Unit IX: HIV/AIDS — Comprehensive Notes (MPhil Clinical

Psychology)

Compiled from: UNICEF/WHO Tools for HIV Counselling for the Asia-Pacific
(counsellor toolkit); Chippindale & French, HIV counselling and the
psychosocial management of patients with HIV or AIDS, BMJ ABC of AIDS
(2001); Woods, Moore, Weber & Grant, Cognitive Neuropsychology of HIV-
Associated Neurocognitive Disorders, Neuropsychol Rev (2009); Unit 9
disease notes (Studocu compilation). NACP/NACO section is drawn from
current government sources (cited inline) since none of the uploaded
material covered it — flagging this since programme details (phase,
targets) change over time.

1. Model of HIV Disease Service Programme in India

National AIDS Control Programme (NACP) — India's flagship

response, run by NACO (National AIDS Control Organization, under
Ministry of Health & Family Welfare, est. 1992). First HIV case in India was
detected in Chennai, 1986, in female sex workers.

Phase-wise evolution:

 NACP-I (1992–1999): Awareness generation, surveillance system

set-up, safe blood supply, prevention services for high-risk groups
(HRGs).

 NACP-II (1999–2006): Shift to (i) reducing spread of infection, (ii)

building long-term national capacity. Introduced National AIDS
Prevention and Control Policy (2002), National Blood Policy, GIPA
(Greater Involvement of People with HIV/AIDS), launch of the
National ART programme, State AIDS Control Societies (SACS) in
every state.

 NACP-III (2007–2012): Goal — "halt and reverse" the epidemic.

Made Prevention and Care, Support & Treatment (CST) the
twin pillars; decentralised management to district level; VCTCs
(Voluntary Counselling & Testing Centres) and PPTCT (Prevention of
Parent-to-Child Transmission) facilities remodelled into unified
ICTCs.

 NACP-IV (2012–2017, later extended): Consolidating the

reversal trend nationally; second-line ART, OI management, social-
protection linkages, public-private partnerships, stigma reduction in
healthcare settings.
  NACP-V (2021–2026): Central Sector Scheme, ₹15,471.94 crore
outlay, aligned with UNAIDS 95-95-95 targets (95% of PLHIV
know status → 95% of those on treatment → 95% of those virally
suppressed) and SDG 3.3. Aims: 80% reduction in new
infections/AIDS deaths from 2010 baseline; dual elimination of
vertical transmission of HIV and syphilis; elimination of HIV-related
stigma. Beneficiaries include sex workers, MSM (men who have sex
with men), transgender persons, and PWID (people who inject
drugs) as priority HRGs.

Service delivery architecture:

 ICTC (Integrated Counselling and Testing Centre): The core

entry point — one-stop for HIV counselling/testing, PPTCT, and HIV-
TB cross-referral. Located in OPDs, ObGyn departments, TB centres,
maternity homes — sited where the relevant risk group already
accesses care. Started 1997; now several thousand centres
nationally (facility-based, stand-alone, PPP, and mobile models
under the 2016/2024 HCTS guidelines). Only ~74–88% of PLHIV
nationally are aware of their status as of recent NACO figures —
case-finding remains the persistent bottleneck.

 ART Centres / Link ART Centres: Provide free antiretroviral

therapy and second-line regimens; Link centres extend drug
dispensing to lower-tier facilities so patients don't need to travel to
district hubs.

 Targeted Interventions (TIs): NGO/CBO-run outreach for HRGs

(sex workers, MSM, PWID via harm-reduction/needle-syringe
programmes).

 SACS (State AIDS Control Societies) and DAPCUs (District

AIDS Prevention and Control Units) handle state/district-level
programme management.

 Laboratory backbone: National/State Reference Laboratories

overseeing thousands of ICTC testing sites, quality-assured via
ICMR-NITVAR.

(Source note: this section is drawn from NACO's official pages and recent
secondary literature, since none of the uploaded readings addressed the
Indian service-delivery model specifically — flagging since exact centre
counts and phase end-dates are updated periodically.)

