2 курс / Микробиология 1 кафедра / Доп. материалы / Kartikeyan_HIV and AIDS-Basic Elements and Properties
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spinal cord (Wright et al., 1997). Toxins, metabolic disorders, or excessive production of cytokines may cause vacuolar myelopathy. It manifests as a progressive spastic paraparesis, with impaired perception of vibration and proprioception in feet and legs. Sensory loss of posterior-column type may be present, which lacks a definite sensory level. There may be loss of sphincter control in late stages of the disease. This condition responds poorly to ARV drugs. Addition of another ARV drug may be helpful. Management includes occupational therapy, physiotherapy, using walking aids, and tackling incontinence (Wright et al., 1997).
12.3 – MYOPATHIES
ZDV may cause myositis. The inflammatory type of myopathy is similar to polymyositis, while non-inflammatory type is not yet understood (Simpson & Wolfe, 1991). Both HIV-related polymyositis and ZDV-associated myopathy manifest as progressive proximal muscle weakness, myalgia, and loss of more than 10 per cent of body weight. ZDV-associated myopathy mainly affects the lower limbs and causes wasting of buttocks. Serum creatine kinase (CK) levels are elevated. Electromyography (EMG) and muscle biopsies are abnormal. A trial of corticosteroids or intravenous Ig is indicated for HIV-related polymyositis. Patients with ZDV-associated myopathy usually recover in 6–12 weeks after withdrawal of the drug. Once the myopathy has resolved, ZDV may be reintroduced at a lower dose. If relapse occurs, another ARV drug should be used.
12.4 – PERIPHERAL NEUROPATHY
HIV-1 Sensory Neuropathy: This type of neuropathy is rare in asymptomatic HIV-infected persons but occurs in up to 35 per cent of AIDS patients (So et al., 1988); disease is due to axonal degeneration with macrophage infiltration that affects all types of nerve fibres. This condition has been associated with infection by MAC. An identical and indistinguishable type of neuropathy is caused by ARV drugs (didanosine, zalcitabine, and stavudine). The neuropathy is distal, symmetrical, and predominantly sensory. Its manifestations include symmetrical numbness, hyperaesthesia, impaired perception of pain, temperature, light touch, vibration, and proprioception. Ankle jerks may be decreased or absent. Burning sensation in soles is a rare manifestation. There is no known specific treatment (Simpson & Wolfe, 1991). Management of HIV-1 sensory neuropathy involves withdrawal of all neurotoxic drugs (ARV drugs, isoniazid, alcohol, diabetes, high-dose metronidazole, thalidomide, and dapsone) and replacement with another non-neurotoxic drug. Mild to moderate neuropathic pain is treated with a combination of paracetamol and codeine. Tricyclic antidepressants (amitriptyline 10 mg at night or sodium valproate 200 mg thrice daily) are to be administered and the dosage may be increased if pain is not controlled. For severe neuropathic pain, narcotic analgesics such as morphine
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are indicated. Clinical improvement may take up to 12 weeks (Wright et al., 1997).
Inflammatory Demyelinating Polyneuropathy: This condition occurs during seroconversion or asymptomatic phase. The acute manifestations of this condition are similar to that of Guillian–Barré syndrome. It is probably an autoimmune disorder (Simpson & Wolfe, 1991). It manifests as progressive weakness, loss of reflexes and rarely, mild sensory disturbances. EMG and nerve conduction studies are essential for confirming the diagnosis. Corticosteroids are to be used cautiously. Plasmaphresis and intravenous administration of Igs have been successfully tried. Physiotherapy and long-term rehabilitation are essential components of management (Wright et al., 1997).
Mononeuritis Multiplex: During the asymptomatic or early symptomatic phases of HIV infection, acute nerve palsies may occur. One or more nerves may be involved. This mild form of mononeuritis is probably an autoimmune disorder (Simpson & Wolfe, 1991). This condition may resolve without specific treatment (So & Olney, 1991). In advanced disease, widespread neuropathy may occur, which requires hospitalisation. Nerve conduction studies are indicated. Since cytomegalovirus has been linked to severe form of mononeuritis multiplex, a trial of ganciclovir may be necessary (Wright et al., 1997).
