minimized so that people can realize than they can continue to live productive lives.
·          Mass advertising and campaigning should be done in order for this to actually occur.
·         Psychotherapy and education are the keys.
·         There are already a number of support groups in place to help people deal with HIV/AIDS, but more informal structures must be established. The formal support groups should not be the only means of support for these children. Rather, the immediate family and extended family should be well-informed and educated in order to provide basic emotional and psychological support.
·         Financial support is also needed for education, health care, etc.,
·         Basic needs should be met thereby alleviating at least one source of stress that is faced on a daily basis.
·         Elders can help by volunteering to teach youth moral responsibilities and self-worth.
·         The awareness of HIV/AIDS and all issues relating to it, such as the physiological and psychological impacts should be made compulsory core modules education curriculum. The education about this should begin at primary school.
·         Public consciousness should be raised by openly recording AIDS deaths as such, in order to educate people and to overcome the shame and stigmatization6.

Role of nurse
      I.        Assessment: Early recognition of psychiatric disorders by understanding the behavior of clients. Failure to assess or diagnose HIV infection denies the client proper treatment and care (Willard, Dean, 2000).
Phases of Assessment: Clients may enter the health care system at different phases of their illness depending on their biopsychosocial and spiritual needs. Ripich (1997) discusses three phases of the HIV continuum (ie, from the time the client tests positive with HIV infection, to the development of AIDS including the progression of the disease). The focus of discussion is on assessment and treatment of the psychosocial impact of HIV/AIDS.
A. Early-Phase Assessment- Clients who first learn that they are HIV-positive are considered to be in the early phase of the HIV continuum.
(1). Formulate a plan of care to improve or stabilize the client's emotional and physical well-being and
(2). Empower the client to maintain a sense of control over as many aspects of his or her life as possible.
The initial assessment of the client in an acute-care hospital or an inpatient  psychiatric setting, or requests testing while receiving psychiatric mental health care as an outpatient. The initial assessment usually includes a comprehensive history and physical evaluation, baseline laboratory testing, nutritional assessment, psychosocial assessment, and determination of the client's knowledge of the disease process (Burnett, 2001). Formal neurologic and psychological testing is often conducted to determine clinical phenomena and the extent of the disease process. To rule out the co-morbid neuropsychiatric syndrome or psychiatric disorder (Kongable, 1998).

The psychiatric mental health nurse assesses the client for:
·         Clinical symptoms of anxiety and depression (eg, fatigue, insomnia)
·         Suicidal ideation
·         Substance abuse or chemical dependency
·         Domestic-violence issues
·         Legal issues
·         Effective coping skills
·         Any fears or myths about the disease
·         Adequate support systems (e.g., family or significant others, spiritual, financial, legal)
·         The initial stage of the grief process (eg, denial)
·         Medical support system to evaluate physical concerns or complaints (Burnett, 2001)
Middle-Phase Assessment
During the middle phase, the HIV-infected client begins to experience symptoms that will ultimately result in a decline in health. Clinical phenomena, challenge coping mechanisms such as denial, as the client realizes he or she is losing control due to uncertainty about the future. The nurse assesses the client's:
·         Sense of isolation and alienation from partner, family, or friends
·         Anger and acting-out behavior
·         Low self-esteem
·         Feelings of guilt, helplessness, vulnerability, and loss of control
·         Fear of violence secondary to homophobia or social stigma
·         Changes in physical appearance
·         Passivity
·         Paranoia or ideas of reference
·         Depression
·         Knowledge of the progression of the disease process
·         Knowledge of and consent to treatment options
·         Coping skills as the disease process progresses
·         Self-esteem
·         Perception of body image
·         Desires regarding the use of life-support systems, emergency measures, and hospice care
·         Concerns verbalized by family members or significant others are identified.
Late-Phase Assessment
By the late phase, the client ideally has reached a realistic level of acceptance of his or her health status and uncertain future and may elect to begin a life-review process (ie, reflecting on one's life and finding peace with it) and make final preparations for death (Ripich,1997). During the late phase of the HIV continuum, the nurse assesses the client for:
·         Changes in mental status (e.g., clinical symptoms of dementia, delirium, acute psychosis, severe anxiety, personality change, depression, or suicidal ideation)
·         An ability to maintain independence and control of his or her environment
·         Physical or cognitive changes that interfere with activities of daily living
·         Any concerns about changes in medical status

Assessment for Immune Recovery Syndrome
The psychiatric mental health nurse must be able to distinguish among significant adverse effects of psychoactive drugs, ART therapy, and symptoms due to the immune recovery process.

