AIDS is a severe, chronic, multiorgan, multisystem illness with multiple and severe comorbid psychiatric and other medical illnesses. AIDS is also a prevalent illness that presents with psychiatric responses to illness, is associated with psychiatric illness because of the affinity of HIV for brain and neural tissue, and occurs with comorbid psychiatric illness as well as other medical illnesses. In many ways, AIDS and other manifestations of HIV infection can be seen as a paradigm of a complex and severe medical illness, the model of illnesses that comprise the field of psychosomatic medicine. There thus is a need for a biopsychosocial approach to the care of persons with HIV and AIDS. A summary of some of the factors involved in a biopsy-chosocial approach to AIDS can be found in Table 1.2.
Psychiatrists make ideal AIDS educators. General psychiatrists who work in the areas of inpatient and outpatient psychiatry settings, private offices, addiction psychiatry, geriatric psychiatry, child and adolescent psychiatry, correctional facilities, and long-term care facilities are all in a prime position to provide education, help prevent transmission of HIV, suggest or provide condoms and information about safe sex, and suggest or offer HIV testing to lead toward early diagnosis and treatment. Most psychiatrists take detailed sexual and drug histories and work with patients to help them change behaviors. The significance of taking a detailed sexual history was especially evident in a population-based study of men in New York City. This study revealed discordance between sexual behavior and self-reported sexual identity; nearly 10% of straight-identified men reported at least one sexual encounter with another man in the previous year (Pathela et al., 2006). Most psychiatrists form long-term, ongoing relationships with their patients and work with patients toward achieving gratification in long-term, intimate-partner relationships. All of these characteristics can be of major importance in primary prevention as well as early diagnosis and treatment of HIV infection.
Psychosomatic medicine clinicians or psychiatrists and AIDS psychiatrists are in a unique position to provide psychiatric care for persons with HIV, from the time ofinfection to the time ofdeath and its aftermath, with provision of support for partners and families. However, AIDS psychiatrists rarely have the chance to provide care for their patients until they are diagnosed with HIV infection. Ruiz (2000) has provided table 1.2. A Biopsychosocial Approach to HIV and AIDS
Opportunistic Infections (Most Common) Protozoal
Mycobacterium avium intracellulare Viral
Cytomegalovirus disease Fungal
Cryptococcal meningitis Esophageal candidiasis
Opportunistic cancers Kaposi's sarcoma
Comorbid Medical Illnesses (Most Common)
Clostridium difficile colitis
Diagnoses (Most Common)
Major depressive disorder Mood disorder due to medical condition with depression Mood disorder due to medical condition with mania Bipolar disorder Cognitive disorders Dementia Delirium Substance use disorders
Adjustment disorders Anxiety disorders
Posttraumatic stress disorder Bereavement
Paresis and paralysis a description of the psychiatric care of one of his patients, extending from before his patient's diagnosis of HIV through the course of his illness and progression to AIDS to end-stage AIDS at the end of his life. Ruiz also documented his provision of support for the family after the death of the patient. AIDS psychiatrists can provide colocated psychiatric services, education and support for trainees, and support and leadership for the multidisciplinary teams of physicians, nurses, social workers, other health professionals, and staff. It is especially gratifying to work as part of a dedicated and compassionate team of clinicians who are providing comprehensive care for persons with HIV and AIDS.
HIV and AIDS also present us with paradoxes. One of the most tragic paradoxes of HIV is the disparity in access to care resulting from racial, political, and economic factors in many areas of the world as well as in certain areas of the United States and other industrialized nations. Another tragic paradox is the disparity in access to care among persons with psychiatric illness. In addition, age, intelligence, and level of education do not necessarily correlate with ability to adhere to risk reduction, safe sexual behavior, and medical care (Cochran and Mays, 1990; De Buono et al., 1990; MacDonald et al., 1990; Reinisch and Beasley, 1990). Among adolescents, who say "I can use a condom, I just don't'' (Mustanski et al., 2006), as well as the elderly (Goodkin et al., 2003; Stoff et al., 2004; Karpiak et al., 2006), who may not feel a need for barrier contraception to prevent pregnancy and whose physicians may be uncomfortable discussing sexual activity, there are high rates of HIV infection. The process of care for persons with AIDS at the end of life is also paradoxical and there is a clear need for provision of care along a continuum that includes both palliative and curative care. This concept has been proposed but appears hard to implement. The need to overcome the "false dichotomy of curative vs. palliative care for late stage AIDS'' has been suggested (Selwyn and Forstein, 2003).
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