Mental Health

1
Mental Health HIV/AIDS

• Murray Bennett, MD, FRCPC
• Clinical Assistant Professor Psychiatry
• University of Washington
• Director Psychiatry Madison Clinic
• Harborview Medical Center

2
Mental Health HIV/AIDS

• HIV/AIDS Impact (2003)
• Worldwide
• 35 Million People with HIV/AIDS
• 18 million HIV Related deaths
• United States
• gt1 Million People with HIV/AIDS ( 1 in 300)
• gt500,000 HIV Related Deaths

3
Mental Health HIV/AIDS

• I Changes In HIV AIDS Epidemic
• II Psychiatric Epidemiology
• III Medication Interactions
• IV Challenging Patients
• V Substance Abuse

4
Mental Health HIV/AIDS

• Changes in the HIV/AIDS Epidemic
• In USA Developed Nations
• Dramatic significant reduction in the mortality
  rate by more than 50 since 1995
• Now moved to 14th leading cause of death overall
• Moved from 1st to 5th leading cause of death
  amongst 25-44 year olds

5
Mental Health HIV/AIDS

• Changes in the HIV/AIDS Epidemic
• However, rate of new HIV infections in USA is
  stable at 40,000 new cases per year
• Demographics of new cases reflect significant
  shifts changes in affected populations

6
Changes in the HIV/AIDS EpidemicNew Infections
USA

• Men 70
• 60 MSM
• 25 IDU
• 15 Heterosexual

• Women 30
• 75 Heterosexual
• 25 IDU

7
Changes in the HIV/AIDS Epidemic

• Medical Treatment Evolution
• Monotherapy in early 1990s
• Dual agent approach by mid 1990s
• Combination antiretroviral therapy (ART), also
  called highly active antiretroviral therapy
  (HAART), since late 1990s 3 or more agents

8
Changes in the HIV/AIDS Epidemic

• ART
• Has produced dramatic significant improvement
  in prognosis for HIV infection
• But has also emphasized the importance of
• Adherence
• Medication Interactions

9
Changes in the HIV/AIDS EpidemicARV Medications

• NRTIs
• Abacavir (Ziagen)
• Didanosine (Videx)
• Emtricitabine (Emtriva)
• Lamivudine (Epivir)
• Stavudine (Zerit)
• Tenofovir (Viread)
• Zalcitabine (Hivid)
• Zidovudine (AZT)
• NNRTIs
• Efavirenz (Sustiva)
• Nevirapine (Viramune)
• Delavirdine (Rescriptor)

• Protease inhibitors
• Amprenavir (Agenerase)
• Atazanavir (Reyataz)
• Darunavir (Prezista)
• Fosamprenavir (Lexiva)
• Indinavir (Crixivan)
• Lopinavir/ritonavir (Kaletra)
• Nelfinavir (Viracept)
• Ritonavir (Norvir)
• Saquinavir (Fortovase)
• Tipranavir (Aptivus)
• Fusion Inhibitor
• T20 (Fuzeon)

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Changes in the HIV/AIDS Epidemic

• Challenging Illness to Treat
• gt20 antiretroviral medications
• Challenging Patient Populations
• Comorbid Psychiatric Disorders
• Substance Abuse
• Poverty
• Homelessness
• Social isolation

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Mental Health HIV/AIDS

• Psychiatric Epidemiology

12
Mental Health HIV/AIDSPsychiatric Epidemiology

• Depression gt2 fold increase
• at risk populations high rate
• PTSD high-risk populations
• women/prisoners/minorities
• Dementia decreased with ART
• Prevalence? MCMD?
• Bipolar primary secondary
• 10 x higher
• Schizophrenia at-risk population
• 2- 10 x higher

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Mental Health HIV/AIDSDepression

• Prevalence estimated at twofold higher
• Meta-analysis 10 studies (Ciesla
  Roberts 2001)
• Risk factor for HIV Infection (Regier 1990)
• 2.5 fold increase when CD4 cell lt200 cells/mm³
• (Lyketsos 1996)

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Mental Health HIV/AIDSDepression

• Negative effects noted
• Adherence to ART (Dimatteo 2000)
• Quality of Life (Lenz Demal 2000)
• Treatment outcomes (Holmes House
  2000)
• Mortality disease progression (Ickovics 2001)
• Personal Health Questionnaire 9 (PHQ9)
• Patient completed survey
• Research validated Primary Care Clinics (Spitzer
  1999)
• APA advocates implementation

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Mental Health HIV/AIDSDepression

