Psychological Dimension of HIV/AIDS and Recent Advances in Its Management

HIV as a chronic illness is manageable but not curable. Psychiatric disorders not only act as risk factors for HIV infection but also result from the diagnosis of HIV infection. The psychiatric disorders range from anxiety, depression to neurocognitive disorders. The diagnosis also means psychological and emotional effects on the patients and the caregivers. This requires that biopsychosocial perspective be employed in managing such patients for better treatment adherence and increased quality of life. There are various psychological interventions available like cognitive behavior therapy, group therapy, mindfulness based therapy etc. Despite wide prevalence of such problems present in India, very few clinicians are aware of these psychological interventions and make them available to the patients.

share needle, more likely to have higher number of lifetime sexual problems, more likely to engage in unprotected anal sex.

HIV/ AIDS AND PSYCHIATRIC DISORDERS
30-60% lifetime prevalence of psychiatric disorders has been reported in HIV patients (Atkinson et al.,1988;Morrison et al 2002). Higher prevalence of psychiatric disorders was found in patients with HIV as compared to the general population (Ahuja et al., 1998).

Stages Disorder
Stage I

'AIDS' phobia
It is the fear of contracting HIV infection, despite the negative test results. Patients with hypochondrias are or OCD may present with a fear of developing / having AIDS as a complaint. Sometimes, this is related to guilt over unprotected intercourse, misinformation and inadequate knowledge. It has been associated with anxious temperament and is more among those with health anxiety.

Depression
In the study on prevalence of psychopathology 36% of the patients tested positive for major depression and 27% for dysthymia (Bing et al., 2001). There has been found increase in depression in HIV infected individuals in recent studies (Nakimuli, 2011) Depression has a negative impact on adherence with medical treatment, quality of life and treatment outcome.
HIV increases the risk of developing major depression through direct injury to subcortical areas of brain, chronic stress, worsening social isolation and intense demoralization.

Mania
Mania can occur in conjunction with bipolar disorder or HIV infection of the brain. Mania occurring early is likely to be due to an underlying bipolar disorder. Mania occurring late in the course of illness ("AIDS mania") is probably due to HIV infection of the brain.
The prevalence of mania is reported to be significantly increased in patients with AIDS compared to the general population (Lyketsos et al., 1993;Ellen et al., 1998).
HIV-associated mania is different from mania with bipolar disorder: more irritability, less hyper talkativeness, more psychomotor slowing and cognitive impairment

Psychosis
Psychotic symptoms can appear as a part of delirium, dementia or any other organic brain syndrome. Drug-induced psychosis is a common cause. 0.2% -15% of patients with HAD develop psychotic symptoms (Sewell, 1996)

HIV associated neuro-cognitive disorders (HAND)
There is high prevalence of milder forms (HIV-associated asymptomatic neurocognitive impairment (ANI) and HIV-1-associated mild neurocognitive disorder (MND) in patients treated with combination antiretroviral therapy (Heaton et al., 2010). Highly active antiretroviral therapy (HAART) substantially decreases the occurrence of dementia.  (Perry, 1990). HIV increases chances of delirium (Sonneville , 2011). It has a high mortality rate and requires immediate treatment. It is characterized by: inattention, disorganized thinking or confusion, fluctuations in levels of consciousness, presence of emotional changes and hallucinations and delusions.

Sleep disorder
Studies have found high sleep disturbances among HIV infected persons (Reid et al., 2005;Crum-Cianflone et al., 2012). Sleep disturbances have been noted to appear soon after initial HIV infection and continue throughout the course of the disease (Cruess, et al., 2003).

Suicide
A study by Chandra et al., 1998 revealed persistent suicidal ideations in 14 per cent, death wishes in 20 per cent and suicidal attempts in 8 per cent HIV patients (Chandra et al., 1998). Suicide rates are found to be 10 times higher as compared to general population (Catalan et al., 2011). Suicidal behaviors in PLWH may be associated with an initial HIV or AIDS diagnosis, advancing disease, symptoms of illness, psychiatric disorders, and substance use . Suicidality may be the direct physiological result of HIV or a reaction to chronic pain, or an emotional reaction to having a chronic and life-threatening illness.

MANAGEMENT
Combined Pharmacological and psychological interventions are both important in these patients to deal with mental health problems. Psychological interventions focus on the individual as well as the caregivers. It deals with the symptoms like depression; anxiety etc. and helps the client and family in dealing with the emotional reactions to the diagnosis. Better mental health may in turn lead to reduction in risk behaviours and improvement in HIV treatment adherence which eventually increases their quality of life (Sikkema et al., 2010).
In the therapy the start of session includes an assessment and discussion of HIV medication adherence and current mood. Motivational interviewing and psycho education is to be done next. Activity scheduling, problem solving training and relaxation and diaphragmatic breathing are the other steps.

Group therapy
Group interventions provide a range of therapeutic processes, both general and specific (Burlingame et al., 1995). Groups offer a forum for peer support, a sense of universalism or shared experience, and an opportunity to learn from others facing similar challenge. Peer support and modeling contributes to new coping resources and self efficacy (Fawzy et al., 1996). A support group has the beneficial effect of moderating the patient's sense of isolation by providing a new social network.

