Counseling Patients With HIV/AIDS – A Multi-Approach

by Myra Partridge

Many patients with HIV/AIDS experience numerous challenges beyond those posed by the physical effects of their disease—including poverty, mental illness, drug addiction, social alienation, racism, and homophobia. Counseling patients who face these issues can be difficult, but a careful risk assessment along with patient education can improve a patient’s ability to cope and lead to better outcomes, said Marshall Forstein, MD, associate professor of psychiatry, Harvard Medical School, Cambridge, Mass, in a presentation at the US Psychiatric Congress in Las Vegas. On the basis of his extensive experience in treating patients with HIV/AIDS, he said it is also important to provide hope and to encourage treatment adherence.1

When conducting a thorough risk assessment, Forstein emphasized the importance of asking all patients about their specific sexual behaviors. This opens the door for candid discussions about HIV prevention and nonoccupational exposure prophylaxis. “It is important to know what these behaviors are so we can try to help patients keep themselves out of harm’s way,” he said. It is critical to discuss the behavior through which the patient contracted HIV. This not only helps the patient come to terms with his or her disease, but it also forces him to consider the manner and risk of secondary transmission. “The issue is how to discuss sexual or drug use behavior with patients without seeming condescending or judgmental,” Forstein said.

Patients should not only be educated about disease prevention and transmission, but also about the course of the illness. In addition, health care providers must be careful to make sure that patients understand the meaning of the medical terms. For example, some patients who have been treated with ART and have HIV that is clinically considered to be “undetectable” (meaning that the viral load is below the ability of the current available tests to detect the level of virus) does not mean that there is no HIV, and thus the risk of viral transmission, though lower, is still possible.  Patients may misinterpret the term “undetectable” and fail to understand that they still have HIV, said Forstein. Others may see HIV now as a chronic disease, so they may think becoming HIV infected is no longer a significant medical illness.

A number of factors also contribute to treatment fatigue and noncompliance with the therapeutic regimen. Adverse drug effects and complicated regimens are chief among these. Constant reinforcement on the need for lifetime adherence may be necessary. Advise patients that 95% adherence is required to suppress viral replication. Forstein also said simplifying dosing schedules  can increase adherence.

Age can also contribute to treatment fatigue. Forstein has treated a number of patients who have had HIV infection since the 1990s but who have no detectable viral loads after years of ART. Some of his older patients (ie, those who are approaching their 60s) want to experience their remaining years free of the effects of medication and opt to discontinue therapy. “It is important for providers to explore that type of thinking,” he said.

All patients with HIV infection will find it difficult to adjust to changes in their medical status, regardless of whether their symptoms are getting better or worse, said Forstein. For example, some patients have had trouble accepting the fact that they might do well, including the possibility of returning to work or thinking about re-engaging in relationships. Some have felt that HIV has given their life a purpose, such as participating in community activism. “Getting well and staying well requires a renegotiation of those factors that inform their lives,” he said.

Republished from: The Aids Reader –

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Sexually transmitted diseases caused by viruses

by Peter Sedesse

There are four  sexually transmitted diseases (STDs) that are caused by viruses.  They are Human Immunodeficiency Virus (HIV),   Human Papillomavirus (HPV), Herpes Simplex Virus (HSV), and Hepatitis C.   An important common feature of all the viruses that cause sexually transmitted diseases is that there is no cure for any of them, but in each case, common STD preventive measures like condom use are highly effective at preventing infection.

1.  HIV is the virus that causes AIDs.  HIV can remain dormant inside the body for months or even years without causing any noticeable symptoms.  This is one of the leading reasons HIV has become the most lethal STD in the world in less than half a century.  Most transmissions of HIV are from people who do not have any symptoms or even realize they are infected.  At some point after infection, the virus begins to destroy CD4 white blood cells which are a vital part of the immune system.  Without medical intervention, death usually occurs as the result of a secondary infection that is lethal because the body is not able to fight back.  Current medications are able to greatly reduce the ability of the virus to reproduce, which slows down the destruction of the immune system.

