APA’s Board of Trustees approved the Association’s 11th practice guideline at its meeting last month in Washington, D.C. The guideline deals with the treatment of patients who are HIV-positive or have AIDS. Information about the epidemiology, virology, and natural history of HIV/AIDS provides a context for the recommendations.

The evidence-based guideline incorporates the most up-to-date scientific research in its recommendation of treatments for adults with HIV/AIDS and mental illness. For example, the guideline deals with treatments for HIV-associated dementia and HIV-related substance use disorders. The guideline also offers help for patients with serious psychiatric disorders, such as psychosis, or symptoms that are less debilitating, such as anxiety or insomnia. Further, the guideline underscores the value of risk-reduction strategies.

John S. McIntyre, M.D., chair of APA’s Steering Committee on Practice Guidelines, commented, "Because of the nature of the disorder and what we know about its transmission, this guideline has some very important information in terms of prevention, more so than other guidelines."

The guideline cites findings from the 1998 NIMH Multisite HIV Prevention Trial Group, believed to be the largest randomized, controlled, HIV behavioral-intervention study conducted in the U.S. to investigate the importance of prevention strategies. It found that even among persons served in public health settings, patients who received just seven sessions in risk reduction reduced reported high-risk sexual behaviors by 50 percent and more than doubled their regular use of condoms.

The necessity of this guideline is evidenced by the number of new infections in the U.S., which shows no sign of decreasing any time soon. Although in the United States the death rate from AIDS has decreased in the past few years, the rate of new HIV infections has remained the same, at about 40,000 a year. The Centers for Disease Control and Prevention (CDC) found that as of late last year, more than 33 million people in the world were estimated to have HIV/AIDS, with most living in developing countries. Through December 1999, in the United States 733,374 persons with AIDS have been reported to the CDC. Such are the grim statistics presented in the guideline, which points to the best treatments and prevention strategies for psychiatrists caring for patients with HIV/AIDS.

Marshall Forstein, M.D., an assistant professor of psychiatry at Harvard University and chair of APA’s Commission on AIDS for the past 10 years, views the guideline as particularly helpful to a subsection of psychiatrists. "The guidelines present us with an opportunity to provide a more uniform approach to HIV care across the country, facilitating knowledge acquisition in places that may not have centers of activity," he emphasized. "It takes what we’re learning in the metropolitan centers where there is a lot of HIV being seen by psychiatrists and spreading the wealth to those who would only be seeing a few patients and not have the breadth of experience and know the more subtle and sophisticated treatment approaches."

J. Stephen McDaniel, M.D., chair of APA’s work group that produced the HIV/AIDS guideline and a professor of psychiatry and behavioral sciences at Emory University in Atlanta, acknowledges the relevance of the guideline to all psychiatrists. "Due to the current epidemiology of HIV and AIDS, it is much more likely today that a psychiatrist will see either a patient who is HIV positive or is at risk for acquiring the infection."

He also believes that psychiatrists, more than any other medical specialtists, have the expertise to work with combinations of psychotropic medications and HIV medications such as protease inhibitors.

Here are some of the topics covered by the guideline:

• Treatments for "high-risk" individuals, such as those with substance use disorders or severe mental illness, or victims of sexual abuse or crimes.

• Counseling for individuals receiving HIV-antibody testing.

• Factors that may influence treatment, such as race/ethnicity, sexual orientation, or socioeconomic factors.

• Complicating factors in patients with HIV/AIDS such as bereavement, suicidality, and personality disorders.

• Differential diagnosis of neuropsychiatric syndromes.

McDaniel also noted that even with general medically ill populations, "neuropsychiatric manifestations of HIV often go undetected, untreated, and/or undertreated. Treating complications like cognitive impairment, depression, and anxiety improve the quality of life," he added. "We also know that in many instances, treatment improves overall morbidity and increases adherence to treatment, both medical and psychiatric."

According to the guideline, future research should focus on whether there is a relation between HIV and the occurrence of psychosis, mania, depression, or other psychiatric disorders in individuals with HIV infection.