• 1 Complexity
• Patient has a good reason to be.. or
• Well, you would be to if you were.... or
• Its reasonable to be depressed
• Fact The majority of patients with chronic
  medical illness are not depressed
• (prevalence is never gt50)

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Mental Health HIV/AIDSDepression

• 2 Complexity
• Overlapping Symptoms -
• 4 out of 9 Sx could be caused by physical
  illness
• Appetite changes
• Sleep disruption
• Energy changes
• Slowed motor movement

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Mental Health HIV/AIDSDepression

• Inclusive Model for Diagnosis of Major Depression
• Count all physical symptoms unless they are
  clearly and fully caused by physical or medical
  illness
• (positive predictive value 54
  80)

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Mental Health HIV/AIDSDepression

• Psychosocial Stress
• High suicide rates
• Initial HIV diagnosis later stages of illness
• Multiple comorbid factors
• Substance abuse
• Poverty
• Homelessness
• Social isolation
• Physical stigma of ART
• Lipoatrophy, lipodystrophy disclosure of
  infection

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Mental Health HIV/AIDSDepression

• Multiple studies indicate almost all
  antidepressants are effective
• Concern for P450 interactions with some
  antiretroviral medications
• Favor citalopram sertraline over paroxetine
  fluoxetine (2D6)
• Caution with nefazodone fluvoxamine (3A4)
• Side effect profile guides choice of agent
• Mirtazipine favored for sedation and appetite
  stimulation

20
Mental Health HIV/AIDSDepression

• Psychotherapy
• Many studies showing benefit with and without
  antidepressants
• Group therapy prominent modality
• Cognitive Behavioral Therapy (CBT)
• Interpersonal
• Supportive
• Themes of guilt, shame, anger

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Mental Health HIV/AIDSPTSD

• Greatly increased rates
• 42 HIV women, County Medical Clinics
• (Cottler 2001)
• 30 pts develop in reaction to HIV diagnosis
• (Kelley 1998)
• Predicts lower CD4 counts (Lutgendorf 1997)
• Higher levels of pain (Smith 2002)

22
Mental Health HIV/AIDSPTSD

• SSRIs show 50 improvement in sx
• prefer to use sertraline (Zoloft) or citalopram
  (Celexa)
• Prazosin often used for intrusive nightmares
• current studies (Raskind SVAMC)
• Psychotherapy effective, using variety of
  approaches (CBT, Abreaction, Supportive)

23
Mental Health HIV/AIDSPanic Disorder

• Panic Disorder Generalized Anxiety Disorder gt 4
  times more prevalent (Bing 2001)
• Affects accessing primary care, adherence to
  treatment, and quality of life
• Especially agoraphobic/housebound
• Responds well to treatment

24
Mental Health HIV/AIDSPanic Disorder

• First line treatment SSRIs
• Then consider dual action agents (venlafaxine
  (Effexor) or duloxetine (Cymbalta)), mirtazepine
  (Remeron), or tricyclics (TCAs)
• Wellbutrin of little benefit
• Responds well to psychotherapy CBT
• Best outcomes both meds psychotherapy
• Use benzodiazepines as last resort
• eg, clonazepam preferred (longer half life)

25
Mental Health HIV/AIDSSocial Phobia

• Fear of social situations, scrutiny and criticism
  of others, unable to eat or speak in public
• Relates to internalized stigma of illness
• exacerbated by lipoatrophy and lipodystrophy
  caused by ART
• Responds well to psychotherapy meds
• First line SSRIs

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Mental Health HIV/AIDSDementia

• CNS Infection
• 10 AIDS pts present with neurological dx
• 75 AIDS pts brain pathology at autopsy
• gliosis, white matter pallor multinucleated
  giant cells
• HIV-Associated Dementia (HAD)
• Minor Cognitive Motor Disorder (MCMD) predict
  shorter survival

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Mental Health HIV/AIDSDementia

• HIV-infected macrophages directly enter CNS early
  in HIV infection
• CNS may be sanctuary for HIV replication
• CSF HIV viral load not correlated with plasma
  viral load when CD4 count lt200 cells/mm³
• CSF viral load correlates dementia severity

28
Mental Health HIV/AIDSDementia

• With effective ART, incidence of CNS OIs dropped
  significantly, since early 1990s
• 2/3 decreased incidence HAD
• (Saktor 1999)
• 75 decrease CMV lymphoma on autopsy
• However 60 with some evidence of
• HIV encephalopathy on autopsy
  (Neuenburg 2002)