Supportive-expressive group therapy
Each supportive-expressive therapy group is led by two therapists. The therapist should have training and experience in psychotherapy or group therapy, as well as training and experience in psychosocial support for patients with life-threatening illnesses or medical management of HIV disease. He should also have at least minimal knowledge of HIV infection, medical complications and treatments, as well as treatment side effects. He should also have the ability to establish and maintain rapport, instill confidence in his or her ability, and display appropriate warmth and caring.
The goals of the therapy is to facilitate mutual support among group members and reduce isolation and improve social and family support/ decrease feelings of loneliness and guilt. The therapy promotes greater openness and emotional expressiveness both within and outside the group and facilitates the integration of a changed self and body image into the patient's current view of self. It also aims to improve coping skills and normalization of experiences, detoxify feelings around death and dying, help patients develop a life project, promote safer sexual practices, and enhance quality of life and greater authenticity.
In a study on older adults with HIV it was found that tele-supportive expressive group therapy reduces more depressive symptoms as compared to a standard of care at post intervention and at 4 and 8 month follow up (Timothy et al., 2013)

Guided imagery
It is a mind-body technique involving the deliberate prompting of mental images, used in the treatment of mental disorders, for performance enhancement, and in helping patients cope with diseases and their symptoms.
In a study by Simonton et al., 1978 surprising results were found in terms of unexpected longevity and improved immune activity as a result of relaxation techniques and imagery

Psychological Dimension of HIV/AIDS and Recent Advances in Its Management
© The International Journal of Indian Psychology | 172 (Simonton et al., 1978). In a study including bi-weekly sessions of biofeedback/progressive muscle relaxation, hypnosis and meditation found improvement in the immunity in patients with HIV (Taylor, 1995).

Acceptance based behavior therapy
HIV/ AIDS patients tend to employ avoidance based coping due to fear of stigmatization and judgement. Avoidance-based coping is associated with lower adherence (Amir, 1997) and higher levels of distress (Thompson et al., 1992).
Acceptance based behavior therapy (ABBT) fosters the ability to accept distressing subjective experiences (thoughts, feelings, sensations, memories, etc.) without efforts to avoid, escape, or otherwise change the content of such experiences.
A pilot study was done by  to see the effect of ABBT to increase HAART adherence in HIV patients and found positive results in this regard .

Art therapy
It is based on the belief that the creative process involved in the making of art is healing (Nainis et al., 2006). It lowers stress and gives patients an alternative focus other than their illness (Malchiodi, 1998). Studies suggest that art therapy can lead to increased awareness of self, as well as improved ability to cope with symptoms, stress, and traumatic experiences (American Art Therapy Association, 2003).
It may enhance the effects of pain medication through disassociating pain from psychological distress (Malchiodi, 1998). Hrenko (2005) found that art therapy was valuable for children diagnosed with HIV/AIDS in a therapeutic day camp. Another study found that art therapy was helpful for Native Americans living with HIV/AIDS who had difficulty articulating these emotions (Bien, 2005). In a study on HIV patients it was seen that one session art therapy resulted in improvement in symptoms associated with HIV/AIDS (Rao et al., 2009).

Dance therapy
Dance movement therapy (DMT) is a science and an art that involves the use of nonverbal communication through the medium of movement and dancing (Boris, 2002). Dance therapy provides an outlet for sadness, fear anger and joy (Levy, 1988). It has shown beneficial effects on immune functioning (Keller, 2002)). DMT enhances self esteem, greater social support and an increased sense of self control (Bojner et al., 2003) and a greater ability to cope with stressful life events (Kober, 1988) A study by Fairfax et al., 2003 found that DMT has a positive impact on Quality of life of individuals with clients with co-occurring HIV, addiction, and mood disorders (Fairfax et al., 2003).

Psychological Dimension of HIV/AIDS and Recent Advances in Its Management
© The International Journal of Indian Psychology | 173

Music therapy
Music therapy uses non-verbal communication as a mode of interacting and expressing of emotional states, and as the basis for developing a meaningful relationship (Ansdell, 1995;Pavlicevic,1997). It requires the implementation of a music intervention by a trained music therapist, the presence of a therapeutic process, and the use of personally tailored music experiences.
These music experiences include listening to live, therapist-composed, improvised, or pre recorded music; performing music on an instrument; improvising music spontaneously using voice or instruments, or both; composing music; and music combined with other modalities (e.g., movement, imagery, art) (Dileo 2007).
Studies have reported that music therapy was effective for enhancing spirituality (Wlodarczyk 2007), reducing tiredness and drowsiness (Horne- Thompson 2008), and alleviating discomfort and sadness (Nguyen 2003).

Mindfulness based therapy
Mindfulness-based interventions (MBIs) are focused on the cultivation of self-regulated attention, acceptance and openness to experiences gained through reflective structured exercises/practices like meditation or yoga. Most commonly used MBIs include mindfulnessbased stress reduction (MBSR) and cognitive therapy (MBCT). MBSR programs have been found to be effective in reducing stress and anxiety and have elicited positive physical outcomes in people living with HIV An RCT with 76 participants compared MBSR to participants on a wait list and found reduced frequency, severity and distress from symptoms resulting from anti-retroviral therapy (ARTs) (Duncan et al., 2012).
Two small studies (one a RCT and one a pilot study) found that HIV positive participants receiving MBSR (Creswell et al., 2009) or practicing mindfulness meditation (Jam et al., 2010) over the course of 8 weeks stabilized or increased their CD4 counts.
Another RCT comparing MBSR to participants receiving treatment-as usual found that MBSR reduced avoidance and improved positive affect in HIV+ gay men who had previously reported difficulty in coping with their HIV and suffered from moderate to severe distress (Gayner, 2011). A study found MCBT as useful in reducing emotional disturbance symptoms (internalizing problems, depression, anxiety, hopelessness, and perceived stress) in HIV/ AIDS affected adolescents (Sinha, 2010).