Psychiatric Issues Can Loom Large in HIV

Article excerpt

NEW ORLEANS -- The neurologic and psychiatric aspects of HIV should be treated at least as aggressively as the impact of the disease on the liver, lungs, and heart, Dr. Marshall Forstein said at the American Psychiatric Association's Institute on Psychiatric Services.

HIV invades the brain beginning at the time of seroconversion, and can progress in the central nervous system independently of the peripheral progression of the disease, resulting in neurologic effects that can adversely affect the course of illness, adherence to treatment, secondary transmission, and survival, Dr. Forstein, of the department of psychiatry at Harvard Medical School, Boston.

Central nervous system (CNS) dysfunction can occur as a result of the effects of HIV on metabolic and endocrine dysfunction. Hypoxia, anemia, hypothyroidism, adrenal insufficiency, and hypogonadism are more common in those who have HIV, for example.

Such dysfunction also can occur as a result of various treatments, such as an-tivirals, antimicrobials, and herbal medicines, and can range from subclinical cognitive impairment to mild neurocognitive disorder to HIV-related dementia, he noted, adding that effective HIV treatment can help, but long-standing adverse effects can occur as a result of subcortical and cortical insult in those who go untreated.

Furthermore, the effects can be aggravated by psychiatric disorders, substance abuse, sleep deprivation, and pain--all of which are common in HIV patients, and thus may contribute greatly to the cognitive problems.

Antiretroviral treatment can help improve neurocognitive function, as can psychostimulants, but it is important to remember that the CNS can be a sanctuary for the virus in the brain. Therefore, it is also important to maintain "a sense of disconnect between what's going on in the periphery and what's going on in the nervous system," he said.

For example, findings in HIV as well as in other diseases such as hepatitis C, suggest that infections of the brain may stimulate inflammatory processes that adversely affect cognition. Bolstering this suggestion are recent findings of a relationship between HIV treatment and a halo effect in the CNS, reducing the consequences of inflammatory processes in the brain regardless of the progression or resistance of the virus in the periphery, Dr. Forstein said.

In addition, viral load does not appear to be linked with cognitive changes; some patients who have a low viral load have extensive cognitive impairment, and some who have a high viral load have no cognitive impairment. …