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Mental Health HIV/AIDSDementia

• Risk Factors
• Seroconversion illness
• Anemia
• Vitamin deficiencies (B6, B12)
• Low CD4 count
• High CSF HIV viral Load
• ETOH, cocaine amphetamine
• Depression

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Mental Health HIV/AIDSDementia

• HIV CNS infection has predilection for
  subcortical brain structures
• Basal ganglia
• Caudate, putamen, nucleus accumbens, globus
  pallidus, substantia nigra, subthalamic nucleus
• Leads to unique clinical manifestations

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Mental Health HIV/AIDSDementia

• Early signs symptoms
• Decreased attention concentration
• Psychomotor slowing
• Reduced speed of information processing
• Executive dysfunction
• Abstraction
• Divided attention
• Shifting cognitive sets

32
Mental Health HIV/AIDSDementia

• Later signs symptoms
• Memory impairment
• Language problems
• Visual-spatial difficulties
• Apraxias

33
Mental Health HIV/AIDSDementia

• Associated behavioral changes
• Apathy
• Depression
• Sleep disturbance
• Agitation mania
• Psychosis

34
Mental Health HIV/AIDSDementia

• Neurocognitive problems
• 30-50 Subclinical
• Neuropsychological testing impaired
• ---------(threshold clinical significance)--------
  ----
• 20 MCMD
• Minor Cognitive Motor Disorder
• 2-4 HAD
• HIV Associated Dementia

35
Mental Health HIV/AIDSDementia

• Mild Manifestation
• MCMD
• Minor Cognitive Motor Disorder
• Severe Manifestation
• HAD
• HIV Associated Dementia
• functional impairment

• Diagnostic Criteria
• 1) At least 2 of impaired attention,
  concentration, memory, mental psychomotor
  slowing, personality change
• 2) Rule out other cause
• Diagnostic Criteria
• 1) Acquired cognitive abn
• 2) Acquired motor abn
• 3) No clouded LOC rule out other cause

36
Mental Health HIV/AIDSDementia

• Treatment
• Most effective treatment is ART
• Raises question of lumbar puncture to confirm
  effectiveness on CSF HIV viral load..
• Slows progression of dementia (Ferrando 1998)
• Reversed periventricular white matter changes
  seen on MRI scan in some cases

37
Mental Health HIV/AIDSDementia

• Potential neuroprotective agents
• Most promising are memantine (Namenda)
  selegeline (L-Deprenyl)
• Many adjuvant agents commonly used, with some
  controversy about use of stimulants
• Improved cognitive performance
• (Brown 1995, Hinkin 2001)
• Accelerated HAD sxs (Czub 2001, Nath 2001)

38
Mental Health HIV/AIDSDementia

• Adjuvant treatments
• Selegeline (L-Deprenyl)
• Buproprion (Wellbutrin)
• SSRIs (Prozac, Paxil, Celexa, Zoloft, Lexapro)
• Dual-action antidepressants (Effexor, Cymbalta)
• Atomexitine (Strattera)
• Modafinil (Provigil)
• Anabolic steroids
• Atypical or second generation antipsychotics

39
Mental Health HIV/AIDSBipolar - Mania

• Prevalence of bipolar disorder in HIV infection
  is 10 times higher than in general population
  (Lyketsos 1993)
• Stress of HIV infection exacerbates pre-existing
  bipolar disorder complicating adherence
• New-onset or secondary mania
• result of HIV infection, opportunistic infections
  or due to antiretroviral medications

40
Mental Health HIV/AIDSBipolar - Mania

• Patients with bipolar disorder (primary) at
  increased risk of HIV infection
• Impulsivity, poor judgment, libido changes all
  part of mood episodes
• Secondary mania seen in later stages of HIV
  infection
• Harder to treat
• More chronic, less episodic course

41
Mental Health HIV/AIDSBipolar - Mania

• Secondary mania
• Associated with impaired cognition
• Increased risk of dementia
• Different clinical features
• Irritable gt elevated mood
• Psychomotor slowing
• More chronic than episodic
• More resistant to treatment

42
Mental Health HIV/AIDSBipolar - Mania

• Treatment
• Not well studied with mostly anecdotal case
  reports
• Depakote (VPA) well tolerated
• Avoid with impaired hepatic function
• Risk anemia with AZT
• Lithium
• Conflicting reports of good response (increases
  WBC) versus intolerable side effects
• Tegretol (carbamazepine)
• Avoid as risks medication interactions (inducer)
  bone marrow suppression

