Presentation and management of psychiatric illness in HIV-infected patients can pose a challenge for clinicians. Psychiatric illness can exist premorbidly or result from the progression and treatment of HIV infection, influencing the course of the illness both through behavior and putative biological factors. Mood disorders, anxiety, psychosis, delirium, dementia, and substance abuse disorders all factor heavily into the care of HIV-infected patients. Management, however, continues to draw on small and skewed datasets, and remains largely an extrapolation from seronegative patient experience. The following is a discussion of treatment considerations derived from recent literature, as well as a consideration of judgments that clinicians may make in the absence of available data. The use of antidepressants, stimulants, mood stabilizers, and antipsychotics is discussed, as are precautions that must be taken with the HIV population when using these medications, not only because of side effect vulnerability, but because of significant drug-drug interactions.

The Handbook of AIDS Psychiatry is a practical guide for AIDS psychiatrists and other mental health professionals as well as for other clinicians who work with persons with HIV and AIDS and a companion book to the Comprehensive Textbook of AIDS Psychiatry (Cohen and Gorman, 2008). The Handbook provides insights into the dynamics of adherence to risk reduction and medical care in persons with HIV and AIDS as well as strategies to improve adherence using a biopsychosocial approach. Psychiatric disorders can accelerate the spread of the virus by creating barriers to risk reduction. Risky sexual behaviors and sharing of needles in intravenous drug users account for the majority of new cases each year. Delirium, dementia, depression, substance dependence, PTSD, and other psychiatric disorders complicate the course and add considerably to the pain and suffering of persons with AIDS. HIV infection and AIDS also are risk factors for suicide, and the rate of suicide has been shown to be higher in persons with AIDS. Psychiatric care can help prevent HIV transmission through recognition and treatment of substance-related disorders, dementia, and mood disorders such as mania. Comprehensive, coordinated care by a multidisciplinary AIDS team, including AIDS psychiatrists, can provide a biopsychosocial approach that is supportive to patients, families, and clinicians. Psychiatric interventions are valuable in every phase of infection, from identification of risk behaviors to anticipation about HIV testing; from exposure and initial infection to confirmation with a positive HIV antibody test; from entry into systems of care to managing complex antiretroviral regimen; from healthy seropositive to onset of first AIDS-related illness; from late stage AIDS to end-stage AIDS and death. There is no comprehensive handbook of AIDS psychiatry to guide clinicians in providing much needed care. The Handbook of AIDS Psychiatry is a practical pocket guide that provides protocols for the recognition and treatment of the psychiatric disorders most prevalent in persons with AIDS and most relevant for primary physicians, infectious disease specialists, and other caregivers because of their impact on health, adherence, behavior, and quality of life.

Since the introduction of combination antiretroviral therapy, clinicians have seen a sharp decrease in the incidence of many HIV-associated comorbidities, and patients with access and adherence to combination antiretroviral therapy are living longer and healthier lives. However, the frequency of endocrine, metabolic, cardiovascular, renal, dermatological, neoplastic, hepatic, renal, pulmonary, and gastrointestinal multimorbid medical conditions remains very significant and in some cases is increasing. Although the incidence of particular HIV-associated comorbidities such as cytomegalovirus (CMV) retinitis has declined considerably, it remains a significant source of distress and suffering for persons with AIDS. This chapter is not intended to provide a lengthy discourse on each topic addressed, but rather be a general overview that will give the reader a basic working knowledge of multimorbid medical conditions and enhance the understanding of associated psychiatric complications and psychological distress. For a summary of these conditions and their respective features and treatment, see Table 10.1. HIV and AIDS have been associated with a wide spectrum of endocrine abnormalities that underscore the complex relationships between immunological, endocrinological, and psychological systems. Endocrinopathies are great mimickers of psychiatric disorders, manifesting in some cases as disturbances of mood, sleep, appetite, thought process, energy level, or general sense of well-being. Endocrinopathies may present insidiously or abruptly, in either case with potentially tragic consequences when misdiagnosed as psychopathology. Prompt recognition of reversible alterations in endocrine function is essential to prevent unnecessary morbidity and mortality. An understanding of the complex interactions between endocrine and psychological systems may improve recognition and treatment of endocrinopathies, diminish suffering, and enhance quality of life and longevity in persons with HIV and AIDS. Many studies have demonstrated alterations in adrenal function in patients with HIV and AIDS. Associated infections and tumors, as well as direct invasion of the adrenal glands by the virus, partly explain these changes. Patients are also commonly prescribed drugs that alter steroid synthesis or metabolism; for example, ketoconazole decreases steroid synthesis, megesterol acetate suppresses pituitary secretion of corticotropin, and rifampin increases p450 activity, leading to increased metabolism of cortisol.

With the advent of effective antiretroviral therapy, persons with access to and engagement in HIV medical care and antiretroviral therapy can live longer and remain healthy with what has become a chronic manageable illness. Despite advances in medical care, without access to HIV medical care and antiretroviral therapy or with access but without viral suppression, persons with HIV still experience opportunistic infections and cancers. This chapter reviews the HIV-associated multimorbidities, including pulmonary manifestations, ophthalmological complications, dermatological manifestations, gastrointestinal and hematological illnesses, as well as HIV-associated malignancies. The proposed mechanisms through which HIV may contribute to premature aging are also discussed.

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