12.5 – HIV-RELATED HEADACHES
During the stage of seroconversion, patients may present with headache, fever, and neck stiffness due to aseptic meningitis. Examination of CSF may or may not show pleocytosis. Headaches are commonly seen in advanced disease. Patients may have generalised headache with photophobia for many weeks or months. The patient should be explained that most headaches resolve within several weeks. HIV-related headaches need to be differentiated from that due to sinusitis, migraine, depression, cryptococcal meningitis, cerebral toxoplasmosis, and cerebral lymphoma. Investigations include CAT or MRI of the cranium with sinus views, CSF examination (cytology, culture, cryptococcal antigen) and serology for cryptococcal antigen. Headache is treated with a combination of paracetamol and codeine. Tricyclic antidepressant (amitriptyline 50–75 mg at night) may also be used.
12.6 – SEIZURES
Seizures are seen in a variety of conditions that include cerebral space-occupying lesion, subclinical HIV-associated CNS involvement or dementia, metabolic disturbances, and cryptococcal meningitis (Holtzman et al., 1989). The cause cannot be determined in up to 46 per cent of patients (Wong et al., 1990). A complete history of the seizure should be recorded and withdrawal effects from alcohol or drugs are to be ruled out. CAT or MRI of the cranium may be undertaken to
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exclude cerebral lymphoma, toxoplasmosis, and PML. If CAT or MRI is normal, CSF examination (protein, glucose, cytology, culture, cryptococcal antigen) is essential. Haematological and serological investigations include total blood count, blood sugar, liver function tests, serum electrolytes, serum calcium and magnesium, and cryptococcal antigen. Electroencephalogram (EEG) helps to exclude focal seizures. If left untreated, seizures may recur. Clonazepam or sodium valproate is the recommended front-line drug. Use of phenytoin and carbamazepine is associated with adverse drug reactions such as skin rash, leukopenia, and abnormal liver function tests (Holtzman et al., 1989).
12.7 – CEREBROVASCULAR DISEASE
Transient Neurological Deficits (TNDs) may occur in advanced HIV disease. These are similar to transient ischaemic attacks. This condition is associated with thrombocytopenia, deficiency of protein S, and presence of anticardiolipin antibodies. Some patients have responded to ARV agents. Cardiac disease, cerebral lesions, cryptococcal meningitis, and neurosyphilis are among the causes of cerebral infarction or haemorrhage. The patient must be hospitalised (Wright et al., 1997). Investigations include CAT or MRI of the cranium, carotid doppler studies (for recurrent TNDs), EEG to exclude focal seizures, echocardiogram, chest radiography, total blood count, clotting profile (bleeding time, clotting time, prothrombin time, estimation of activated C, protein C, and protein S), and serological tests – cardiolipin antibody, syphilis serology, and cryptococcal antigen titre. Underlying cardiac or cerebral disease must be treated. If TNDs are recurrent, without underlying pathology, switch to a new ARV drug. Some patients may require anticoagulation therapy with low dose aspirin or warfarin (Wright et al., 1997).
REFERENCES
Brew B.J., 1992, Medical management of AIDS patients: Central and peripheral nervous system abnormalities in HIV-1 infection. Med Clin North Am 76: 63–81.
Brew B.J. and Currie J., 1993, HIV-related neurological disease. Med J Aust 53: 104–108.
Currie J., Benson E., Ramaden B., et al., 1988, Eye movement abnormalities as a predictor of the acquired immunodeficiency syndrome dementia complex. Arch Neurol 45: 949–953.
Dal Pan G.J., Glass J.D., and McArthur J.C., 1994, Clinico-pathologic correlations of HIV-1 associated vacuolar myelopathy: an autopsy-based case-controlled study. Neurology 44: 2159–2164.
Glass J.D., Wesselingh S.L., Selnes D.A., and McArthur J.C., 1993, Clinical-neuropathologic correlation in HIV-associated dementia. Neurology 43: 2230–2237.
Holtzman D.M., Kaku D.A., and So Y.T., 1989, New-onset seizures associated with human immunodeficiency virus infection: causation and clinical features in 100 cases. Am J Med 87: 173–177.
McArthur J.C., Hoover D.R., Bacellar M.A., et al., 1993, Dementia in AIDS patients: incidence and risk factors. Neurology 43: 2245–2252.
Maruff P., Currie J., Malorie V., et al., 1994, Neuropsychological characterization of the AIDS dementia complex and rationalization of a test battery. Arch Neurol 51: 689–695.
New Mexico AIDS Education and Training Center, 2006, Fact Sheet 505. Dementia and nervous system problems. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised May 15.
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New Mexico AIDS Education and Training Center, 2006, Fact Sheet 516. Progressive multifocal leucoencephalopathy. University of New Mexico Health Sciences Center. www.aidsinfonet.org. Revised February 21.