43
Mental Health HIV/AIDSBipolar - Mania

• Treatment
• Second generation (atypical) antipsychotics all
  have indication as mood stabilizers, well
  tolerated and effective for psychotic sxs
• Olanzapine (Zyprexa) gt risperidone (Risperdal)
  quetiapine (Seroquel) gt ziprasidone (Geodon)
  aripiprazole (Abilify)
• - Risk of metabolic effects wt gain, DM,
  hyperlipidemia, etc
• Note clozapine (Clozaril) contraindicated for
  several reasons

44
Mental Health HIV/AIDSSchizophrenia

• Patients with chronic mental illness at increased
  risk for HIV infection
• Prevalence rates 2 to 10
• Medical providers often do not test for HIV
• Incorrectly assume pts not sexually active
• Substance abuse significant co-morbidity
• Pts do not implement HIV risk behavior knowledge

45
Mental Health HIV/AIDSSchizophrenia

• Treatment
• Coordinate between medical psychiatric
  providers as much as possible
• Typical or 1st generation antipsychotics
• Increase risk of EPS tardive dyskinesia
• Atypical or 2nd generation antipsychotics are
  preferred but risk weight gain
• Olanzapine (Zyprexa) gt risperidone (Risperdal)
  quetiapine (Seroquel) gt ziprasidone (Geodon)
  aripiprazole (Abilify)
• Note clozapine (Clozaril) contraindicated for
  several reasons

46
Mental Health HIV/AIDSSchizophrenia

• Substance-induced psychosis
• Least studied most resistant to treatment
• Methamphetamine gt cocaine gt hallucinogen
• Possibly increased susceptibility in patients
  with later stage HIV infection (C3)

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Mental Health HIV/AIDS

• Medication Interactions

48
Mental Health HIV/AIDSMedication Interactions

• Metabolism excretion
• Hepatic metabolism
• Phase I prepare for excretion
• Phase II conjugation
• Renal metabolism
• Creatinine clearance
• Affects lithium or gabapentin
• P-Glycoproteins
• Present in gut, liver, gonads, kidneys, brain
• Transport hydrophobic substances

49
Mental Health HIV/AIDSMedication Interactions

• Hepatic metabolism
• Phase I
• Oxidation Cytochrome P450
• Reduction
• Hydrolysis
• Phase II
• Glucuronidation - UGT
• Acetylation
• Sulfation

50
Mental Health HIV/AIDSMedication Interactions

• Drug-drug interactions - metabolism
• Substrate (goes through the funnel)
• drug metabolized by an enzyme
• Inducer (opens the funnel)
• drug increases activity of metabolic enzyme
• Inhibitor (plugs the funnel)
• drug decreases activity of metabolic enzyme

51
Mental Health HIV/AIDSMedication Interactions

• Induction
• May cause decreased amounts circulating drug,
  thereby lowering therapeutic effect
• Funnel is opened wider
• Inhibition
• May cause increased amounts circulating drug,
  thereby creating toxic effect
• Funnel is plugged.

52
Mental Health HIV/AIDSMedication Interactions

• Occur in 3 situations
• Add interacting drug (inhibitor or inducer) to
  existing regimen containing a substrate drug
• Withdraw interacting drug (inhibitor or inducer)
  from existing regimen containing a substrate drug
• Add substrate drug to a regimen containing an
  interacting drug (inhibitor or inducer)

53
Mental Health HIV/AIDSMedication Interactions

• Hepatic cytochrome P450
• Enzyme system that catalyzes Phase I reactions
• Responsible for most metabolic drug interactions
• 11 families
• 3 of which are important to humans
• designated by a number
• e.g. CYP1, CYP2, CYP3

54
Mental Health HIV/AIDSMedication Interactions

• Hepatic cytochrome P450
• Families are broken down into subfamilies
• designated by capital letter
• e.g. CYP3A
• Subfamilies are broken down into isoenzymes
• designated by a number
• e.g. CYP3A4

55
Mental Health HIV/AIDSMedication Interactions

• Hepatic cytochrome P450
• Most important cytochrome P450 enzymes
• 1A2
• 2C9 2C19
• 2D6
• 3A4

56
Mental Health HIV/AIDSMedication Interactions

• Phase II Glucuronidation
• H2O-soluble molecules conjugated
• more easily excreted
• Uridine Glucuronosyltransferase (UGT)
• 2 clinically significant subfamilies
• 1A 2B

57
Mental Health HIV/AIDSMedication Interactions

• Phase II Glucuronidation
• eg, UGT 2B7 site of conjugation of
  benzodiazepines
• Lorazepam (Ativan), temazepam (Restoril)
  oxazepam (Serax) are substrates at UGT 2B7
• Inhibited by NSAIDS
• Induced by ritonavir, phenobarbital, rifampin
  oral contraceptives

58
Mental Health HIV/AIDSMedication Interactions

• Antiretrovirals
• Major culprit ritonavir
• Most potent known inhibitor of 3A4!

