HIV/AIDS AND MENTAL ILLNESS: TODAY’S CHALLENGE

Prof Seggane Musisi MD, FRCP (C)Department Of Psychiatry

Makerere University

Global Mental Health and Africa: Opportunities, Challenges And CollaborationsMbarara University Of Science And Technology: Aug. 15th - 16th , 2011

ACKNOWLEDGEMENTS• MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY

• MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES

• ACADEMIC ALLIANCE FOR AIDS CARE AND PREVENTION IN AFRICA (IDI)

• UGANDAN MENTAL HEALTH ASSOCIATIONS: • UPA, APRO, MHRC

• RESEARCH GRANTS: – ARCH, ROGERS FOUNDATION, SIDA/SAREC, USHS, FULBRIGHT COMMISSION, NIH.

• MY STUDENTS AND RESEARCH COLLEAGUES

Overview of Presentation: History of The Epidemic

Progression Of The Epidemic

Nature & Extent Of The Mental Health Problems

Etiological Factors

The Mental Health Problems Themselves

Mental Health Problems Of HIV/AIDS In Children

Orphans & Caregivers

HIV/AIDS Among The Elderly

The Challenge

Conclusions & Recommendations: The Future & Research

THE HIV/AIDS BURDEN IN AFRICA

PROGRESSION OF THE EPIDEMIC

• STARTED IN EARLY 1980s

• MOST ADVANCED & SERIOUS IN SUB-SAHARAN AFRICA

• LINKED TO POVERTY & LOW EDUCATION

• 70% OF PLWHA ARE IN SUB-SAHARAN AFRICA

• RAN ITS COURSE, PEAKED & HAS SHOWN DIFFERENT WAVES.

OBSERVATIONS :THE AIDS WAVES • EARLY 1980s – FIRST AIDS CASES

• INFECTION WAVE• Very physically ill – Wasted : SLIM Disease• Early death• Ran mad : Bewitched (From Tanzania)

• DEATH WAVE• Widows• Orphans

• ORPHAN WAVE• COTOs• HIV-positive Adolescents

• THE ELDERLY HIV- POSITIVE WAVE• Effect of HAART• Effect Of Ageing

IK Missoula 2003

IK Missoula 2003

WHY MENTAL HEALTH PROBLEMS OCCUR

• SEXUAL DISEASE• FAMILY DISCORD• STIGMA (Cultural, Religious & Disease Factors)• INFECTIOUS• FATAL• CHRONIC• DISFIGURING• INVOLVES CNS• OPPORTUNISTIC INFECTIONS• THE MEDICATIONS

THE MENTAL HEALTH PROBLEMS• PREMORBID PSYCHOPATHOLOGY & ADJUSTMENT PROBLEMS

• PSYCHO-BEHAVIORAL PROBLEMS : PERSONALITY & SUBSTANCE ABUSE DISORDERS

• THE ANXIETY DISORDERS

• THE HIV-RELATED AFFECTIVE (MOOD) DISORDERS

• THE HIV-RELATED PSYCHOTIC PROBLEMS

• THE HIV-RELATED COGNITIVE DISORDERS

• HIV/AIDS MENTAL HEALTH PROBLEMS IN CHILDREN– HIV-POSITIVE CHILDREN– HIV-NEGATIVE ORPHANS

• FAMILY PROBLEMS

PERSONALITY DISTURBENCES

• PREMORBID ADJUSTMENT

• PERSONALITY CHANGES– Antisocial behaviour– Irresponsibility– Giving up– Irresponsible Sexuality

PREMORBID PSYCHOPATHOLOGY• PRE-EXISTING PSYCHIATRIC ILLNESS

– Bipolar Disorder– Depression– Schizophrenia– MR

• SUBSTANCE ABUSE– Alcohol– Marijuana, Mayirungi– IV Drug use

• HIGH HIV RISK POPULATIONS– 4H Club– Prostitutes & Truck drivers– Professionals– The War-affected

SUBSTANCE ABUSE →Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.