Sidtis J.J. and Price R.W., 1990, Early HIV-1 infection and the AIDS dementia complex. Neurology 40: 323–326.
Simpson D.M. and Wolfe D.E., 1991, Neuromuscular complications of HIV infection and its treatment. AIDS 5: 917–926.
So Y.T. and Olney R.K., 1991, The natural history of mononeuropathy multiplex and simplex in patients with HIV infection. Neurology 41(Suppl 1): 375.
So Y.T., Holtzman D.M., Abrams D.I., and Olney R.K., 1988, Peripheral neuropathy associated with acquired immunodeficiency syndrome: prevalence and clinical features from a populationbased survey. Arch Neurol 45: 945–948.
Wong M.C., Suite M.D., and Labar D.R., 1990, Seizures in human immunodeficiency virus infection. Arch Neurol 47: 640–642.
Wright E.J., Brew B.J., Currie J.N., and McArthur J.C., 1997, HIV-induced neurological disease. In: Managing HIV (G.J. Stewart, ed.). North Sydney: Australasian Medical Publishing, pp 76–79.
CHAPTER 13
HIV-RELATED PSYCHOLOGICAL DISORDERS
Abstract
The psychological reactions experienced by an individual to the news of HIV positive test result depends on factors such as available social support systems and pattern of coping with major stresses in the past. In order to avoid anticipated social stigma, some individuals deny reality or bear the additional burden of secrecy from family, friends, and colleagues. With the onset of symptoms and visible signs of illness, denial, and secrecy cannot be sustained as coping mechanisms. Some individuals strive to achieve a purposeful life, and associate themselves with self-help groups of HIV-infected persons. There is a need for ongoing guidance after preand post-test counselling sessions. Counselling sessions are also necessary when patients develop new symptoms. Anxiety and stress should be treated. The individual may be referred to organisations that provide counselling and support services. Persons involved in care of HIV patients may also face psychological stress due to the emotionally demanding task of giving bad news, fear of accidental occupational exposure to HIV, distressing manifestations of the disease, and a feeling of powerlessness at the limitations of some treatments. Hence, HIV care providers should take regular breaks, develop a range of professional and personal interests and relationships outside the workplace, recognise early signs of excessive stress and seek support, when necessary.
Key Words
Burnout, Closet homosexuals, Denial, Depression, Dichotomy, Frustration, Gays, Guilt, Impact on providers, Isolation, Secrecy, Social stigma, Withdrawal
13.1 – PSYCHOLOGICAL REACTIONS TO DIAGNOSIS
The reaction of an individual to the news of HIV positive test result involves a sequence of psychological reactions that may require specialist intervention. Diagnosis of HIV positive status precipitates a great amount of changes in life, which has been rated as equivalent to the death of a spouse or a prison sentence. Thus there is a need for preand post-test counselling sessions. Counselling sessions are also necessary when patients develop new symptoms. The individual’s response may depend on factors such as social support system available to the individual and pattern of coping with major stresses in the past. These factors are also predictors of both physical and psychological illnesses (Cohen, 1988). The stages of psychological reactions have been studied in asymptomatic homosexual
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men, but these are similar in heterosexuals and persons infected by non-sexual routes. All individuals do not go through these stages (Ross et al., 1989).
On receiving the news of HIV positive test result, the individual experiences emotional shock, leading to feeling of “guilt” (self-blame) or “denial” (refusal to accept the diagnosis). Due to denial, the individual may get the HIV test repeated at different laboratories hoping for a negative test result. Guilt about their high-risk behaviour (promiscuity or use of injecting drugs) is another source of psychological stress. Once the individual realises the truth, frustration sets in. If the individual knows others who indulge in the same type of highrisk behaviour but are HIV negative, the reactions vary from anger, distress, feeling of powerlessness, and blaming one’s fate or destiny. “Dichotomy” is an issue to be tackled. People are seen as infected (“us”) and non-infected (“them”) and responded accordingly. For such persons, HIV status becomes the central defining issue in life. On realising the gravity of the situation and the ultimate outcome of the condition, the person may go into depression. Worry about social stigma leads to withdrawal and isolation. The individual may start worrying about his or her spouse and family members and may have fear of infecting others.
