Abstract

Present day research programmes have shown that the life expectancy of people living with HIV has increased. The increased life expectancy is due to the advent of antiretroviral therapy that was introduced by researchers not so long ago. Even though life expectancy has gone up, medical practitioners have had several encounters with the neuropsychiatric presentation of HIV.  The HIV- triggered neurotoxin cascades present in the central nervous system (CNS) has presented various patients with cognitive deficits. The illness presents patients having depression in the early stages as well as in the critical full-blown stages whose pathogenesis has not been able to be clearly stated. The various Psychological disorders among patients can result in severe conditions that may predispose the patient to insanity and even death. It is therefore essential to have a better understanding and awareness of these neuropsychiatric manifestations even as the quality of life becomes advanced when it comes to managing the chronic disease.

Keywords: HIV, Antiretroviral, Neurocognitive, Central Nervous System (CNS), Minor cognitive and minor dysfunctions (MCMD)

Introduction

More than forty people all over the world are estimated to be living with HIV with the most common being HIV type 1 (De Almeida, Kamat, Cherner, Umlauf, Ribeiro, De Pereira, and Ellis, 2017). This report is one that was given by the Joint United Nations Program. Approximately five hundred and forty thousand adult and one million children in North America are said to be living with the disease (De Almeida et al., 2017).  The number of women infected with the virus across the world has also rapidly increased over the past few years. As a result of the rapid increase, women have accounted for half of the world’s population living with the disease. Life expectancy has improved; however after the introduction and advancements in treating the illness. Despite these improvements, medics are still having a problem of dealing with psychiatric manifestations of the disease in the neurons of the patients. Minor cognitive and motor disorder (MCMD) and HIV- associated dementia (HAD) are the most common forms of neurological manifestations. Clinicians should practice appropriate intervention such as early diagnosis on seropositive patients exhibiting these syndromes. In this article, we are going to look at some of the neuropsychiatric manifestations of HIV as well as treatment methods and diagnosis.

Etiology of the disease

In 1981, researchers reported the first cases of HIV. Two years later, there was an identification of the virus and reported. However, in the early stages of the disease, various neurological conditions were able to be detected. Research has shown that HIV can cross into the blood-brain barrier. The crossing over is because HIV can be secluded from the cerebrospinal fluid (CSF) and can also exist in the brain tissue. HIV-associated dementia incidences were reported to be approximately twenty cases per a thousand person-years. With the invasion of the highly active antiretroviral therapy (HAART) in the late 1990S, the cases dropped to around ten per a thousand person-years. There was also a significant reduction in opportunistic infections in the central nervous system (CNS) (Woods et al., 2016). Other qualified researchers also noticed a reduction in the spread of opportunistic nervous infections.  The HIV prevalence, however, was detected after an autopsy report to have increased after the invasion of the antiretroviral therapy. This increase clearly shows that there was a continuous infiltration of HIV in the central nervous system despite the improvement in therapeutic alternatives. HIV moves over the blood-brain barrier by a mode of a mechanism known as the Trojan –horse. After finding its way to the brain, the virus moves to the glial cells, secreting neurotoxins that bring about damages in the neurons and even death. The clinical neurological deficits determine the extent to which the neurons have suffered damage (Woods et al., 2016). Autopsy reports on HIV positive patients have reported the presence of the virus in cortical as well as subcortical structures. The structures are namely the frontal lobes, the basal ganglia, and the subcortical white matter. Other studies believe that the primary areas for the pathogenesis of the HIV infection are the basal ganglia and the caudate nucleus.

Individuals with severe neurocognitive deficits or HIV-associated dementia have been found to exhibit HIV viral load and higher plasma levels. HIV viral loads in the plasma are more or less the same as those present in serum. Even though HIV may remain inactive in the central nervous system, its existence may lead to a reduction in cognitive operations. These deficits fail to show in some patients, and as a result, many researchers suggest that there might be involvement in external triggers (Woods et al., 2016).  For the determination of which group of people is more susceptible to neurological conditions, extensive research should be carried out. Indirect and direct effects of HIV on the CNS lead to neurocognitive deficits. For asymptomatic patients, there is conflicting evidence on whether there is an existence of similar deficits.        Some researchers have found neuropsychological deficits in asymptomatic individuals while others have detected almost the same levels of neurocognitive impairment in the seropositive and negative patients (Woods et al., 2016). Research, however, reveals that, when there is a presence of deficits in asymptomatic patients, they are limited to lesser cognitive domains. Psychomotor retardation due to depressive symptoms results in deficits in verbal and memory.