• SUBSTANCE PERCENTAGE Alcohol 48 Cigarettes 9 Marijuana 2 Pipe smoking 6 None 35 Partner Use Of Alcohol 54

ADJUSTMENT AND REACTIVE DISORDERS

• ACUTE STRESS DISORDER

• SUICIDALITY

• ADJUSTMENT DISORDERS:– WITH ANXIOUS MOOD– WITH DEPRESSED MOOD– WITH DISTURBENCE OF CONDUCT– WITH MIXED FEATURES

ANXIETY DISORDERS

• ANXIETY DISORDER : ACUTE & RECURRENT

• Kuganda S. (2011): M.Med (Psychiatry)Thesis, MakCHS– 6% Psychological Distress– 27% Panic Attacks & 27% Generalised Anxiety Disorder– Factors associated with Anxiety Disorder:

• Unemployment• Poor Social Support• Oral Thrush

• Other researchers : AIDS Phobia, OCD, PTSD

MOOD DISORDERS• HIV-RELATED DEPRESSION

– Akena’s et al: (2010) African Journal Of Psychiatry Vol 13, No. 1– F>M. Later age of onset. Negative F/H. Cognitive impairment. Widowhood. Frequent medical illnesses. Severer sleep & appetite disturbances. Guilt.

• HIV-RELATED MANIA– Nakimuli et al: (2006) Am J. Psychiatry 163: 8– F>M. Later age of onset. Severer Psychosis. Negative F/H. Cognitive

impairment. Widowhood

• BIPOLAR DISORDER– Nakimuli et al: (2008) Psychosomatics Journal 49:530-534– Early onset: Bipolar I; Later onset: Secondary mania. Quick Rx

response

PSYCHOTIC DISORDERS

• HIV-RELATED PSYCHOSIS:– SCHIZOPHRENIA-LIKE– PARANOID– MIXED– PRE-EXISTING SCHIZOPHRENIA

• Maling’s et al: (2011). AIDS Care, Vol. 23, No. 2, 171-178– 18.4% Prevalence in First Episode Psychosis– F>M; Older age of onset (41 years). More auditory,

visual & tactile hallucinations. More likely to remit.

DISORDERS OF COGNITION• HIV-RELATED DELIRIUM

• Musisi et al.(2000): Makerere Medical School Journal• 40% of all C-L referrals. Early & Late stages of HIV/AIDS. Se/CRAG

• Lukwago et al. (2009): Delirium. In Psychiatric Problems Of HIV/AIDS & Their Management In Africa. Fountain Publishers

• 38% of ER attendees at Mulago Hospital. Associated with OI & ↑ viremia

• HIV ASSOCIATED DEMENTIA• Sactor N, Nakasujja N et al (2005): AIDS 19:1367-1374• The IHDS can screen for Dementia in Uganda/Africa• 31% prevalence Of Dementia: Cognitive impairment ↓ with HAART • Question: When can we start HAART with CD4>200?

• Nakasujja N et al(2010): BMC Psychiatry 10:44• Depressive & cognitive symptoms are common in HIV/AIDS • Cognitive deficits persist despite adequate treatment for depression

FAMILY PROBLEMS• FAMILY TYPES AND CONJUGAL PRACTICES AMONG HIV-POSITIVE

CLIENTS IN CARE IN UGANDA IN PAST 5 YEARS :→ Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.

• 64% started off in monogamous unions, 28% got separated/divorced & 10% got into visiting unions with many partners,

• About 60% reported having lived in visiting unions at one point• Conclusion: Considerable flexibility, variability and volatility of marital

unions & conjugal practices among the HIV-positive TASO clients.

• DISCORDANT COUPLES: 10%

• WIDOWS: 30%

DISCLOSURE OF HIV STATUS TO PARTNER Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.

Yes44%

Sometimes5%

Never39%

Not answered12%

CONDOM USE Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.

Yes28%

No33%

On and Off35%

Not answered4%

PARTNER VIOLENCE Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.

Verbal

Physical

Sexual

No Violence

Verbal and Physical

Verbal, Physical and Sexual

Not answered

45

20

3

50

14

2

1

Series1

HIV/AIDS AND CHILDREN (Wakhweya et al, 2000)

• ORPHANS– >2 million orphans in Uganda, >14 million orphans in Africa

• Types of Orphans:– Paternal orphans (50%)– Double orphans (30%)– Maternal Orphans (20%)

• Classification Of AIDS orphans:– HIV-positive orphans

• Have all the neuropsychiatric disorders, many physical illnesses associated with HIV + psychosocial problems

– HIV-negative orphans• Have only psychosocial problems but no major disorders

• Elderly caretakers (30%), Child-headed households• Poverty , Prostitution, Destitution• Mother to Child Transmission (25%)• >90% of infected children are orphans• >60% are in stage III of illness by 10 yrs

Impact Of HIV/AIDS-related Parental Death On Children’s Home Life

Increased:

. Poverty . Household responsibility

. Psychosocial distress

. Vulnerability to sexual & labor abuse, . Stigma and isolation . Hunger and malnutrition

Reduced:

- Access to food

- Access to health services

- Access to school

- Material goods : clothes, supplies

- Guidance, protection, and love

HIV-POSITIVE CHILDREN IN UGANDA.- Musisi S & Kinyanda E (2009), East African Medical Journal, Vol. 86, No. 1, 16-24.

