HIV/AIDS AND MENTAL ILLNESS: TODAY’S CHALLENGE Prof Seggane Musisi MD, FRCP (C) Department Of Psychiatry Makerere University Global Mental Health and Africa: Opportunities, Challenges And Collaborations Mbarara University Of Science And Technology: Aug. 15 th - 16 th , 2011
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HIV/AIDS AND MENTAL ILLNESS: TODAY’S CHALLENGE
Prof Seggane Musisi MD, FRCP (C)Department Of Psychiatry
Makerere University
Global Mental Health and Africa: Opportunities, Challenges And CollaborationsMbarara University Of Science And Technology: Aug. 15th - 16th , 2011
ACKNOWLEDGEMENTS• MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY
• MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES
• ACADEMIC ALLIANCE FOR AIDS CARE AND PREVENTION IN AFRICA (IDI)
• UGANDAN MENTAL HEALTH ASSOCIATIONS: • UPA, APRO, MHRC
• Maling’s et al: (2011). AIDS Care, Vol. 23, No. 2, 171-178– 18.4% Prevalence in First Episode Psychosis– F>M; Older age of onset (41 years). More auditory,
visual & tactile hallucinations. More likely to remit.
DISORDERS OF COGNITION• HIV-RELATED DELIRIUM
• Musisi et al.(2000): Makerere Medical School Journal• 40% of all C-L referrals. Early & Late stages of HIV/AIDS. Se/CRAG
• Lukwago et al. (2009): Delirium. In Psychiatric Problems Of HIV/AIDS & Their Management In Africa. Fountain Publishers
• 38% of ER attendees at Mulago Hospital. Associated with OI & ↑ viremia
• HIV ASSOCIATED DEMENTIA• Sactor N, Nakasujja N et al (2005): AIDS 19:1367-1374• The IHDS can screen for Dementia in Uganda/Africa• 31% prevalence Of Dementia: Cognitive impairment ↓ with HAART • Question: When can we start HAART with CD4>200?
• Nakasujja N et al(2010): BMC Psychiatry 10:44• Depressive & cognitive symptoms are common in HIV/AIDS • Cognitive deficits persist despite adequate treatment for depression
FAMILY PROBLEMS• FAMILY TYPES AND CONJUGAL PRACTICES AMONG HIV-POSITIVE
CLIENTS IN CARE IN UGANDA IN PAST 5 YEARS :→ Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
• 64% started off in monogamous unions, 28% got separated/divorced & 10% got into visiting unions with many partners,
• About 60% reported having lived in visiting unions at one point• Conclusion: Considerable flexibility, variability and volatility of marital
unions & conjugal practices among the HIV-positive TASO clients.
• DISCORDANT COUPLES: 10%
• WIDOWS: 30%
DISCLOSURE OF HIV STATUS TO PARTNER Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
Yes44%
Sometimes5%
Never39%
Not answered12%
CONDOM USE Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
Yes28%
No33%
On and Off35%
Not answered4%
PARTNER VIOLENCE Lwanga Musisi (2011): BA (Social Anthropology) Thesis. MUK.
Verbal
Physical
Sexual
No Violence
Verbal and Physical
Verbal, Physical and Sexual
Not answered
45
20
3
50
14
2
1
Series1
HIV/AIDS AND CHILDREN (Wakhweya et al, 2000)
• ORPHANS– >2 million orphans in Uganda, >14 million orphans in Africa
• Classification Of AIDS orphans:– HIV-positive orphans
• Have all the neuropsychiatric disorders, many physical illnesses associated with HIV + psychosocial problems
– HIV-negative orphans• Have only psychosocial problems but no major disorders
• Elderly caretakers (30%), Child-headed households• Poverty , Prostitution, Destitution• Mother to Child Transmission (25%)• >90% of infected children are orphans• >60% are in stage III of illness by 10 yrs
Impact Of HIV/AIDS-related Parental Death On Children’s Home Life
Increased:
. Poverty . Household responsibility
. Psychosocial distress
. Vulnerability to sexual & labor abuse, . Stigma and isolation . Hunger and malnutrition
Reduced:
- Access to food
- Access to health services
- Access to school
- Material goods : clothes, supplies
- Guidance, protection, and love
HIV-POSITIVE CHILDREN IN UGANDA.- Musisi S & Kinyanda E (2009), East African Medical Journal, Vol. 86, No. 1, 16-24.