2. Pre-Test and Post-Test Counselling

Aims of HIV counselling (Chippindale & French, BMJ)

Two dual, non-negotiable aims:

1. Prevention — determining risk exposure, helping the client

understand it, identifying the meaning of high-risk behaviour to
them, assessing real potential for behaviour change, sustaining that
change.

2. Support — individual, relationship, and family counselling to

prevent/reduce psychological morbidity from HIV infection and
disease.

All counsellors should have formal training and receive regular clinical
supervision.

Pre-test discussion

Purpose: informed consent + realistic risk assessment + health education

(even for low-risk clients, this is an opportunity for safer-sex messaging).

Points counsellor/physician must cover (BMJ checklist):

 What the antibody test is (including seroconversion — the period

when the body starts producing detectable antibodies)

 Difference between HIV and AIDS

 The window period (~12 weeks/3 months since last exposure must
elapse before a negative result is reliable)

 Medical advantages of knowing status + treatment options

 Transmission routes; safer sex and safer injecting

 How the client would cope with a positive result — personal

resources, support network

 Who to tell, partner notification issues, whether the regular partner

knows about testing

 Confidentiality

 Whether client needs more time / further counselling

 How results will be given (in person)

Sexual/injecting risk history must be taken sensitively and specifically

— gender of partners, age at first sex, number of partners (6–12 months
and lifetime), specific practices and duration, STI history, condom-use
context, transactional sex history. If the client can't be honest here, the
whole risk assessment collapses (BMJ stresses this).
Indications for referral to specialist counsellor: high HIV-prevalence
area exposure; MSM; HIV-positive partner (past/present); symptomatic
presentation; high-risk sexual/injecting practice; learning or language
difficulty.

UNICEF Pretest Counselling Form (Tool 4.1) — structured items

include: prior test history; individual risk assessment tabulated by
exposure type (vaginal/anal/oral sex, needle-sharing, blood products,
tattoo/piercing, occupational exposure) crossed against whether it falls
inside the window period; pregnancy status; STI/TB symptom screen;
assessment of coping strategies ("How do you think you would cope if
the test shows you have HIV?"); a specific suicide-intent screen ("if
positive, would you harm yourself/someone else/fear violence from
partner?"); condom orientation; harm-reduction orientation for injecting
drug users.

Types of HIV testing (confidentiality models)

 Nominal — name recorded on requisition.

 Non-nominal — a code/initials substitute for the name.

 Anonymous — random code only; identity never linked to the

result.

Post-test counselling

For HIV-negative result: Reinforce risk-reduction messaging (this is a

"teachable moment" — BMJ notes information is best "heard" here);
recheck window period and whether retesting is needed; consider referral
for behavioural strategies (individual/group).

For HIV-positive result (BMJ + UNICEF Tool 4.5 checklist):

 Give results simply, in person, only after re-confirming the result

internally

 Allow time and space for emotional "ventilation" (shock, denial,

distress) before loading further information

 Assess suicide risk (formal tool — see §4)

 Focus on the immediate, not the whole future: what are

today's/this evening's plans, who can they be with tonight — not an
exhaustive HIV education dump (BMJ explicitly warns against
overloading the patient, noting this often reflects the counsellor's
anxiety rather than the client's need)

 Practical arrangements written down; medical follow-up scheduled

  Discuss partner-disclosure strategy using structured problem-solving

 Confirm client can get home safely

 Coping-management plan for next 48 hours

 Types of support to line up: ongoing counselling, medical/treatment,

peer/positive-network, financial, specialised mental health

For indeterminate result: explain possible window-period cause; urge

continued precautions; schedule retest at 12 weeks (4–6 weeks if
pregnant); provide stress-management support.

Confidentiality and referral tools: Tool 4.6 (referral form — specifies

what's being sought: medical/psychiatric/drug-alcohol/legal/welfare) and
Tool 4.7 (consent for release of information — separately covers disclosure
to referral agency vs to partner/family, and the manner of disclosure:
counsellor discloses in client's presence/counsellor discloses in
absence/client discloses themselves / a nominated third party discloses).