On the other hand, the absence of depressive symptoms results in deficits in verbal and non-verbal cognitive domains. The progression of HIV results in the impairment of additional cognitive domains. The existence of HIV in the frunto- subcortical system as well as its harmful impact on functioning memory suggests that the official function is also impaired. Memory and learning are also affected by the process. Psychomotor retardation or slowness is the most prominent and common neurocognitive deficit (De Almeida et al., 2017). It is possible to see the cognitive with or without normal functioning of the motor. It is therefore essential to assess the HIV-seropositive patients for these neurocognitive impairment types. This assessment should be carried out in the presence or behavioral indications. Several diagnostic criteria for HIV associated dementia (HAD) as well as the MCMD have been put forth by the American Academy of Neurology. MCMD is perceived to be a lesser form of HAD while HAD on itself is considered to represent neural death. MCMD represents neural dysfunction. CNS pathology must be ruled out because both HAD and MCMD are diagnoses of exclusion.

There is a need to examine tumors, CNS infectious pathogens as well as encephalopathy causes. Researchers and clinicians should conduct this examination before attributing the cognitive and motor deficits to HIV infection. Progressive multifocal leukoencephalopathy, as well as toxoplasmosis, are the most common CNS infections. They are brought about by papovavirus. The ruling out of opportunistic infections brings about two potential therapeutic options for neurocognitive deficits: Removal of the viral effects on the CNS through advanced control of viral load or development of neuroprotective agents to protect the CNS from coming in contact with HIV-induced low virotoxins (López et al., 2017). Antiretrovirals are not always guaranteed to cross over the blood-brain- barrier. However, by the reduction of HAD after the introduction of the antiretroviral therapy (HAART) excellent results have been achieved.

Symptoms and cause

HIV infection brings about various psychiatric conditions. The recognition of the mental states may, however, be complicated. The complexity is as a result of social and psychological circumstances linked with the disease (Lopez et al., 2017). Psychiatric symptoms may go unnoticed and hence untreated. HIV patients may develop certain conditions that end up interfering with the CNS. Depression being one of the mental disorders may be brought about by mortality rate among the seropositive women living with HIV as well as the progression of the disease in seropositive men. Conditions such as psychosis and mood disorders may arise as a result of this condition. Depression again comes as a result of failing to accept the situation. Stigmatization of HIV patients in society makes them feel sidelined in the community. The feeling of being sidelined may force individuals to develop self-hatred and disgust and may end up developing suicidal thoughts (López et al., 2017). A lot of individuals tend to associate HIV with death and immorality and carelessness. Therefore the person who has just received a diagnosis of the disease is more likely to fall into a depression as a result of mental conflicts. Depression remains undiagnosed and uncontrolled in the HIV- infected group. When it comes to HIV, depressive diagnosis disorders can be severe.  This challenge is as a result of vegetative symptoms like insomnia, Alzheimer’s, amnesia and fatigue in most of the HIV patients even in the absence of depression (Marin-Webb, V, Jessen, Kopp, Jessen, and Hahn, 2016). These symptoms, however, relate with more of mental disorder than with clinical correlations of the disease. Therefore it is essential for clinical detections on the depressive symptoms to be established. The treatment of depressive symptoms has been found to improve the psychological functioning as well as the quality of life for the patients.

Mania is another psychological disorder associated with HIV infection. The increase in mania cases links to cognitive changes or dementia. Mania or insanity is considered a secondary syndrome due to HIV attack on the CNS. It may also be referred to as AIDS mania and is a phenomenologically different condition from the typical manic syndrome. Clinicians associate a typical manic syndrome with bipolar disorder in its severity as well as symptom profile.