13.2 – DENIAL
Some individuals cope with early HIV infection by denying its reality. The onset of symptoms and visible signs of illness creates a situation of disclosure and denial is difficult to sustain as a coping mechanism. Dealing with loss of denial is equivalent to dealing with emotional shock at the time of diagnosis. If the diagnosis of HIV infection has not been revealed to family members and close contacts, it can create psychosocial problems, both at home as well as at the workplace, and aggravate the stress experienced by the patient.
13.3 – EFFECT OF SOCIAL STIGMA
Family members and close friends may not be aware of sexual habits of some male homosexuals (also called “gays”). These persons have been called “closet homosexuals”. Such persons may not be able to share the news of their HIV positive test result with their family members and close friends. This leads to lack of social support that aggravates their stress. The social reality is that people generally react to HIV-infected persons with fear and prejudice. Homosexuals and drug users are socially marginalised and stigmatised. Irrespective of mode of infection, HIV positive individuals suffer from the prejudiced assumption that they may have been infected through “deviant” or illegal activities. This assumption challenges the social identity of persons who may have been infected by heterosexual contact or through medical interventions such as blood transfusion. Anticipation of social discrimination complicates the psychological response to the news of HIV positive test and affects the person’s ability to cope.
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It may damage self-esteem of HIV-infected persons and may cause or worsen feeling of depression. In order to avoid anticipated social stigma, some individuals bear the additional burden of secrecy from family, friends, and colleagues (Miller, 1987).
13.4 – LIVING WITH HIV
A great amount of courage is required to face a disease that seems to have no cure so far. Many HIV-infected people experience fear, anxiety, hopelessness, loneliness, and depression. Some patients accept their diagnosis and come to terms with their condition. During the time period between diagnosis and the onset of serious illness, some strive to achieve a purposeful life. They may test the reactions of others; look for other HIV positive persons for sharing and positive reinforcement (Miller, 1987). Group cohesiveness leads to altruistic behaviour and a feeling of belonging to the group. These groups usually have a positive attitude to being HIV positive and also have role models that are open about their HIV positive status. Some individuals select their sexual and other partners only from within the community of infected persons. This solves problems like fear of rejection by a prospective partner and of transmitting HIV to an uninfected partner (Miller, 1987). Though yoga cannot replace professional counselling, yoga techniques are known to help in reducing excessive fear and anxiety, and learning stress-coping skills. Meditation helps in self-awareness and in building inner strength through relaxation.
13.5 – ROLE OF THE DOCTOR
The infected persons experience considerable anxiety about becoming dependent on others for basic physical care and stress related to actual or anticipated discrimination or abandonment. Psychological reactions such as denial, anger, and depression that occur in HIV-infected individuals may result in lack of trusting relationship with health care providers and missed opportunities for prevention and treatment of opportunistic infections. Psychological reactions such as shock, denial, and depression also occur in family members and may affect their ability to care for the HIV-infected person. Hence, family members also need to be considered while managing the HIV-infected individual. It is the responsibility of the doctor to provide accurate HIV-related information, address and treat anxiety and stress, and refer the patient to organisations that provide counselling and support services (Miller, 1987).
It is essential that the patient be fully informed so that both the doctor and the patient make their decisions with full knowledge of the circumstances. Lack of rapport between the doctor and patients results in poor compliance with prescribed treatment, visits to multiple doctors who may use multiple drug regimens, and self-medication with traditional or alternative medicines that lead to interactions.
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13.6 – SYMPTOMATIC HIV INFECTION
The emotional and psychological conflicts are related to changes in life circumstances caused by symptomatic illness and can be as varied as the symptoms themselves. The social support systems that worked well before the onset of symptoms may become irrelevant. The responses may include fear, anxiety, and uncertainty about dependence on others, depression, and suicidal ideas. The psychological state can affect the quality of life beyond the impact of physical illness. The patients and their family members usually experience these psychological problems during the phase of recovery, when investigations and medical interventions do not distract them. These problems may also manifest when the patient is discharged from the hospital. Hence, the family physician may have to provide patients and their family members with support and interventions that include: (a) information on likely opportunistic infections, (b) information on legal issues (Will, pensions, and power of attorney), and occupational issues (sick leave, loss of capacity to work), (c) psychiatric interventions including specific counselling, and (d) spiritual support. If the patient and family members are mentally primed to deal with symptomatic illness, the onset of symptoms may have a positive impact because they can prepare themselves for further significant changes in life. When HIV seropositivity is discovered late in the course of an illness, the psychological stress may be aggravated and coping becomes more difficult (Kelly et al., 1997).
