Introduction

HIV infection presents a series of challenges to the psychotherapist, testing his or her ability to respond compassionately and sensitively. The psychiatrist will often benefit from a thorough working knowledge of the issues faced by people infected with HIV.

In most ways, people living with HIV do not differ significantly from other psychotherapy patients. The main differences are:

1. the ongoing possibility of crisis

2. uncertainty about the future

3. The complex nature of HIV disease expression, antiretroviral treatments and associated side-effects

4. the strong countertransference reactions these patients may evoke.

Therapists should try to adapt the psychotherapy method they are most comfortable with to the special needs of the person living with HIV. Although most forms of psychotherapy are likely to be helpful for people living with HIV, a psychiatrist's formulation of the case and knowledge of differential therapeutics should inform the method choice.

Due to its potentially fatal outcome, HIV disease has the effect of imposing time pressure on patients, which may serve as a catalyst for work in therapy and make brief models ideally suited to this group of patients. They may feel more comfortable doing one or more successive “pieces of work” in therapy as they progress through different stages of the illness and their needs change. On the other hand, with the advent of HAART, people living with HIV now have indeterminate life expectancies and may benefit from the insight and knowledge gained from open-ended psychotherapy.

Pretest counseling

A person's for HIV testing should be honored.

• Explore risk history and discuss reasons for the test.

• Assess the person's risk of having been exposed to or of being infected with HIV.

• Provide information about HIV infection and testing, including the meaning of positive, negative, and indeterminate test results, and the impact of the window period. Discuss risk reduction and explore specific ways in which the person can avoid or reduce risk-producing behavior.

• Identify testing options available in the region, specifically nominal, non-nominal and anonymous testing.

• Discuss the potential benefits and harms of being tested and of being found HIV-positive.

• Discuss the confidentiality of test results in relation to office or clinical procedures, communicating results to other healthcare officials, provincial reporting requirements and partner notification.

• Discuss the stress related to waiting for test results and possible reactions to learning the results.

• Assess the window period by identifying the most recent risk event and plan an appropriate time for testing. Obtain and record informed consent, whether provided in writing or verbally, before testing is conducted.

• Arrange a return appointment after a predetermined interval for a face-to-face visit to inform the patient of his or her test results.

A person has the right to decline testing.

Post-test counseling

HIV test results are given only in person.

• Assess the patient's understanding of the test result.

• Encourage the patient to express feelings and reactions.

Negative and indeterminate result

• Discuss any need for repeat testing.

• Review the ways in which HIV is transmitted.

• […]

It was in 1996. The manuscript for the first edition of this Training Manual, produced under the auspices of Health Canada and the Canadian Psychiatric Association, was being completed. Many clinicians caring for HIV-infected individuals were becoming demoralized. The nucleoside reverse transcriptase inhibitors (NRTIs), the only class of antiretrovirals available at the time, were failing to make a significant impact on mortality. The full implication of the development of resistance to these medications was being felt.

Then, a second class of antiretroviral agents, the protease inhibitors (PIs) became available. Clinical trials were initiated and, at the International AIDS Conference held in Vancouver (Canada) in 1997, it became clear that a turning point had been reached. Antiretrovirals from different classes, used in combination, were exerting a very significant impact on mortality among HIV-infected individuals (Figure 0.1). Clinically, the result was striking. The waiting rooms of HIV clinics were the theaters of astonishing scenes. Patients on the brink of death were putting on weight and regaining stamina. Enthusiasm among patients and clinicians alike was palpable.

Psychiatrists too, were enthused. There was a sense that the psychological and neuropsychiatric burden associated with this infection would significantly decrease. Almost 10 years down the road now, it has become clear that the need for psychiatric care has far from decreased. As patients live longer, psychological and psychiatric difficulties negatively impact on quality of life.

The efficacy of Highly Active Antiretrovial Therapy (HAART) has a price: strict adherence to a complex medication regimen.