Assessment as a Secondary Prevention
Secondary prevention of HIV during mental health care visits for clients who are at risk is as critical with HIV as it is for breast, cervical, or prostate cancer (Konkle-Parker, 1998). The psychiatric mental heath nurse should tell the client that he or she
is not being singled out, but rather is being given an opportunity to discuss sensitive issues that could place him or her at risk for HIV infection. A nonjudgmental approach is essential while obtaining a history of blood transfusions, drug use, and unprotected sex. The importance of HIV testing for those clients at risk should also be discussed.
Nursing Diagnoses
1.    Ineffective Health Maintenance related to lack of motivation to seek treatment for HIV/AIDS
2.    Disturbed Thought Processes related to neurologic changes as evidenced by a decline in cognition
3.    Anticipatory Grieving related to knowledge that HIV/AIDS is a terminal illness
4.    Death Anxiety as evidenced by statement, afraid to die, during individual therapy
5.    Hopelessness related to deterioration of physical condition secondary to HIV/AIDS
6.    Impaired Social Interaction related to alienation from others secondary to low self-concept
7.    Ineffective Coping related to altered appearance (significant weight loss) due to HIV/AIDS disease process
8.    Deficient Knowledge regarding illness and safe use of medication
9.    Situational Low Self-Esteem related to loss of independence and autonomy secondary to debilitating illness
10. Spiritual Distress related to challenges to belief system secondary to terminal illness.
Planning Interventions and Implementation
 A holistic, multidisciplinary approach that augments the available treatment and management options for clients is used to improve palliative outcomes and enhance overall well-being.

Early-Phase Planning and Implementation
During the early phase, the nurse encourages the client to
·         Personal values and internal conflicts are explored. Encourage to express thoughts and feelings,
·         Assists the client in accepting the diagnosis, and
·          Reassures the client
·          Crisis intervention- If the client verbalizes thoughts about death or suicide, interventions are planned to help the person explore such thoughts and feelings.
·         counseling,
·         Client education and referral to support groups.
Middle-Phase Planning and Implementation
Clinical phenomena of the middle phase may last for years. They include Physical, physiological, intellectual, cognitive, and sensorimotor function and disturbances in personality or behavior. Interventions for clinical symptoms related to dementia, delirium, depression, anxiety, and personality disorders. Individualizing the plan of care is important to address deficits in the client's ability to meet basic needs, as well as to meet the client's psychosocial needs.
1.    Assistance with Meeting Basic Needs: interventions are provided by the psychiatric mental health nurse personally or in collaboration with members of the treatment team if a multidisciplinary treatment team approach is used.
Interventions include:
a)    Assisting the client with activities of daily living if the client has impaired sensorimotor function or intellectual and cognitive dysfunction
b)    Providing adequate nutrition
c)    Providing an environment that includes safety measures and support, to prevent injury secondary to impaired sensorimotor function or confusion
d)    Monitoring vital signs and laboratory results during ART therapy to minimize adverse effects.
e)    Providing pain management as the clinical symptoms of HIV/AIDS progress
f)     Providing opportunities for the client to socialize with friends and family