2.  Human Papillomavirus (HPV) is the virus that causes genital warts.  While in most situations, the virus and the warts are harmless to the individual and only cause slight irritation, the virus is also the leading cause of cervical cancer in women.  Women infected with the virus should be sure to have yearly pap exams done.  While there is no treatment for the virus itself, the warts can be removed by means similar to other warts; freezing, laser or through surgery.

3.  Herpes simplex virus is transmitted through sexual activity and results in open sores on the genitals of both men and women.  Herpes can infect the genitals, mouth and anus, and once infected, the virus lies dormant in the nerve cells.  When infected, an individual will usually have a rather extreme outbreak approximately two weeks after infection.  The virus then will remain quiet for an unknown amount of time before causing more symptoms.  Antiviral medications are effective at keeping the virus in its dormant state and diminishing the severity of symptoms when an outbreak does occur.  It is important to know that Herpes can be spread to other individuals even if there are no visible sores on the person with the virus.

4.  Hepatitis C is transmitted through sexual activity and causes long term and permanent damage to the liver.  While Hepatitis C is transmitted through the genitals, the major symptoms associated with the virus occur throughout the body as the liver gradually is destroyed.  There is no cure for Hepatitis C and the best treatments only attempt to minimize the rate of destruction of the liver.

As with all sexually transmitted diseases, the most common mode of infection is unprotected sexual activities with a person infected with the virus.  Increased chances for infection occur when the integrity of the skin of the sexual organs is impaired or broken.  The most common cause of this is a sore caused by a different STD, or from traumatic sexual behavior such as anal sex.  While each of the four viral STDs have no current cure, they all have treatments aimed at reducing the severity and frequency of symptoms.

Viruses cause four of the most significant and dangerous forms of sexually transmitted diseases.  Because of the nature of viruses, these STDs cannot be cure, but can be treated which greatly reduces the severity and duration of symptoms.  HIV, Herpes, HPV and Hepatitis C all share similar characteristics and are much more easily transmitted during unprotected sex, especially traumatic sex which results in direct contact with blood.

This article was originally posted on

Urban Mindfulness – Finding peace in the middle of it all

by Jonathan Kaplan, Ph.D.

Subway Meditation: No Cushion Required

Meditating on the subway is probably not ideal, but it sure beats playing Brick Breaker on your Blackberry, messing with your iPhone (or PSP), or skipping a meditation session altogether. It is safer (and easier) to meditate at home or as part of a meditation group, but sometimes we simply don’t have the time. So, here is a simple way to meditate “on the go.”

It is very important to maintain some level of awareness for your safety, however. So, please do not attempt this meditation if it’s crowded or if you notice someone around you who is drunk, acting erratically, or doing anything else that might seem threatening or unpredictable. You don’t want to have your bag or wallet stolen or miss some kind of approaching danger. And, meditation-wise, you can always try again later. So, if it seems unsafe or unwise to meditate for you to meditate on the subway, then don’t do it.

If it is safe, then here are the steps in meditating while standing. The meditation essentially is a version of a “body scan” in which you notice the sensations in your body relative to the movement of the train. In my next post, I’ll provide guidelines on how to meditate when you’re fortunate enough to have a seat.

  • Check-in with your environment and people around you to make sure that it’s safe to practice now.
  • Turn off your iPod or mp3 player. You might want to continue wearing the earphones however, in order to reduce the likelihood that someone will disturb you, however.
  • Gather your belongings close to you in order to ensure that they will be secure during the meditation.
  • Stand with your feet about shoulder width apart. Try to position your feet to be at a 45° angle to the centerline of the train, if possible. This will help you maintain balance as the train moves and stops. If necessary, hold onto a bar or railing.
  • Roll your shoulders back and raise your chin up so that your head is level. Adopt a posture that embodies confidence and dignity.
  • Lower your gaze to be looking at a window or a nondescript area next to someone seated. You could also look at your hand or arm if you’re holding onto part of the train. Do not look directly at another person. This is the city after all-you don’t want to be starting something! Also, it is helpful to keep your eyes open in order to be sensitive to any possible approaching danger.
  • Mentally, rest your attention on the physical feelings in your body in the moving train. Pay particular attention to the sensations in your feet and legs. You might notice the way in which your muscles tense and release in order to help you maintain balance as the subway train accelerates and slows down. Become aware of the shift in your body as the train lurches forward or starts to brake. Maintain your awareness on your physical sensations for the duration of your trip.
  • Whenever the train stops at a station, take a moment to check calmly and see if this is your stop. The stops, while disrupting your mindful awareness of your body, are like the sounds of a meditation bell, which invite you to refocus your attention.
  • Exit when you reach your destination.
  • Once you leave the train and move a safe distance away from the platform, take a moment to reflect on the activity and what you noticed. Proceed with your journey with mindful awareness and deliberate action.