Counselling during combination ART (BMJ)

Optimism about long-term management has grown with combination

antiretroviral therapy, but the daily pill burden is itself a constant
reminder of infection; side-effects sometimes feel worse than the
disease itself. Counselling here focuses on realistic adherence assessment
and supporting the psychological adjustment to a lifelong medication
routine.

Psychological responses to a positive result (BMJ)

Framed as normal, expected responses to news of a chronic, life-

threatening condition — not inherently pathological, though pre-existing
morbidity can surface and must be screened for (depressed patients
should always be assessed for suicidal ideation).

Response Typical content

of diagnosis; recognition of mortality; loss of hope for the

Shock
future

uncertain prognosis; treatment effects/failure; isolation,

Fear/anxiety abandonment, rejection; fear of infecting/being infected;
partner's reaction

adjusting to chronic viral illness; absence of cure; health-

Depression imposed limits; social/occupational/sexual rejection;
treatment failure

Anger/ at becoming infected; involuntary lifestyle restriction;

Response Typical content

frustration demanding drug regimens

interpreting HIV as punishment (e.g., for being gay or

Guilt
using drugs); anxiety caused to partner/family

Causes of ongoing uncertainty: cause/course of illness, management

of dying, prognosis, others' reactions, treatment effects, long-term ART
impact, disclosure management.

Coping strategies to encourage: counselling, problem-solving,

participating in treatment decisions, social/family networks,
relaxation/massage, identifying areas of manageable personal control,
disclosure + support options.

The "worried well"

Present with multiple somatic complaints interpreted as certain proof of

infection; fears reach obsessive/hypochondriacal proportions; rarely
reassured for long even after repeated negative tests. Repeated testing is
not the answer — refer for behavioural psychotherapy/psychiatric
assessment instead.

Characteristic profile: repeated negative tests; low-risk but guilt-

laden sexual history; poor post-adolescent sexual adjustment; social
isolation; dependence in relationships; multiple misattributed somatic
symptoms (often undiagnosed viral/postviral states or anxiety/depression,
not HIV); psychiatric history; high anxiety/depression/obsessionality;
raised potential for suicidal gestures.

Counselling partners together

Only with explicit patient consent. Useful for: joint discussion of

lifestyle/sexual adjustment; serodiscordant-couple issues (partner HIV-
negative); correcting transmission misconceptions; normalising both
parties' psychological responses; couples planning or already having
children.

3. Psychosocial Issues and Their Resolution During HIV

Progression

The trajectory of psychosocial response (Unit 9 flowchart)

1. Exposure/diagnosis → triggers emotional, cognitive, behavioural,

existential cascade.
2. Initial emotional reactions — shock, denial, anger; may progress
to depression, grief, hopelessness, suicidal ideation; families enter
parallel grieving.

3. "Worried well" (see above) — high-risk but untested individuals

with preoccupation, anxiety, rumination.

4. Crisis phase (post-diagnosis) — shock, derealisation/dissociation,

guilt, self-blame, depressive onset/recurrence, heightened suicide
risk; worsened by stigma, loss of support, witnessing peer deaths.

5. Adjustment & coping phase — movement toward acceptance at

individual pace:

o Constructive: mobilising strength, activism, healthy routines

o Overcompensation: unrealistic fixation on

diet/supplements/exercise

o Maladaptive: persistent denial, dependence on caregivers

o Dependent style: needs reassurance, stable care relationships

Clinician's role: maintain empathic continuity, explain health
changes patiently.

6. Asymptomatic phase ("infected but well") — often reduces

risky behaviour (esp. gay men); adopts safer sex; may still carry
hidden distress.

7. Symptom emergence — loss of self-control, demoralisation, self-

blame, homophobic guilt (in MSM), partner-blaming, forced
disclosure of sexual orientation.

8. Depression/cognitive overlap — forgetfulness, poor

concentration, anhedonia, withdrawal, apathy, low self-esteem; can
mimic or overlap with AIDS Dementia Complex. Triggers: financial
strain, disfigurement, isolation, fear of abandonment, perceived loss
of dignity.

9. Suicide risk — driven by illness losses, stigma, lack of treatment

access, isolation. Protective: active grief counselling, early referral.

