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antihypertensive medications, the discontinuation rate for adverse cardiovascular events for sildenafil was equal to that for placebo. In these same studies, the incidence of MI for those using sildenafil was 1.7 per 100 man years of treatment, versus 1.4 for those on placebo-yielding no statistically significant difference between the two groups. Open-label sildenafil studies provided an even lower rate of MI: 1 infarction per 100 man years. Sildenafil clearly is safe as long as it is properly prescribed. Patients receiving sildenafil must be able to tolerate moderate exercise and must not receive nitrate agonists. BIBLIOGRAPHY
I . Condra M, Morales A, Surridge D, et al: The unreliability of nocturnal penile tumescence recording as an outcome measurement in the treatment of organic impotence. J Urol 135:280-282, 1986. 2. Drugs that cause sexual dysfunction. Med Lett 34:73-78, 1992. 3. Fava M, Rankin M, Alpert J, et al: An open trial of oral sildenafil in antidepressant-induced sexual dysfunction. Psychother Psychosom 67:328-331, 1998. 4. Goldstein I, Lue TF, Nathan-Padma H, et al: Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 338:1397-1404, 1998. 5. Kaplan HS: The New Sex Therapy. Active Treatment of Sexual Dysfunction. New York, Bruner/Mazel, 1974. 6. Masters W, Johnson V: Human Sexual Inadequacy. Boston, Little Brown, 1970. 7. Morales A, Gingell C, Collins M. et al: Clinical safety of oral sildenafil citrate in the treatment of erectile dysfunction. Int J lmpot Res 1059-74,1998. 8. Nadig PW: Vacuum constriction devices in patients with neurogenic impotence. Sexuality Disability 12:99-105, 1994. 9. Nathan-Padma H, Hellstrom WJ, Kaiser FE, et al: Treatment of men with erectile dysfunction with transurethral alprostadil. N Engl J Med 336:l-7, 1997. 10. Rendell M, Rajfer J, Wicker P Sildenafil for treatment of erectile dysfunction in men with diabetes. JAMA 281:421-425, 1999.

7 1 . PSYCHIATRIC ASPECTS OF AIDS


Carl Clark, MD.

1. What are HIV and AIDS? Human immunodeficiency virus (HIV) is a retrovirus that infects humans and causes various clinical problems ranging from an asymptomatic carrier state to fatal immune deficiency. Acquired immunodeficiency syndrome (AIDS), the most serious form of HIV infection, results from progressive destruction of the immune system.

2. How does HIV act in the body?


HIV propagates best in lymphocytes and leads to the destruction of its host cell, primarily the CD4 helper-inducer cells. Destruction of CD4 helper-inducer cells impairs the bodys ability to mount an effective immune response. HIV also infects the central nervous system cells and leads to dysfunctions such as peripheral neuropathies and encephalopathies. Current treatments attempt to stop viral replication and maintain viral suppression in order to assist immune system functioning.

3. How is HIV detected?


HIV antibodies, which develop in most people in response to HIV infection, can be detected by two standard laboratory tests, the enzyme immunoassay (EIA, formerly ELISA, or enzyme-linked immunosorbent assay) and the Western Blot. The EIA uses a reactive serum and is regarded as positive if

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measured absorbance is equal or greater than a defined cut-off value. The EIA has a sensitivity of 99.7%,but a specificity of only 98.5% (for double-reactive EIAs). Therefore, the EIA is used as a screening test for HIV antibodies. A positive EIA result is confirmed with the Western Blot test, an immunoblot test that detects antibody to specific viral proteins and glycoproteins. The Western Blot is highly specific. In general, patients are diagnosed with AIDS if they are positive for HIV antibodies and have an opportunistic infection or cancer, HIV encephalopathy, or a helper T-cell (CD4) count < 200 cells/mm3. The Centers for Disease Control (CDC) developed the original case definition for AIDS in 1981 before understanding of its etiology or pathophysiology.