Give this meditation a try and let me (and others) know what you think.  Please post suggestions and share your experience in order to help guide us in this endeavor together

This article was originally posted on Psychology Today:

Good Grief Versus Major Depressive Disorder

By Allen Frances, MD

On August 15, I published an op-ed piece in The New York Times expressing the view that normal grief is normal and should not be confused with Major Depressive Disorder (MDD). The DSM 5 suggestion to remove the bereavement exclusion for MDD would convert grief after losing a loved one into mental disorder. Two short weeks of expectable symptoms like sadness; loss of interest, appetite, and energy; insomnia, and difficulty working would qualify for an MDD diagnosis. This mislabeling would then often trigger stigma and unnecessary medication treatment. More details can be found in the op-ed piece itself or on previous numbers of this blog.

On August 20, the Times published a number of letters taking all sides on the issue. There were two rejoinders to my view that I believe are misleading enough to require comment:

Counter argument 1:
Patients experiencing a well-established Major Depressive Episode (MDE) beginning during bereavement are no different in presentation and treatment response than those whose MDE follows after other severely stressful life events.

Reply: True enough, but totally irrelevant to my concern. Well-established MDD is not in question (it is already diagnosable in DSM- IV-TR). The respondents continue to confuse the issue by focusing only on the already well-established cases of MDD with a duration in studies usually greater than two months These are the true positives and there is no controversy whatever regarding their diagnosis. Well-established (ie, severe or enduring) MDD during bereavement has never been the issue.

It is the false positives I worry about -those with normal and time limited grief that will remit in the natural course of things without diagnosis or treatment. Two weeks is far too short a duration when we are considering relatively mild symptoms that are so intrinsic to grieving. Rushing to judgment that a mental disorder is present will lead to remarkably high false positive rates and transform normal grief into a medical disorder.

Counter argument 2
: The respondents claim that the DSM 5 intention is only to diagnose MDD, not to include normal grief.

Reply: The crucial and clinching point is that these are clinically completely indistinguishable at frequently encountered levels of normal grief. Prospective studies show that almost half of all the bereaved reach MDE two week symptom thresholds sometime during the first year after their loss, usually within the first two months. I challenge anyone to distinguish clinically between two weeks of normal grief and two weeks of mild MDD under these circumstances. I certainly can’t make this distinction, I very much doubt that my respondents can, and I feel sure that primary care physicians can’t manage it while seeing a grieving patient in a seven minute evaluation.

Distinguishing grief from MDD is no problem when symptoms become severe or are enduring. DSM-IV-TR already recognizes this. It allows the diagnosis of MDD anytime during bereavement when there is suicidality, psychosis, morbid worthlessness, psychomotor retardation, or inability to function. This is meant to encourage early diagnosis and active psychiatric intervention whenever this is needed. There is no compelling problem that needs fixing. Grieving patients who need psychiatric help already get it.

Before jumping the gun to a premature and potentially harmful diagnosis, why not watchfully wait a few more weeks to determine if the grief is severe and enduring enough to warrant the label of mental disorder. To do as DSM 5 suggests would instead mislabel a substantial portion of normal grievers and would inappropriately stretch the boundary of psychiatry by medicalizing grief.

This article originally appeared at Psychiatric Times: