Transcript Coping with HIV and hep c

COPING WITH HIV AND HEP C
By Bill Coleman PhD
People with hepatitis C as well
as HIV are at increased risk for
mental health issues compared
with people in the general
population.
Living with HIV affects your mood.
Living with the hepatitis C virus doesn’t just take
a toll on your liver. It can also affect your mind.
Negative mental health effects can also stem
from your hepatitis C treatment.
Our mental health is key to our sense of well-being, and HCV can affect our
brain in many ways.
•Mental stress is very bad on the liver, which can worsen symptoms
of HCV. Mental and physical health of HCV+ people are strongly
related.
•Hepatitis C viruses have been known to cross the ‘blood-brain
barrier’.
•Liver damage can also cause toxins to remain in the blood,
eventually causing damage to the brain.
•Psychotropic (antidepressants - antianxiety drugs} can also
interact dangerously with other drugs such as those taken to fight
HCV and its symptoms.
•Some people with HCV may already have mental health and
addiction issues which are made worse as the virus does its
damage.
•Psychiatric problems are significantly more prevalent in hepatitis
C and HIV - infected people.
•Mental health problems are associated with an increased risk of
acquiring hepatitis C and HIV.
•Symptoms such as depression, fatigue can appear in HIV+
persons.
• Cognitive impairment (Brain Fog) could be due to the effect of
hepatitis C on brain chemistry or inflammation.
•Hepatitis C and HIV infections are associated with stigma, anxiety
and reduced quality of life, leading to high levels of psychosocial
distress.
•There is evidence that hepatitis C alters the metabolism of the
central nervous system.
EMOTIONAL SIDE EFFECTS OF HIV/HEP C
BRAIN FOG
IN HEP C
HCV doesn’t just affect the liver. It
can have profound affects of the
brains of HCV+ people. In chronic
HCV, brain function is often
impaired, characterized by a
syndrome combining mild
confusion, forgetfulness, and
difficulty concentrating or focusing,
which many refer to as
“Brain Fog”.
This can range from very mild forms
which no one really notices except
the HCV+ person experiencing the
cognitive difficulty, all the way to a
“gray area” between severe Brain
Fog and mild Encephalopathy.
If you have Brain Fog:
•Consult your liver specialist, nurse, and/or mental
health professional for advice and support.
•Do what you can to de-stress your life – this will
improve both your physical and mental health!
•Join a HCV+ peer support group.
•Exercise regularly, preferably with others.
•Take pleasure in simple things you enjoy and excel
at; don’t be hard on yourself.
DEPRESSION
Common in HIV and HEP C
DEPRESSION
Anyone can suffer from depression,
but with HIV and HCV it is more
common than in the general
population, and often develops or
worsens during treatment.
Addressing mental health symptoms
is important to antiviral treatment
success.
Close adherence to and completion
of multiple-week (HEP C) and
ongoing adherence with (HIV)
therapy are required for achieving
treatment success
(Sylvestre & Clements, 2007).
Depression is a very common symptom of chronic hepatitis C.
Key points:
•Drugs used for depression can be very bad for the liver. Consult with
your pharmacist, mental health professional, liver specialist, and/or
family physician to make sure you are not damaging your liver
unnecessarily.
•Depression can cause stress, which can damage your liver, and liver
damage can even make your depression worse, resulting in a vicious
cycle!
•HCV treatment is known to make depression worse, or cause it in
people who never experienced it before. If this happens, get help
immediately.
•If you or a friend or family member is experiencing severe
depression, never hesitate to ask for help. There is nothing to be
ashamed of, and people are there whose job it is to help you.
Mood changes, including anxiety and
irritability, can come with a diagnosis of
HIV as well as hepatitis C.
These same mood changes may also be
a side effect of hepatitis C treatment.
For example, irritability is an underacknowledged side effect of interferon
therapy,
according to a study published in the Journal of Clinical Nursing in 2011.
People who never had problems with anxiety,
depression, or irritability might experience these as a
result of treatment for chronic hepatitis and HIV, and
stable patients with previous mental health problems
might have exacerbations.
Some early symptoms of treatment-related depression might also mimic opioid withdrawal.
This can complicate clinical management for the large subset of
patients with chronic hepatitis C who have a history of opioid
injection drug use
(Schaefer & Mauss, 2008).
Sleep disturbances are common among people with
Hep C, affecting about 60 percent of people with the
infection, according to the Hepatitis Monthly
research review.
Sleep disturbances are also common with HIV+
persons.
Some sleep issues may be due to psychiatric
problems, substance abuse issues, or advanced
liver disease. In turn, not getting proper rest can
increase your risk for depression, anxiety, and not
feeling well in general.
Help lift your mood by seeking social support
from loved ones and others who also have the
condition. If the feelings of sadness become
overwhelming, it may be time to seek medical
help.
It’s important to deal with any mental health
issues, especially depression, because they
can get in the way of faithfully taking
medications.
It also increases the risk for engaging in
unhealthy behaviors.
Hepatitis C and HIV is often contracted through needles or
other equipment used to inject drugs, and many people
with hepatitis C and HIV also struggle with substance use
as well as the mental health issues that can go hand-inhand with that use.
Pre-existing mental health issues
can increase risk for substance
abuse and risk of getting HIV and
hepatitis C.
HIV MEDS AND
RECREATIONAL
DRUGS
ALCOHOL
• Excessive alcohol use may weaken the immune system
function and threatens the long-term benefits of ARV
therapy.
• Alcohol can increase blood levels of abacavir (Ziagen, fact
sheet 416).
• Chronic alcohol use affects treatment adherence by
interfering with a person’s ability to stick to a regular ARV
regimen.
• Alcohol use may increase the risk of pancreatitis when used
with didanosine
COCAINE
• Although interactions between
cocaine and ARVs are unlikely to
increase cocaine toxicity, the cocaine
use may decrease ARV
effectiveness by diminishing
adherence.
CRYSTAL METH,
METHAMPHETAMINE, GLASS, TINA
• A recent study found that gay men who
use crystal meth have five times the risk
of HIV infection as non-users.
• Serious and dangerous drug interactions
are highly likely.
• When methamphetamine is used with
ritonavir (Norvir, fact sheet 442),
amphetamine levels can double or triple.
ECSTASY/MDMA
• Ecstasy uses the same liver pathway as
protease inhibitors.
• This can cause very high levels of
ecstasy in the body of people taking
protease inhibitors.
• . Ecstasy can also increase the risk of
kidney stones when used with indinavir
(Crixivan, fact sheet 441) due to
dehydration.
GHB
• This drug is primarily metabolized by
the liver.
• There are no known interactions
between GHB and ARVs.
• Protease inhibitors may increase
GHB levels.
• Protease inhibitors may increase
GHB levels.
KETAMINE (K, SPECIAL K)
• This drug is primarily metabolized by the
liver.
• All protease inhibitors may cause high
levels of ketamine.
• This could cause hepatitis.
• To date, there are no case reports or
studies of interactions between ketamine
and ARVs.
MARIJUANA
• There are no known interactions
between marijuana and ARVs.
• Interactions may be greater if
marijuana is eaten rather than
smoked.
• Use with protease inhibitors may
increase effect of marijuana.
METHADONE AND HEROIN
•
Methadone increases by roughly
twofold the levels of AZT, some
people believe that people taking
both drugs need only take half the
standard dose of AZT to get the
same anti-HIV effect. (Check with
your MD.)
METHADONE AND HEROIN
• The NNRTIs efavirenz and
nevirapine speed up methadone
metabolism and this can result
in substantially decreased levels
of methadone
METHADONE AND HEROIN
• Patients began to report opiate withdrawal
symptoms eight to ten days after starting
nevirapine, but it is not recommended that
methadone dosage be increased at the
same time as starting nevirapine.
• Instead, it may be better to monitor
withdrawal symptoms and increase the
methadone dose if withdrawal does begin to
occur.4
METHADONE AND HEROIN
• Ritonavir reduces blood levels of
both methadone and heroin.
• Ritonavir-boosted protease
inhibitors have shown widely varying
effects on methadone levels.
• So the best advice is to monitor
carefully for methadone withdrawal
and increase the dose accordingly.
RECREATION DRUGS AND HIV
• Some doctors recommend leaving as many
hours as possible between a dose of a
protease inhibitor and a drug such as Ecstasy.
• There is no hard evidence that this will reduce
the risk of an interaction, but it is unlikely to
increase the risk either.
• Skipping the protease inhibitor dose is never a
good idea, as it may lead to drug resistance.
•The impact of psychosocial support
on HCV treatment outcomes was
evaluated and found that while
patients with mental health and
substance use disorders take longer to
initiate treatment. . . . (This may also
be true of HIV+ persons.)
• Psychosocial support helps these
patients access and complete
treatment with outcomes similar to
the general patient population.
Many patients with HIV and HCV infection had
complex neuropsychiatric and psychosocial
problems.
These problems are challenges for management
of the infection, and affects the patient’s care
significantly and might alter the course of the
disease.
A multidisciplinary approach, a supportive
environment, and a nonjudgmental healthcare
team are required for optimal medical and
psychosocial management of patients.
Neuropsychiatric side-effects of pegylated interferon
Hepatitis C therapy based on pegylated interferon is associated
with increased incidence of depression, fatigue, sleep
disturbances, fatigue, irritability, cognitive disturbances and
thoughts of suicide.
Therapy is less frequently associated with mania, confusion,
psychotic syndromes, attempted suicide and aggressive or
compulsive behaviour.
Symptoms including fatigue, sleep disturbances and decreased
appetite appear almost immediately after treatment is started.
Depression and cognitive problems usually emerge between
weeks 4 and 24 of therapy and are at their most intense
between weeks 8 and 16.
Therapy based on pegylated interferon is associated with
changes in neurobiology.
Changes to the serotonin and dopamine metabolism may be
an important cause of depression and fatigue.
Alterations in brain chemistry and toxicities may be contributing towards cognitive changes
on management of mental health for people with hepatitis C
European guidelines
Risk factors for depression or suicide associated with pegylated
interferon
•Depression during a previous course of
therapy based on pegylated interferon.
•Depression before treatment was started.
•Sleep problems during therapy.
•The emergence soon after starting therapy of
sleep problems or loss of appetite.
•Stress or lack of social support before
initiating treatment.