Psychosis is yet another disorder related to HIV-dementia in the CNS. Antiretroviral may at times precipitate psychosis, but it is not a common phenomenon. Psychosis was predominantly detected in patients having neurocognitive impairments related to AIDS (Marin-Webb et al., 2016). Navia and price used chart reviews to find out that 15% of a possible 46 patients with HIV-associated dementia experienced symptoms of psychosis (Price, Bartlett and Bloom, 2016). Psychosis can have detrimental results on the patients as it may cause them to lose themselves and their sanity.

Treatment options

The Psychiatric manifestation of HIV infection can. Trycyclin antidepressants (TCA) should be administered to HIV-seropositive patients (Woods et al., 2016). The FDA has provided positive reports on the efficacy and safety of the tricyclic antidepressants. Imipramine being one of the TCA has been found very useful in depression treatment. Clinicians are also advised to provide HIV patients with mood stabilizers as the FDA has also accepted them for efficacy (Price et al., 2016). The knowledge on the influence of various agents on the general metabolism of the drug is essential even as medical practitioners administer the mood-stabilizing medicines to HIV patients. Carbamazepine being a mood-stabilizing drug may react with antiretroviral. The use of antipsychotic agents may as well be used to treat neurological disorders resulting from HIV. The method of these antipsychotic agents is not well studied and further research ought to be conducted to establish a familiar ground. The healing process also depends on how the patients choose to cope with the disease (Marin-Webb et al., 2016). Psychological therapies and counseling come in handy in such a situation. The patients should be made aware that they can as well live with the disease without necessarily letting the whole thought of death go into their subconscious.

Conclusion

In conclusion, individuals living with HIV are more privileged when it comes to life expectancy than in the olden days. The recent advancement in the antiretroviral has made things better for them. The relations in the immune system the neuropsychiatric symptoms and the neuroendocrine symptoms remain undefined, neuropsychiatric emergence complications in HIV can have detrimental consequences if not correctly identified. Careful diagnosis should be carried out on the patients to avoid complications. Patients diagnosed with HIV should accept their situations and deal with them. Psychologists should conduct thorough counseling on the patients just for the sake of their sanity. HIV is not a death sentence. It can be addressed and managed to ensure a prolonged life expectancy as well as a sound sense of judgment amongst the people living with it.

References

De Almeida, S. M., Kamat, R., Cherner, M., Umlauf, A., Ribeiro, C. E., de Pereira, A. P., … & Ellis, R. J. (2017). Improving detection of HIV-associated cognitive impairment: comparison of the International HIV Dementia Scale and a Brief Screening Battery. Journal of acquired immune deficiency syndromes (1999), 74(3), 332.

López, E., Steiner, A. J., Smith, K., Thaler, N. S., Hardy, D. J., Levine, A. J., … & Goodkin, K. (2017). Diagnostic utility of the HIV dementia scale and the international HIV dementia scale in screening for HIV-associated neurocognitive disorders Applied Neuropsychology: Adult, 24(6), 512-521.

Marin-Webb, V., Jessen, H., Kopp, U., Jessen, A. B., & Hahn, K. (2016). Validation of the international HIV dementia scale as a screening tool for HIV-associated neurocognitive disorders in a German-speaking HIV outpatient clinic. PloS one, 11(12), e0168225.

Price, R., Bartlett, J., & Bloom, A. (2016). HIV-associated neurocognitive disorders: epidemiology, clinical manifestations, and diagnosis. UpToDate Web site https://www. uptodate. com/contents/HIV-associated-neurocognitive-disorders-epidemiology-clinical-manifestations-and-diagnosis.

Woods, S. P., Iudicello, J. E., Morgan, E. E., Cameron, M. V., Doyle, K. L., Smith, T. V., … & Ellis, R. J. (2016). Health-related everyday functioning in the internet age: HIV-associated neurocognitive disorders disrupt online pharmacy and health chart navigation skills. Archives of Clinical Neuropsychology, 31(2), 176-185.

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