• 97% of HIV-infected children are orphans

• >60% are in stage III of illness by 10 yrs

• They manifest major psychiatric disorders:

Anxiety (58.5%) Depression,(42%)

• Psychosis, (30%) Mania(7.2%)

• HPE (4.9%) Seizures(8.5%)

• Suicide, (20%) , Substance Abuse(4.8%).

• Somatoform Disorders (18.3%)

• No special services are available for them. •

The Psychosocial Problems Of Orphans (Musisi S, Kinyanda E, Nakasujja N (2007): African Health Sciences Journal, 7(4)

• Emotionally needy - No parental guidance, love, support, & security

• Are materially deprived, abused, isolated & neglected,

• Lack Scholastic materials, Fees, Food, Clothing , Shelter, Protection.

• Need Role Modeling , Social & Vocational Skills, and Health care.

• Live in poverty & exploitation (labor, sexual, spiritual & inheritances)

• Lack family & individual counseling / support & community resources

• Live in Fear & engage in survival behavior: – – Girls: Prostitution, early marriage or domestic help for girls. – Boys: Street children with petty theft , child labor & fights

• Have high rates of depression, suicide & substance abuse

Shelter: To build and/or repair houses

Psycosocial Interventions: Care, Protection, Schooling

School fees, scholastic materials and LUNCH

Contributing to a better future…

ELDERLY HIV-POSITIVES• NEW WAVE & INCREASING

• ↑ STIGMA, ↑ SECRECY, with ↓ACCESS TO CARE

• MULTIPLE PHYSICAL & MENTAL PROBLEMS

• HAD Vs OTHER DEMENTIAs

• SEXUALLY ACTIVE, SOME HAD >1 PARTNER. FEW USED CONDOMS

• ↓ SOCIAL SUPPORT, ARV TREATMENT & CLINIC ATTENDANCE

• NO SPECIFICALLY TARGETTED PREVENTION PROGRAMS

• LAXITY OF CARE ON THE PART OF THE STAFF

Elderly HIV-Positive Age Distribution (N=118)

AGEGROUP

>8076-8071-7566-7060-65

Pe

rce

nta

ge

70

60

50

40

30

20

10

0

The Elderly Sexual Behavior (last 3 months)

17.8%

12.7%

69.5%

no

yes

Missing data

The Challenge in Uganda’s HIV/AIDS Care:

The Apparent Absence of Mental Health In HIV-care

Problems In Scaling Up HIV care

Adherence, Resistance: The role of mental health

Substance Abuse

Unreached Pockets Of Infection : The marginalised (Trauma , mentally ill,

elderly, orphans, disabled)

Interventions & Policy

THE FUTURE• INTEGRATED MENTAL HEALTH IN ALL HIV CARE PROGRAMS.

• ORPHAN POLICY : – ORPHAN REGISTRY, LEGAL PROTECTION, – CHILDRENS AID SERVICES– LEGAL GUARDIANSHIP, – SCHOOLING,SHELTER, HEALTHCARE FOOD SECURITY– CHILD PSYCHOLOGY & GUIDANCE, – DISTRICT RUN FAMILY SERVICES

• RESEARCH INTO :– HIV CARE FOR THE ELDERLY, – LONG TERM OUTCOME OF MENTAL HEALTH DISORDERS OF HIV/AIDS,– COMFOUNDING MENTAL HEALTRH FACTORS IN HIV CARE IN UGANDA, – TASK SHIFTING APPROACH TO MENTAL HEALTH CARE PROVISION IN PHC HIV SETTINGS– ADHERENCE & MENTAL HEALTH SERVICES IN HARD TO REACH HIV COMMUNITIES– MENTAL HEALTH INITIATIVES TO ENHANCE THE SCALE UP OF HIV CARE IN UGANDA

LETS MOVE FORWARD IN PARTNERSHIP