10. Grief and bereavement (family/partners) — pre-death

mourning common; families often already bereaved multiple times.
Worden's Tasks of Mourning: (i) accept reality of loss, incl.
physical deterioration; (ii) experience the pain of grief; (iii) adjust to
life without the person/former self; (iv) reinvest emotional energy in
new relationships/roles.
 11. Preparation for death — bargaining ("if I take care of
myself, maybe I'll live longer"), reckoning with mortality,
reconnection with family, practical planning, fatigue as a dominant,
whole-QoL complaint. Intervention goal: holistic management of
physical/emotional/spiritual fatigue.

Issues specific to women

 Relationship disruption: stigmatisation/fear/blame from family or

friends; isolation from fear of casual transmission or desertion; self-
esteem loss and self-blame; secrecy undermines coping and
worsens disease progression via chronic fear/anger/depression.

 Family caregiving concerns: lack of social support; grief and loss.

Social stigma as a chronic stressor

Persistent; prevents disclosure to family/friends; forces patients to bear

distress alone; can become internalised stigma.

Palliative and psychosocial care infrastructure

Comprehensive palliative care (part of PEPFAR — President's Emergency

Plan for AIDS Relief) is holistic and interdisciplinary, not just end-of-life.
Intervention intensity is matched to disease stage:

1. Emergency Plan model: (a) Clinical care

(asymptomatic/symptomatic/end-of-life & bereavement care); (b)
Vital/physical care; (c) Spiritual care; (d) Social care — plus
prevention counselling for HIV-infected persons.

2. Home-based — requires trained/educated medical providers +

community caregivers.

3. Community-based — free-standing OPD clinics, day-care centres,

school/university clinics, community health centres, workplace
clinics; provide primary care, acute/chronic condition
managemXMMent, supportive care.

4. Facility-based — hospital OPD/IPD with more advanced clinical

care and trained staff for diagnosis and management.

5. Hospice — end-of-life care delivered at home by trained

nurses/community caregivers; includes intensive family and
bereavement support.

Psychosocial intervention modalities

 Counselling services — coping with distress from diagnosis;

addressing discrimination/job-loss fears; educating on transmission-
 risk reduction to partners/children; voluntary counselling and testing
is evidence-linked to increased condom use. Should extend to at-risk
(not just positive) individuals — STI referrals, harm reduction,
condom access.

 Multidisciplinary team/case management — necessary given

the multiple chronic stressors PLHWA face; connects medical,
psychosocial, support services; client-centred, promotes adaptive
coping.

 Initial psychosocial assessment (newly diagnosed):

occupational/social functioning, support systems, prioritised
referrals (psychology, social work, dietetics), correcting myths,
realistic expectation-setting; nonjudgemental provider stance is
essential for rapport.

 Support groups — reduce isolation, open discussion; patient-led

and caregiver-led variants; often NGO/clinic-organised.

Cognitive-Behavioural Group Treatment (CBGT)

Ingredients: stress reduction, coping improvement, social-support

building, healthy emotional-expression space.

Process: conceptualise HIV-related cognitions → identify negative

automatic thoughts (NATs) → challenge them → substitute with adaptive
alternatives, via redefining, generating alternatives, examining evidence,
decatastrophizing, re-attribution, thought-recording, cognitive rehearsal.

Assessment domains: HIV status (symptomatic/asymptomatic, stage);

personality/coping/adjustment style; family attitude/support; distress
severity.

Behavioural techniques: relaxation, activity scheduling, behavioural

task assignment, role-play, social-skills training. Supportive techniques:
problem-solving, catharsis/ventilation, environmental manipulation,
externalisation of interests, creative art therapy, spiritual/philosophy-of-
life work.

Structure: groups of 6–8, led by 1–2 psychotherapists, weekly for 2–3

months. Reported effective for QoL and mood in HIV-infected individuals.

