Since releasing its 2000 Practice Guideline for the Treatment of Patients with HIV/AIDS, the American Psychiatric Association has provided updated guidance for treating this disease that has shifted epidemiologically.
According to the updated guideline, there also has been a change in the HIV/AIDS patient population in recent years. Previously, the epidemic was seen mostly in men who have sex with men, intravenous drug users, pregnant or breast-feeding women, and blood-transfusion recipients. Since the 2000 guideline, there has been increased prevalence of the disease in patients who have unprotected sexual intercourse. Although the main transmission routes are via MSM and intravenous drug use, heterosexual sex is the most common means of transmission for women. Evidence culled from recent studies increasingly suggests that hidden risk behaviors by male partners, particularly homosexual sex, are a significant source of transmission to women.
For this reason, the updated guideline emphasized that psychiatrists should evaluate specific HIV risk factors in their patients, rather than making assumptions based on known lifestyle practices or marital status.
The guideline update cited changes in the Department of Health and Human Services’ guidelines for antiretroviral therapy in treating HIV/AIDS. The update discussed a new class of antiretroviral medications, fusion/entry inhibitors, and the emergence of combination antiretroviral therapy (CART).
The document also was updated to reflect the introduction of non-nucleoside reverse transcriptase inhibitors to the market, specifically nevirapine, delavirdine and efavirenz. These drugs often are used for treatment-naive patients as first-line therapy. The use of protease inhibitors is reserved for cases where other treatments have failed, due to the association of these drugs with development of metabolic syndrome.
While associated cognitive-motor disorders in HIV/AIDS patients are common, the updated guideline noted that HIV-associated dementia has been significantly decreased with the advent of CART. Patients with cognitive-motor disorders may benefit from early CART, as well as adjuvant treatment of symptoms affecting the central nervous system.
The guidelines also outlined changes in the classifications of neurocognitive impairments. Under these changes, what was previously known as “HIV-associated minor cognitive-motor disorder” is now termed mild neurocognitive disorder; “AIDS dementia complex” is now classified as HIV-associated dementia; and “cognitive-motor disorder” has been changed to neurocognitive disorder.
The guideline cited data suggesting that depressive symptoms affect nearly 50% of HIV patients, and depression often goes undetected in this population. The document recommended the use of psychotherapy and psychopharmacology for these patients.
HIV-related mood disorders, such as bipolar disorder and psychosis, also are common, according to the guideline. In these cases, the mood stabilizer divalproex sodium appears to be well tolerated and does not increase disease burden or viral load.