Comorbidities in Difficult-To-Treat HIV Patients

Michael Robert Clark, MD, MPH, MBA, Joyce King, MD, Glenn J. Treisman, MD, PhD

Michael Robert Clark, MD, MPH, MBA
Associate Professor & Director, Chronic Pain Treatment Program
Department of Psychiatry & Behavioral Sciences
The Johns Hopkins Hospital
Baltimore, MD

Joyce King, MD
Chair, Patient Care Advisory Committee
Director, Inpatient Training for Family Practice Residents
Franklin Square Hospital
Baltimore, MD

Glenn J. Treisman, MD, PhD
Professor of Psychiatry and Behavioral Sciences and of Medicine
Director, AIDS Psychiatry Service
The Johns Hopkins University School of Medicine
Baltimore, MD

Mood disorders are significant contributors to HIV infection. Individuals with mood disorders are demoralized and usually have a history of high-risk behaviors that can lead to infection; these include substance abuse and unsafe or addictive sexual practices. The importance of addressing these behaviors is paramount. Once HIV, (or hepatitis C or is contracted, further physiologic changes, such as elevated cytokine levels and neural inflammation can lead to worsened depression. In the same way, disease-induced or idiopathic mood disorders can also become significant barriers to effective treatment. As a patient’s mood deteriorates, they are less likely to take their medications and adhere to a treatment protocol. This also can result in a further worsening of the patient’s overall health status.

Many difficult-to-treat HIV patients have had negative experiences with organized medicine and some have been inaccurately diagnosed with personality disorders by physicians who find it difficult to treat them. This is often the source of de novo hostility or paranoia. Negative experiences commonly reinforce previous assumptions, and adversely influence patient cooperation and compliance with prescribed therapies. Clinicians, especially primary care physicians (PCPs) can, however, alter this cycle through cognitive therapy that improves a patient’s treatment experience and, ultimately, their behavior so that positive experiences will reinforce therapeutically desirable behaviors. In many HIV patients, the need for addressing psychiatric comorbidities such as affective disorders, personality vulnerabilities, and psychosocial stressors, is as essential as the need to treat chronic pain and other treatment-resistant illnesses. One technique is to use the patient’s dependence on prescription narcotics to psychologically guide their affective behaviors and dedication to pursuing healthy behaviors

Finally, direct communication of patient information between the primary care physician (PCP) and psychiatrist will help clinicians recognize and anticipate disorders and improve treatment. Typically, PCPs are the clinicians best equipped to formulate a treatment plan for difficult patients, as they are typically more familiar with individual personalities, medical backgrounds, families and support structures.

References

Eller LS, Bunch EH, Wantland DJ, et al. Prevalence, correlates, and self-management of HIV-related depressive symptoms. AIDS Care. 2010 Sep;22(9):1159-1170.
VanDevanter N, Duncan A, Burrell-Piggott T, et al. The influence of substance use, social sexual environment, psychosocial factors, and partner characteristics on high-risk sexual behavior among young Black and Latino men who have sex with men living with HIV: A qualitative study. AIDS Patient Care STDS. 2011 Feb;25(2):113-21. Epub 2011 Jan 15.
Mutchler MG, Wagner G, Cowgill BO, McKay T, Risley B, Bogart LM. Improving HIV/AIDS care through treatment advocacy: going beyond client education to empowerment by facilitating client-provider relationships. AIDS Care. 2011 Jan;23(1):79-90.

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