The changing profile of mental health problems in people with HIV

HIV affects 33.2 million people worldwide, including 2.5 million children. An estimated 77,000 people are affected in the UK, a quarter of whom are unaware of their diagnosis; each year there are more than 7000 new cases. HIV results in slowly progressive immunodeficiency and/or progressive neurodegeneration. Disease markers are CD4 count and viral load. With a CD4 count below 500 cells/ml, generalized symptoms of decreased immunological function occur including fatigue and minor cognitive decline. With a count below 200 cells/ml, opportunistic infections, neoplasms, and HIV-related dementia develop. When the count falls below 50 cells/ml, fatal HIV-related illnesses develop. HIV is treated with three main classes of antiretroviral; often three or more drugs are required. Antiretroviral treatment may cause psychological symptoms, particularly mood and sleep problems. In resource-rich countries with access to antiretrovirals, HIV has become a chronic disease, altering the profile of associated mental health problems. Organic problems such as encephalitis, meningitis and other deliriums, and dementia have declined, as have adjustment disorders and manic presentations. Depression and anxiety have increased and problems specific to survival, adherence, and risk-reduction behaviours have emerged. Psychosexual problems are also important. Certain groups are particularly vulnerable to contracting HIV; amongst them are people with pre-existing psychiatric problems and drug use. A wide range of psychological and pharmacological treatments is available, some of which are HIV specific. Caution should be exercised in prescribing psychotropic medication because of the potential difficulties that can arise from interactions with antiretrovirals, not least the reduction in efficacy of antiretroviral medication.