HIV/AIDS psychiatry – a paradigm for HIV prevention and integrated compassionate care
Authors: Mary Ann Adler Cohen, Getrude Makurumidze, Luis F. Pereira, James A. Bourgeois, Kelly L. Cozza
Journal: World Psychiatry (2019)

The WPA Section on HIV/AIDS Psychiatry defines its field as the subspecialty of consultation-liaison psychiatry that focuses on prevention, care and treatment of HIV and AIDS; psychiatric aspects of risk behaviors and their antecedents; psychiatric manifestations of HIV and its stigma; psychological consequences of HIV infection and its multimorbidities, and their impact on persons infected with and affected by HIV; and the imperative for an integrated biopsychosociocultural approach to prevention, care and adherence1. In 1981 AIDS was a novel, severe, complex and devastating fatal systemic illness of unknown cause characterized by immune suppression, multimorbid opportunistic infections and cancers, and psychiatric disorders including dementia. Our contemporary definition takes into account the remarkable strides that have transformed AIDS into a preventable and manageable chronic illness for persons with access to HIV medical care and treatment with antiretrovirals. However, if HIV medical care is unavailable and/or psychiatric illness impedes access to diagnosis and treatment, persons with HIV are vulnerable to unnecessary and avoidable suffering and progression of illness, as was common in the early stages of the HIV epidemic. Despite progress in HIV prevention, di-agnosis and treatment, 36.9 million people are living with HIV worldwide and 1.8 million become infected with HIV each year2. Of 36.9 million persons living with HIV, an estimated 9.4 million are unaware that they are infected and can unknowingly transmit the virus to others2. As the HIV pandemic ends its fourth decade, psychiatrists and allied mental health professionals can play a role in both prevention of HIV and compassionate care of persons infected with HIV and its stigma. HIV/AIDS is a highly stigmatized preventable illness caused by a virus and most commonly transmitted through risky human behaviors. The HIV pandemic is catalyzed and maintained by psychiatric disorders which can be vectors of HIV transmission and barriers to treatment adherence. HIV prevention and care are relevant at many points throughout the life cycle. Psychiatric treatment has a significant impact on morbidity and mortality and special implications for public health and general medical and mental health care1. Psychiatrists are in a unique position to mitigate HIV risk behaviors, minimize risk of HIV transmission, and provide education and psychiatric care to improve HIV diagnosis and treatment. All psychiatrists in clinical practice can play a direct role in HIV prevention by including HIV testing as part of routine evaluation of every patient. Through encouraging routine HIV testing, psychiatrists can improve diagnosis in persons living with HIV and begin to normalize HIV testing. Awareness of HIV status through routine testing can lead to early initiation of antiretroviral therapy and thus reduce morbidity, suffering and mortality as well as HIV transmission. People living with HIV who adhere to antiretroviral therapy and have achieved viral suppression with an undetectable viral load cannot transmit HIV sexually. This is the premise behind the Undetectable equals Untransmittable (U=U) initiative. The U=U message embodies the concept of treatment as prevention and enables persons with sustained viral suppression to live without fear of transmitting HIV. The knowledge that U=U can help reduce fear and stigma associated with HIV3. Psychiatrists routinely take psychosocial, trauma, substance use and sexual histories and evaluate for psychiatric disorders, and can refer HIV negative persons who are at substantial risk of infection for evaluation for pre-exposure prophylaxis (PrEP)4, 5. PrEP was approved by the US Food and Drug Administration in 2012 to prevent the transmission of HIV. It is comprised of a two-drug antiretroviral regimen (emtricitabine and tenofovir disoproxil fumarate, TDF) that is available in a single tablet5. Its use is recommended for HIV negative persons at substantial risk of HIV acquisition, including men who have sex with men and intravenous drug users. PrEP must be taken on an ongoing basis while the HIV negative person remains at substantial risk. While the evidence for prevention with the use of PrEP is strong, its efficacy is highly dependent on consistent use4, 5. Psychiatrists have a crucial role in assessing for barriers to adherence as well as identifying potential risk compensation. Generally, PrEP is well tolerated, but TDF may cause nephrotoxicity and bone loss4. Crisis intervention and emergency psychiatry are areas in which post-exposure prophylaxis (PEP) for HIV negative persons accidentally exposed to HIV during a sexual encounter or injection drug use can take place. Accidental exposure to HIV is a medical emergency. Referral or treatment with a three-drug regimen (tenofovir, emtricitabine, and raltegravir or dolutegravir) for 28 days can prevent infection as long as it is started within 72 hours after exposure6. The WPA Section on HIV/AIDS Psychiatry was developed from an Academy of Consultation-Liaison Psychiatry Special Interest Group that was founded in 2003. It was designated a Section of the WPA in 2012 and has grown from 32 members in 2003 to 459 in 2019. Members have defined our subspecialty, given numerous presentations, contributed articles and chapters, and edited or written three textbooks7-9 on HIV/AIDS psychiatry. They have presented at WPA meetings throughout the world and have collaborated in presentations with other WPA Sections. As a result of the biopsychosocial complexities of HIV/AIDS psychiatry, there is potential for intersectional collaborative work with WPA Sections on Addiction Psychiatry; Old Age Psychiatry; Perinatal Psychiatry and Infant Mental Health; Psychiatry and Human Sexuality; Psychiatry, Medicine and Primary Care; Psychotherapy; Public Policy and Psychiatry; Stigma and Mental Illness; Suicidology; Transcultural Psychiatry; Urban Mental Health; and Women's Mental Health. HIV/AIDS psychiatry provides a paradigm for consultation-liaison psychiatry and integrated compassionate care. Our Section members are dedicated to academic, clinical, research and administrative aspects of HIV and AIDS. They use consensus surveys to inform research on best practices of HIV psychiatric care and have published work on use of psychotropic medications. They explore ways to improve doctor-patient communication skills and diminish stigma in the care of persons with HIV and AIDS. HIV/AIDS psychiatry has broadened the depth and scope of consultation-liaison psychiatry to include prevention, public health, and global psychiatry1.