4. How is HIV transmitted? HIV is transmitted by three routes: sexual, parenteral, and perinatal. Sexual transmission of HIV. Get an accurate sexual history to assess a patients risk of HIV transmission or infection. Sexual transmission may occur when genital secretions and blood are transferred from one partner to another. Risk is decreased by using latex protective barriers (e.g., condoms). Lubricants must be water-based; petroleum or oil-based lubricants damage latex condoms. Note that use of condoms alone will not decrease transmission. Attitudes and feeling about safe sexual practices must be explored and discussed before meaningful and lasting changes occur. Sexual behaviors considered to contribute to HIV transmission include the following (by order of risk): Unprotected anal intercourse. HIV transmission may occur when the virus comes in contact with the rectal mucosa. The rectal mucosa may sustain small rectal tears that allow HIV direct entry into the blood stream. Activities that increase the risk of damaging the rectal mucosa prior to intercourse may increase the risk of HIV transmission (e.g., enemas, manual rectal manipulation or fisting). Unprotected receptive anal intercourse is more risky than unprotected insertive anal intercourse. Oral ingestion of semen. HIV may enter the blood stream through breaks in oral or gastrointestinal mucosa. Epidemiologic studies of homosexual men do not support the ingestion of semen as a risk for HIV infection. Oral contact with feces. Parenteral transmission. Before it was possible to screen the blood supply for HIV, transmission occurred through blood products. The primary route of parenteral transmission currently is through the sharing of needles by intravenous drug users. Needle exchange programs are effective in reducing HIV transmission. Cleaning needles also reduces risk for drug users who share needles. The additional step of cleaning a needle before injecting a drug is unreliable because of the intensity of addiction and difficulty in delaying the desired drug effect. Perinatal transmission. In the United States less than 30% of HIV-infected mothers transmit the virus to their infants. The primary prevention for HIV transmission to infants is to prevent infection in women. Breast feeding may result in HIV transmission to the infant. HIV-infected mothers reduce the risk of transmission by using safe alternatives to breast feeding. The U.S. Public Health Service Task Force recommends the use of zidovudine (AZT) to reduce perinatal transmission of HIV.

5. Which interventions decrease transmission?


Mode of Transmission

Interventions to Decrease Risk


Education regarding safe sex practices Latex condoms (with water-soluble lubricants) Screening of blood products prior to transfusion Needle exchange programs for IV drug users Primary HIV prevention (see above) ? Avoid breast feeding ? Pharmacologic treatment during pregnancy of HIV-infected mother

Sexual transmission Parenteral Perinatal

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6. Describe the epidemiology of HIV infection and AIDS. In the United States the AIDS epidemic has occurred in all social groups. The largest number of AIDS cases have been in homosexual and bisexual men, followed by intravenous drug users. HIV disease occurs disproportionately in certain racial and ethnic groups. Three-fourths of pediatric cases and fourth-fifths of cases associated with IV drug use occur in minorities. The AIDS epidemic has paralleled the drug epidemic. Primary prevention efforts have resulted in a decrease in new cases of HIV infection in homosexual men; however, prevention efforts have been less successful in reducing transmission rates in other populations. Knowledge of the sociocultural aspects of each group is important if primary prevention efforts are to be successful.

7. Describe the psychological and emotional impact of HIV infection. Patients should receive education about HIV and AIDS before being tested for HIV antibodies. Nevertheless, a patient can never be fully prepared for the emotional impact of learning that he or she is HIV-positive. This information disrupts the psychological state of the patient and may lead to a stress response that includes a process of denial (refusal to believe or hear the information about being HIV-positive), disorganization (being flooded with thoughts, fantasies, and feelings about being HIV-positive), symptom formation (e.g., anxiety, sadness, depression, anger), and an adaptive or maladaptive response. Examples of adaptive responses include incorporation of the information into personal lifestyle and active attempts to promote well-being and health. Examples of maladaptive responses include denial, avoidance of medical care, impulsive behaviors, suicidal behavior, and other behaviors that do not help patients to attend to their health needs, including continued highrisk sexual behdViOr. Symptoms are assessed for severity and for their impact on the persons ability to deal with the current situation.
8. How might anxiety affect the HIV-positivepatient? Anxiety may produce somatic symptoms, nervousness, sweating, tremors, gastrointestinal disturbances (diarrhea, nausea), or visual impairments. Such symptoms can result from HIV illness, anxiety, or both; elicit a careful history to determine the cause of the dysfunction. Reactions to being HIV-positive rarely result in specific anxiety disorders such as phobias, generalized anxiety disorder, or panic disorder. A form of posttraumatic stress disorder has been described. Treatment interventions include supportive therapy and referral to community support groups and agencies that can assist with both the physical and emotional impacts of the illness. Family members (both biologic and chosen) should receive education about the disorder and supportive counseling. 9. Is treatment of depression advisable in the HIV-positive patient? Depression ranges from mild symptoms with little interference in the persons functioning to major depression. Treatment is indicated if the depression interferes with the persons functioning and does not depend on the underlying medical condition. The psychiatric consultant should differentiate between major depression and the cognitive deficits that may accompany early signs of dementia. Treatment interventions include cognitive therapy, group therapy, and antidepressant medications or psychostimulants. People with HIV infection can be especially vulnerable to the memory impairments caused by the anticholinergic side effects of antidepressants. Therefore, selection of antidepressants with the least anticholinergic side effects is recommended (e.g., venlafaxine, fluoxetine). People in support groups may become demoralized when members of the group die. In general, groups are more effective if the members of the group have a similar stage of HIV infection (e.g., grouping individuals who are asymptomatic or individuals with AIDS). 10. Is psychosis a possible response? Psychosis may result from the direct effect of HIV infection in the brain. The differential diagnosis includes acute CNS infections, drug reactions, untreated psychiatric disorders (e.g., bipolar disorder or psychotic depression), and continued effects of drug abuse in the drug-using population.