• 97% of HIV-infected children are orphans
• >60% are in stage III of illness by 10 yrs
• They manifest major psychiatric disorders:
Anxiety (58.5%) Depression,(42%)
• Psychosis, (30%) Mania(7.2%)
• HPE (4.9%) Seizures(8.5%)
• Suicide, (20%) , Substance Abuse(4.8%).
• Somatoform Disorders (18.3%)
• No special services are available for them. •
The Psychosocial Problems Of Orphans (Musisi S, Kinyanda E, Nakasujja N (2007): African Health Sciences Journal, 7(4)
• Need Role Modeling , Social & Vocational Skills, and Health care.
• Live in poverty & exploitation (labor, sexual, spiritual & inheritances)
• Lack family & individual counseling / support & community resources
• Live in Fear & engage in survival behavior: – – Girls: Prostitution, early marriage or domestic help for girls. – Boys: Street children with petty theft , child labor & fights
• Have high rates of depression, suicide & substance abuse
Shelter: To build and/or repair houses
Psycosocial Interventions: Care, Protection, Schooling
School fees, scholastic materials and LUNCH
Contributing to a better future…
ELDERLY HIV-POSITIVES• NEW WAVE & INCREASING
• ↑ STIGMA, ↑ SECRECY, with ↓ACCESS TO CARE
• MULTIPLE PHYSICAL & MENTAL PROBLEMS
• HAD Vs OTHER DEMENTIAs
• SEXUALLY ACTIVE, SOME HAD >1 PARTNER. FEW USED CONDOMS
• ↓ SOCIAL SUPPORT, ARV TREATMENT & CLINIC ATTENDANCE
• NO SPECIFICALLY TARGETTED PREVENTION PROGRAMS
• LAXITY OF CARE ON THE PART OF THE STAFF
Elderly HIV-Positive Age Distribution (N=118)
AGEGROUP
>8076-8071-7566-7060-65
Pe
rce
nta
ge
70
60
50
40
30
20
10
0
The Elderly Sexual Behavior (last 3 months)
17.8%
12.7%
69.5%
no
yes
Missing data
The Challenge in Uganda’s HIV/AIDS Care:
The Apparent Absence of Mental Health In HIV-care
Problems In Scaling Up HIV care
Adherence, Resistance: The role of mental health
Substance Abuse
Unreached Pockets Of Infection : The marginalised (Trauma , mentally ill,
elderly, orphans, disabled)
Interventions & Policy
THE FUTURE• INTEGRATED MENTAL HEALTH IN ALL HIV CARE PROGRAMS.
• ORPHAN POLICY : – ORPHAN REGISTRY, LEGAL PROTECTION, – CHILDRENS AID SERVICES– LEGAL GUARDIANSHIP, – SCHOOLING,SHELTER, HEALTHCARE FOOD SECURITY– CHILD PSYCHOLOGY & GUIDANCE, – DISTRICT RUN FAMILY SERVICES
• RESEARCH INTO :– HIV CARE FOR THE ELDERLY, – LONG TERM OUTCOME OF MENTAL HEALTH DISORDERS OF HIV/AIDS,– COMFOUNDING MENTAL HEALTRH FACTORS IN HIV CARE IN UGANDA, – TASK SHIFTING APPROACH TO MENTAL HEALTH CARE PROVISION IN PHC HIV SETTINGS– ADHERENCE & MENTAL HEALTH SERVICES IN HARD TO REACH HIV COMMUNITIES– MENTAL HEALTH INITIATIVES TO ENHANCE THE SCALE UP OF HIV CARE IN UGANDA