59
Mental Health HIV/AIDSMedication Interactions

• Antiretrovirals
• 1A2
• Induction by ritonavir nelfinavir
• 2C9
• Induction by ritonavir nelfinavir
• Inhibition by delavirdine
• 2C19
• Induction by efavirenz nelfinavir
• Inhibition by efavirenz delavirdine

60
Mental Health HIV/AIDSMedication Interactions

• Antiretrovirals
• 2D6
• Inhibition by ritonavir
• 3A4
• Induction by ritonavir, nelfinavir, efavirenz,
  nevirapine
• Inhibition by ritonavir, fosamprenavir,
  indinavir, nelfinavir, saquinavir, tipranavir,
  delavirdine

61
Mental Health HIV/AIDSMedication Interactions

• Remember
• Most interactions are not clinically significant
• Impossible to memorize all interactions
• Must look up or reference to be sure
• www.madisonclinic.org
• http//hivinsite.ucsf.edu/arvdb?pagear-00-02

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Mental Health HIV/AIDSMedication Interactions

• Antidepressants
• Most metabolized at 2D6
• Exceptions
• Fluvoxamine (Luvox)
• AVOID
• Nefazodone (Serzone)
• AVOID or dose cautiously
• Bupropion (Wellbutrin, Zyban)
• _at_ 400 mg, dose cautiously with ritonavir

63
Mental Health HIV/AIDSMedication Interactions

• Antidepressants
• SSRIs
• Fluoxetine (Prozac) paroxetine (Paxil)
• some interactions, but not clinically significant
  for most antiretrovirals
• Citalopram (Celexa), escitalopram (Lexapro),
  sertraline (Zoloft)
• have fewest interactions

64
Mental Health HIV/AIDSMedication Interactions

• Antidepressants
• Tricyclic antidepressants
• Generally well tolerated with antiretrovirals
• Nortriptyline desipramine (secondary amines)
• Narrow metabolism at 2D6
• Levels can be elevated by other medications
• Get a blood level if in doubt

65
Mental Health HIV/AIDSMedication Interactions

• Antidepressants
• Dual-action agents
• Venlafaxine (Effexor) duloxetine (Cymbalta)
• Well tolerated without adjusting dose
• Mirtazipine (Remeron)
• Well tolerated

66
Mental Health HIV/AIDSMedication Interactions

• Anxiolytics
• Mostly metabolized at 3A4
• Avoid
• Alprazolam (Xanax)
• Triazolam (Halcion)
• Midazolam (Versed)

67
Mental Health HIV/AIDSMedication Interactions

• Anxiolytics
• Safest to use glucuronidated benzodiazepines
• Lorazepam (Ativan)
• Temazepam (Restoril)
• Oxazepam (Serax)
• Caution with buspirone (Buspar), and dosing of
  other benzodiazepines with ART (3A4)

68
Mental Health HIV/AIDSMedication Interactions

• Antipsychotics
• Typicals (first generation D2 blockers)
• Atypicals (second generation multiple
  neurotransmitters)
• Both are mostly metabolized at 2D6

69
Mental Health HIV/AIDSMedication Interactions

• Antipsychotics
• for use with ritonavir, start with low dose
• 1A2 2D6
• Haloperidol (Haldol) (risk EPS TD)
• Avoid chlorpromazine (Thorazine), thioridazine
  (Mellaril)
• Olanzapine (Zyprexa) clozapine (Clozaril)
• 3A4
• Aripiprazole (Abilify) clozapine (Clozaril)
• Avoid pimozide (Orap)

70
Mental Health HIV/AIDSMedication Interactions

• Stimulants
• Atomoxetine (Strattera) nonstimulant
• Caution with impaired hepatic function
• Metabolized at 2D6
• Inhibits at 2D6
• Modafinil (Provigil) be cautious
• Metabolized at 3A4
• Induces at 1A2 3A4

71
Mental Health HIV/AIDSMedication Interactions

• Herbal remedies
• Kava Kava
• Anxiolytic
• Increases bleeding time
• Risk of hepatotoxicity
• St Johns Wort
• Mild antidepressant effect
• Induces 3A4
• Caution with certain ARV medications- may lead to
  regimen failure

72
Mental Health HIV/AIDS

• Challenging Patient Population

73
Mental Health HIV/AIDSChallenging Patient
Population

• Dual, Triple, Quadruple Diagnosed
• HIV-AIDS diagnosis
• Psychiatric diagnoses
• Axis I Axis II
• Substance abuse dependence
• Co-morbid medical illness
• Hepatitis C
• Diabetes mellitus.