13.7 – PSYCHOLOGICAL IMPACT ON PROVIDERS
13.7.1 – Psychological Stress
Persons caring for HIV patients may face psychological stress due to the emotionally demanding task of giving bad news such as HIV positive status and likelihood of death, fear of contracting HIV infection through accidental occupational exposure, the distressing nature of manifestations of the disease, increased scrutiny by consumer rights organisations and AIDS activists, and a feeling of powerlessness at the limitations of some treatments (Kelly et al., 1997).
13.7.2 – Burnout
“Burnout” refers to physical and emotional symptoms caused by task-related stress (Ross & Seeger, 1988). This condition is caused by working harder for long periods of time, without being able to set reasonable time limits. This leads to development of indifference and negative attitudes. Burnout may lead to feeling of lack of personal accomplishment; emotional exhaustion or emotional numbness, depression, and anxiety; antagonised relationship with patients; and estranged family relationships. Health care personnel should be aware of these problems and be able to take preventive measures and seek assistance if required.
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13.7.3 – Coping Strategies: Dos and Don’ts
●Set limits to occupational commitment that one can take.
●Take regular breaks (clearly defined work-free time, holidays).
●Maintain personal interests such as hobbies, physical exercise, and relationships outside the workplace.
●Recognise early signs of excessive stress, and seek advice and support from friends and colleagues.
●Avoid using self-medication such as sedatives or alcohol to cope with symptoms of stress.
●Develop a range of professional interests to balance the intensity of occupational commitment and avoid professional isolation.
●Participate in institutional activities that promote healthy coping – continuing medical education (CME), in-service training, and team meetings (Kelly et al., 1997).
REFERENCES
Cohen L.H., 1988, Life events and psychological functioning. Newburg Park, CA: Sage. Cited in: Kelly et al., 1997.
Kelly B.J., Todhunter L., and Raphael B., 1997, HIV care: impact on the doctor. In: Managing HIV (G.J. Stewart, ed.). North Sydney: Australasian Medical Publishing.
Miller D., 1987, Living with AIDS and HIV. London: Macmillan.
Ross M.W. and Seeger V., 1988, Determinants of reported burnout in health professionals associated with the care of patients with AIDS. AIDS 2: 395–397.
Ross M.W., Tebbie W.E.M., Vilunas D., et al., 1989, Staging of psychological reactions to HIV infections in asymptomatic homosexual men. J Psychol Human Sexol 2: 93–104.
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CHAPTER 14
CO-INFECTION WITH HIV AND TUBERCULOSIS
Abstract
As compared to their HIV negative counterparts, HIV positive individuals infected by Tubercle bacillus, have about 10 times higher risk of progression from latent to clinically active tuberculosis. In India, the strategy of HIV testing of all newly diagnosed tuberculosis patients is neither feasible nor cost-effective, due to the large number of new cases of tuberculosis that are detected each year. The standard treatment regimens used in the Revised National Tuberculosis Control Programme (RNTCP), are equally effective in HIV positive patients. Directly Observed Treatment, Short Course (DOTS) strategy has been shown to improve survival of patients with co-infection. Concurrent treatment with protease inhibitors can either reduce activity or prolong half-life of rifampicin. Chemoprophylaxis against tuberculosis is currently not recommended in India.
Key Words
Adult tuberculosis, ART in tuberculosis, BCG vaccine, Childhood tuberculosis, DOTS, Ghon focus, Granuloma, Immune reconstitution syndrome, Langhan’s giant cells, Mantoux test, Multi-drug resistance, Post-primary infection, Primary infection, Primary complex, RNTCP, Tubercle
14.1 – MAGNITUDE
14.1.1 – Tuberculosis
Currently, tuberculosis is the single biggest infectious disease that kills about 2–3 million persons worldwide each year. Annually, about 8 million new cases are diagnosed. The global incidence of tuberculosis is increasing at the rate of 0.4 per cent per year. Globally, the economic cost of tuberculosis is estimated at US$12 billion. Despite the availability of effective drugs, tuberculosis remains a global health challenge. In 1993, the WHO declared tuberculosis a global emergency (Health Action Information Network – HAIN, 2003). The re-emergence of tuberculosis in the developed countries in the 1990s is attributed to the HIV epidemic and environmental and social changes. The advent of HIV epidemic and multi-drug resistant (MDR) strains of tuberculosis has made the re-emergence of tuberculosis even more dangerous (HAIN, 2003). In 2001, the WHO drafted a “Global Plan to Stop TB”. The plan seeks to expand the DOTS approach and to
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