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
11. www.bmj.com