74
Mental Health HIV/AIDSChallenging Patient
Population

• Multiple comorbid psychiatric disorders
• Substance abuse dependence
• Personality disorders
• Chronic mental illness
• Further challenges
• Poverty, lower SES
• Minorities over represented
• Language and cultural barriers to care

75
Mental Health HIV/AIDSChallenging Patient
Population

• Personality disorders
• Cluster B traits predominant
• Borderline, Antisocial, Histrionic,
  Narcissistic
• Common features of impulsivity, risk taking,
  novelty seeking, self destructive behavior place
  themselves and others at risk of HIV infection
• Added factors exploitative, manipulative,
  chaotic, entitled, dramatic, and demanding all
  make provision of care more challenging

76
Mental Health HIV/AIDSChallenging Patient
Population

• Goal as provider to take empathic approach yet
  able to set non-punitive limits
• Narcissism reaction or defense to low self
  esteem, need to devalue others, unable to make
  empathic connections with others
• Splitting manipulation manner in which
  patients understand their world (Borderline) or
  get their needs met (survival on streets)
• Multidisciplinary team approach improve
  communication, minimize splitting

77
Mental Health HIV/AIDSChallenging Patient
Population

• Chronically Mentally Ill
• Bipolar, schizophrenic, schizoaffective
• At increased risk of HIV infection
• Less adherent to medical psychiatric care
• Receive care across systems
• Community Mental Health system not integrated
  with Primary Care, Medical Clinics, or Hospitals

78
Mental Health HIV/AIDSChallenging Patient
Population

• Strategy
• Communicate between providers systems
• Utilize mental health case managers to assist
  with adherence to ART, appointments
• Monitor blood work
• Do not assume other provider is following hepatic
  or renal function, electrolytes or blood levels
• Monitor for medication interactions
• Communicate between pharmacies

79
Mental Health HIV/AIDSChallenging Patient
Population

• Lower Socio-Economic Status
• Most needs
• Fewest resources
• Increased risk of violence
• Increased chaos in daily lives
• Affecting adherence to ART
• Not showing for appointments
• Access to chemical dependency treatment

80
Mental Health HIV/AIDS

• Substance Abuse

81
Mental Health HIV/AIDSSubstance Abuse

• Triple Diagnosis
• HIV infection, psychiatric diagnosis,
  substance abuse
• Epidemiology
• 30 AIDS patients are Injection Drug Users
• gt50 HIV patients have some kind of substance
  abuse/dependence
• Madison Clinic 65 psychiatric pts
• lt 5 self report a problem with drugs or EtOH

82
Mental Health HIV/AIDSSubstance Abuse

• Substances
• Alcohol
• Amphetamines
• Cocaine
• Heroin
• Club drugs
• GHB, MDMA (Ecstasy), Ketamine (Special K)

83
Mental Health HIV/AIDSSubstance Abuse

• Injection drug users (IDU)
• Present later in illness for medical care
• Once in care, do not have accelerated course
• Active use impairs access complicates care
  through non-adherence
• Alcohol, amphetamines, cocaine, heroin
• suppress immune function or increase HIV
  replication (Kibayashi 1996)

84
Mental Health HIV/AIDSSubstance Abuse

• Characteristics of injection drug users
  non-adherent to ART (Moatti 2000)
• Younger age
• Active IDU (5 fold higher)
• Alcohol abuse or use
• Stressful life events

85
Mental Health HIV/AIDSSubstance Abuse

• Treatment
• Detoxification complicated by HIV illness
  withdrawal from multiple substances
• Chronic opioid users
• Refer to methadone maintenance programs
• Certain ARV medications may decrease methadone
  levels
• Integrated settings most effective
• Directly Observed Therapy (DOT) may assist ART
  adherence

86
Mental Health HIV/AIDS Summary

• Changing epidemic with significant impact
• Challenging illness patient population
• Team approach, multidisciplinary care
• Remember to look up medication interactions!
• www.madisonclinic.org
• http//hivinsite.ucsf.edu/arvdb?pagear-00-02