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Treatment includes antipsychotic medications with minimal anticholinergic side effects (e.g., risperidone, haloperidol), in the lowest effective dose; behavior management; and, in severe cases, electroconvulsive therapy.

11. When does a patient need a psychiatric evaluation? Patients who experience a disturbance in mood, cognition, or behavior that interferes with their ability to care adequately for themselves or to keep themselves safe warrant a psychiatric consultation. Emergency intervention is necessary when patients are suicidal, homicidal, or unable to care for themselves. Suicide rates are higher for people with chronic illnesses than for the general population. People with AIDS have a 7.4-fold higher rate of suicide than the general population; people who are HIV-positive also have higher rates of suicide. HIV seropositivity may be a significant risk factor for suicide in general hospital patient populations. Some communities of people living with AIDS consider suicide a legitimate response to the debilitation of the disease and dementia. This view was supported by the Hemlock Society in Final Exit (1991). Patients with suicidal ideation must be carefully evaluated for major depression, dementia, andlor delirium.

12. Describe HIV dementia.


HIV dementia is a syndrome of progressive dementia that results from direct infection of the brain with HIV. The diagnosis is difficult to make and requires documentation of HIV infection accompanied by decrements in abstract reasoning, difficulties in learning and memory, self-reports of changes in cognition and motor functioning, and observations of such changes by friends and family. The differential diagnosis includes other neurologic diseases associated with HIV (such as CNS infection, neoplasms), medication-induced cognitive impairments, alcohol- and drug-induced impairments, and malnutrition or other metabolic imbalances.

Clinical Manifestations of HIV-Related Dementia

Early Stages Psychotic symptoms Cognitive impairments Hallucinations Short-term memory deficit; forgetfulness rather than amnesia Suspiciousness and delusions Agitation and inappropriate behavior Decreased concentration and attention Motor symptoms Confusion and disorientation Ataxia, loss of coordination, weakness Overall intellectual ability generally well preserved Tremors until late in the disease Generalized systemic symptoms Visuospatial perception deficits Fatigue, sleep changes (hypersomnia) Changes in personality or behavior Anorexia, weight loss Apathy, decreased interest Impaired judgment, erratic behavior Enuresis Social withdrawal Hypersensitivity to medications and alcohol Rigidity of thought Speech impairment: slow dysarthria, hypophonia, difficulty in following other speakers Advanced Stages Motor symptoms Cognitive symptoms Global cognitive impairment Ataxia Rudimentary or impaired social relationship Spastic weakness Disorientation Paraplegia, quadriparesis Hyperreflexia, myoclonus, seizures Psychomotor retardation, decreased spontaneity Bladder and bowel incontinence Agitation, sundowning (e.g., nighttime delusions) Coma
13. What is a critical factor to consider when HIV dementia is present? Safety is a concern for demented patients and their caregivers. Caring for a patient with dementia is physically and emotionally demanding. Often, significant others try to care for the severely

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demented patient for longer than they can reasonably do so. Hospice and nursing home care should be considered. The patient and family may struggle with such options, feeling that they represent surrender to the disease. Work is needed to help them to understand that getting assistance with the symptoms of the illness is not the same as giving up on the patient.