2.    Medication Management: The nurse must be fully aware of the pharmacokinetic and pharmacodynamic properties of the prescribed psychotropic agents and antiretroviral drugs used to treat HIV/AIDS. Due to the potential for medication interactions, appropriate dosages for psychotropic agents (e.g., antidepressants, antianxiety agents, or Neuroleptic agents) are calculated based on the guidelines used for older adult populations. Benzodiazepines should be avoided because they compromise cognitive function (Sadock, 2003).
3.    Assistance with Emotional Needs: The nurse also provides interventions for special concerns verbalized by the client and his or her partner, family, and friends. For example, sexuality and safe-sex education is discussed with the client and partner if desired, healthy lifestyles are explored, and family therapy is provided to discuss rejection or reconciliation issues.
Interactive therapies are provided to assist the client in:
·         Verbalizing feelings and fears related to disfigurement and loss of control
·         Finding new meaning in life while adapting to limitations of his or her illness
·         Coping with possible condemnation and rejection from society, family, friends, and health care workers
·         Maintaining continuing communication among all involved social and medical agencies and providers
·         Resolving multiple and complex financial and legal concerns
·         Reconciling with estranged family members or significant others
·         Facing and discussing death and dying issues while maintaining respect and dignity
·         Discussing and exploring ethical and moral beliefs about rational suicide
Late-Phase Planning and Implementation
The nurse provides palliative care interventions. The wishes of the client set forth in a living will or relegated by durable power of attorney to a family member or significant other are respected and implemented at this time. In some instances, a health care surrogate may be designated to make decisions (Coyne, et al, 2002). The nurse remains available and assists the client in expressing his or her feelings regarding this final stage of life. The nurse encourages the client to express feelings and may ask if there are friends or relatives to call or messages to send. The needs of family members and significant others are also considered; the nurse assists them in understanding and experiencing their own grief. This may be done without the physical presence of the client (Ripich, 1997).

Client and Family Education:
HIV/AIDS education generally begins when the client is first diagnosed as being HIV-positive. Ideally, members of the family or a significant other would be involved
during this process. The comprehensive services provided include, for example, 24-hour telephone hotlines, community AIDS clinics, educational groups, financial counseling, and hospice services.
Community Support Groups
Support groups have become the key element in providing treatment. These groups, established by community and gay oriented organizations to respond to this health crisis and to lessen the isolation of people with AIDS, involve a variety of concerned volunteers. Through the assistance of trained professionals, these specialized groups provide emotional and physical support, assistance with daily chores, legal and financial planning, and advocacy with the appropriate social and government agencies. Lawyers can minimize some of the emotional trauma by helping the individual make crucial decisions regarding hospital visitation rights, treatment options, power of attorney, and disposition of property. Hirsch (1985) describe the benefit of helping the person with AIDS retain legal and personal control over his or her life for as long as possible.
Continuum of Care
Many hospitals and long-term care units have responded to the demand for continuum of care by providing a special care unit for clients with the AIDS, specifically designed to address the particular medical and psychological needs of the AIDS client. They are staffed by health care professionals and gay volunteer counselors who have been trained in working with the terminally ill client.
Evaluation
The outcomes should reflect the uncertainty of the client's life. Failure to develop such outcomes often results in client frustration (Ripich, 1997). During the evaluation process, the nurse may identify the need to make several adjustments due to the progression of the disease process and development or existence of a comorbid mental illness. Continuum of care is evaluated to determine if all possible support systems are in place as the client deals with the final stage of life3.

CONCLUSION:
“ …… If we do not appreciate the nature and impact of stigma, none of our interventions can begin to be successful. AIDS is probably the most stigmatized disease in history” – Justice Edwin Cameron (South Africa).
Stigma and discrimination can be perceived as “seriously as the illness itself”.
HIV-related stigma and discrimination are critical barriers to effectively address HIV. These operate throughout society: within individuals, families and communities. Stigma and discrimination are major “road blocks” to universal access to HIV prevention, treatment care and support. Nurses play a key role in reducing stigma and discrimination11.

REFERENCE:
1.    Sadock, et al, Kaplan & Sadock's Synopsis Of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition, Lippincott Williams & Wilkins, 2007:374-380
2.    Michael G. et al, New Oxford Textbook Of Psychiatry, Oxford University Press, 2000:1168-1171
3.    Louise Rebraca, et al,  Basic Concepts Of Psychiatric-Mental Health Nursing, 6th Edition, Lippincott Williams & Wilkins,  2005:545-558
4.    Nurses’ Manual ,HIV/AIDS and Art Training for Nurses, National Aids Control Organization, Indian Nursing Council,2009 , New Delhi.23-31
5.    Anxiety Disorders in Patients with HIV/AIDS. In: Mental Health Care for People with HIV Infection: HIV Clinical Guidelines for the Primary Care Practitioner. New York , New York State Department Of Health; 2006: 1-8
7.    www.gateway.nlm.nih.gov
8.    www.sacbc.org.za
9.    www.who.int
11. www.bmj.com