14. What is the risk of acquiring HIV infection in a health care setting? The fear of infection is a complex response based on personal history and development, including cultural and emotional components. Health care workers should educate themselves about the risk of acquiring an infection from blood-borne pathogens. Universal blood and body fluid precautions protect health care workers from the probability of infection with HIV, hepatitis B, or other blood-borne pathogens. HIV is not acquired through casual contact such as hand shaking or physical examination.

15. What is safe sex? Safe-sex practices decrease the risk of acquiring HIV infection through sexual transmission. The goal is to modify behavior. Most educators currently use a risk reduction model when working with sexually active adults who want to decrease unsafe sexual behaviors. This model encourages people to continue attempts at behavior modification, even if they have an episode of unsafe sex. Safe-sex education has been successful in decreasing transmission rates of HIV in the homosexual community; recent reports, however, show that some gay men have begun to disregard safe-sex practices. Safe sex may be difficult for some women to negotiate if they feel that discussions with their partner may threaten other aspects of the relationship or influence self-perception. This issue may be particularly difficult for adolescents. Note that alcohol and drug use decreases adherence to safe-sex guidelines and has been associated with behaviors that transmit HIV.
Safe Sex Guidelines
SAFE POSSIBLY SAFE UNSAFE

Mutual masturbation Social (dry) kissing Body massage, hugging Body-to-body rubbing (frottage) Light S & M activities (without bruising or bleeding) Using ones own sex toys

Anal or vaginal intercourse with a condom Fellatio (sucking; stopping before climax) Mouth-to-mouth kissing (French kissing, wet kissing) Urine contact (water sports) Cunnilingus (oral-vaginal contact)

Receptive anal intercoursewithout a condom Insertive anal intercourse without a condom Manual-anal intercourse (fisting) Fellatio (sucking to climax) Oral-anal contact (rimming) Any activities involving bruising or bleeding (heavy S & M) Using someone elses sex toys

16. How should the clinician teach patients about prevention of HIV transmission? Patients must understand that they cannot be given absolute assurance that their sexual activities are safe; they must assess the relative risk of their sexual behaviors. Although HIV has been detected in saliva, there are no documented cases of transmission through saliva. Patients must assess whether they will alter their kissing behaviors based on this information and how they judge the relative risk of each behavior. Safe-sex education addresses the emotional impact of changing sexual behaviors (for example, the need to eroticise the use of condoms). Many communities offer courses on safesex practices through public health departments or community-based AIDS organizations. Questions from physicians or medical personnel about sexual practices may be the first opportunity for patients to discuss openly their concerns about HIV infection. 17. How does HIV infection affect the patients sexual self-image? Some HIV-infected patients come to view themselves as pariahs who no longer deserve sexual feelings or expression. Fear of transmitting the virus may stop all sexual activities. Fear of rejection

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by a sex partner may interfere with self-disclosure about HIV status. Issues of sexuality need to be addressed to help HIV-positive patients make informed decisions about future sexual activities. Risk assessinent should be based on current knowledge, not on uninformed fears and misconceptions.

18. How does discrimination interfere with the treatment of a person with AIDS? HIV and AIDS have affected large numbers of gay and bisexual men. Especially in the earlier years of the epidemic, discrimination against people with AIDS was based on homophobia, prejudice, and fear of contagion. Discrimination also occurs because people fear transmission of HIV. Homophobia is the fear and rejection of homosexuality and homosexuals; the attitude that homosexuality is undesirable, hateful, or evil; and a condensation of various negative cultural stereotypes about gay men and lesbians. As the epidemic has continued, education about homosexuality in the U.S. has helped to decrease the negative stereotypes of gay people. Gay men and lesbians may be reticent to disclose their sexual orientation to healthcare providers for fear of receiving inferior care. Healthcare providers may be uncomfortable treating them because of strong cultural beliefs, feelings, or views about homosexuals. Healthcare providers must address such issues so that patient care is not compromised. HIV-infected people may be concerned about confidentiality and fear discrimination in the workplace, from both employers and employees. Each state has its own statutes concerning the reporting of HIV status to the health department. In confidential reporting of HIV status, a persons name is kept on record at the health department in confidential files. Health departments with such approaches try to assure the public that records are safe from public disclosure. In states with anonymous testing for HIV, information about the number of HIV positive tests is known, but no record of the HIV-positive person is kept. The largest rise in new cases of HIV infection is among minority groups. Racism and culturally inappropriate educational materials contribute to the ineffective preventive efforts among ethnic populations.

19. How should the clinician teach intravenous drug users about prevention of HIV transmission? Needle exchange programs have been shown to be effective in decreasing HIV transmission. Complex social barriers prevent real implementation of this intervention. Clean needles must be used to decrease transmission of HIV and hepatitis. Some states have programs that teach drug users to clean needles with bleach and/or water. Cleaning of needles is somewhat effective. Bleach may cause blood to clot in needles, and clots may lead to transmission of HIV. Addicts may have difficulties in taking time to clean needles, especially when they are withdrawing from their drug of choice.
20. How can the clinician introduce the topic of HIV and AIDS in history taking? The mnemonic AIDS facilitates interviewing and identifies patients at risk for HIV infection. The mnemonic begins with a general and less threatening question before moving to more specific questions that deal with sensitive areas. A = Are you afraid you may have been exposed to AIDS? I = Intravenous drug use D = Diagnostic signs and symptoms of HIV infection S = Sexual behaviors A yes answer to any question signals the need for further exploration and consideration of serologic testing for HIV. 21. What are the particular issues of discrimination for families? Children with AIDS frequently come from families in which multiple members may be infected with HIV. Complex social problems often face such families, including drug addiction, poverty, and social ostracism. Communication among family members may be thwarted by the need to keep HIV infection a secret. This need often is a result of the familys fear of discrimination for the child in nursery or school settings. HIV-positive children are confronted with the deterioration of developmental skills, social isolation, and the possibility of imminent death. HIV-infected mothers are confronted

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with the question of how their child became infected. They must cope with illness, motherhood. disclosure of information about the illness to their children, and the effect of HIV infection on their reproductive choices.
BIBLIOGRAPHY
1.

2. 3.
4.

5.

Alfonso CA, Cohen MA, Aladjem AD, et a]: HIV seropositivity as a major risk factor for suicide in the general hospital. Psychosomatics 35:368-373, 1994. Chung JY, Magraw MM: A group approach to psychosocial issues faced by H1V-positive women. Hosp Community Psychiatry 43391-894, 1992. Cote TR, Biggar RJ, Dannenberg AL: Risk of suicide among persons with AIDS-a national assessment. JAMA 268:2066-2068, 1992. Mahler J , Stehinger A, Yi D, et al: Reliability of admission history in predicting HIV infection among alcoholic inpatients. Am J Addictions 3:222-226, 1994. Mueller TL, Swift RM: Screening for risk of HIV exposure using the A-I-D-S mnemonic. Am J Addictions
1:203-209. 1992.

72. PSYCHIATRIC CONSULTATION IN PATIENTS WITH CARDIOVASCULAR DISEASE


Andrew B. Littwan, M.D.
1. Describe type A behavior. The best known psychosocial risk factor for the development of coronary artery disease (CAD) is the type A behavior pattern. Type A behavior is defined as the habitual response to perceived demands with impatience and easily provoked aggravation, anger, and/or aggression. The global type A concept includes components of hard-driving nature, perfectionism, and low self-esteem. These global factors have waned in importance as hostility repeatedly has been found to be the toxic element of the type A syndrome. Hostility is linked to poor CAD outcomes by numerous mechanisms: increased atherosclerosis and sudden cardiac death, precipitation of myocardial ischemia and coronary vasospasm, and persistent cigarette smoking. 2. What other psychosocial factors are associated with poor outcomes in CAD? Phobic anxiety Lack of social support Anxiety disorders Social isolation and/or alienation Low socioeconomic status Vital exhaustion Depressive symptoms Lack of economic resources Job strain (low control and high demand) Major depressive disorder
3. What is the impact of major depressive disorder and depressive symptoms in patients with CAD? The impact is profound. Major depressive disorder is common in patients with CAD, and 20% have depressive disorder before their cardiac diagnosis. Only around 30% of these depressed patients and virtually none of the patients with depressive symptoms alone are diagnosed or treated. In a recent study, 18% of patients hospitalized for myocardial infarction (MI) had major depressive disorder, and depression predicted mortality at 6 months with a relative risk of 4.3, equivalent to left ventricular dysfunction and history of previous MI, the most potent prognostic measures known. In the past, in the absence of full-blown major depressive disorder, depressive symptoms were considered to be self-limited and of minimal importance. However, depressive symptoms also are common in coronary patients (1 840%). Like major depressive disorder, depressive symptoms commonly predate the onset of the initial clinical manifestations of CAD.