Cognitive-Behavioural Stress Management (CBSM): 10 structured

modules — health education, awareness of thoughts/emotions/physiology,
cognitive techniques, coping-skills training, interpersonal-skills training,
relaxation (diaphragmatic breathing, autogenic training, progressive
muscle relaxation, imagery, mindfulness), enhancing support resources.
Managing memory deficits (practical strategies):
diaries/calendars/notebooks, reminder notes, medication alarms,
cassette/noise-activated key-chain aids. Managing attention deficits:
reduce information overload, single-tasking, break tasks into steps, reduce
distractors (e.g., TV), one conversation partner at a time.

Hope Theory (Snyder & colleagues, 1991)

Hope out-predicted negative affectivity and optimism for problem-

focused coping. Defined as a cognitive set built from two reciprocal
components: (1) Agency — goal-directed determination; (2) Pathways
— planning routes to the goal. In HIV/AIDS, hope is implicated in sexual
practice choices, protection use, testing behaviour, and treatment
adherence — a useful strengths-based lever in intervention.

Objectives of psychosocial care overall: prolong survival, improve

quality of life, enable reintegration into society. Enhancing self-care
capacity is central to normal living.

4. Psychological Assessment and Intervention — Adults, Children,

and Family/Caregivers

Psychiatric/psychological screening algorithm (UNICEF Tool 6.2 —

adapted mhGAP-style)

Work down the checklist until a positive response is hit, then branch to the
relevant decision-tree:

1. Confusion/disorientation/impaired consciousness → screen for

physical cause first (always rule out organic cause before any
psychiatric flowchart)

2. Suicidal thoughts/acts

3. Incredible beliefs / hallucinations

4. Agitation/excitement

5. Withdrawn behaviour

6. Abnormal speech

7. Concentration/memory difficulty

8. Depressed mood/loss of interest

9. Anxiety/worry

Presenting Problem 1 (physical cause screen) — red flags requiring

immediate medical referral: impaired/clouded consciousness, recent-onset
confusion/disorientation, brief awareness lapses, fever, diabetes, seizure
earlier that day, recent head injury. Possible underlying causes: delirium,
opportunistic CNS/systemic infection, medication toxicity.

Each subsequent flowchart (2–9) systematically rules out, in order:

physical/organic cause → substance intoxication → trauma/stress reaction
→ mood disorder → possible HIV-related neurocognitive syndrome (HIV
encephalopathy/dementia) — before settling on a primary psychiatric
diagnosis such as depression, bipolar disorder, generalised anxiety, panic
disorder, OCD, or psychotic disorder. This ordering matters clinically: in
HIV populations, an organic/substance/neurocognitive cause must always
be excluded before attributing symptoms purely to a primary psychiatric
disorder.

Suicide risk assessment (Tools 5.1–5.2)

Interview structure: normalise the question ("often the pressures of

living with HIV are so overwhelming that some people think of ending their
life...") → frequency of ideation → duration of thoughts → bleakness rated
0–10 → specific plan (how/when/where) → access to means →
preparatory acts (note-writing, giving away possessions) → past attempts
→ perceived family/friend support → mood/appetite/sexual-functioning
changes → what would need to change for ideation to resolve.

Suicide Risk Matrix (Tool 5.2) — cross-tabulates Lower/Medium/High

risk across: plan specificity, means availability, timeframe, method
lethality, chance of intervention; previous attempts; recent stress;
coping/depression symptoms; available resources; directness of
communication (indirect/internalised expression = higher risk, not lower);
lifestyle stability; medical status (chronic debilitating illness = high risk).

Follow-up counselling form (Tool 6.1) — a running psychosocial

assessment covering:

 Medical follow-up and medication difficulties

 Brief psychological coping check (PHQ-style symptom list —

sad/anxious/empty mood, sleep/appetite change, anhedonia,
withdrawal, agitation, unexplained physical symptoms,
concentration/memory difficulty, hallucinations, fatigue,
guilt/worthlessness, suicidal thoughts) — ≥5 symptoms >2 weeks,
or functional interference, triggers a fuller assessment or referral

 Social/welfare (accommodation, finances, food/medication access,

relationships)
  Positive prevention: disclosure status and plan (who discloses,
how, in whose presence); condom-use pattern; sexual-dysfunction
screening as a barrier to condom use

 Substance use screen (triggers Tool 9.2 if positive)

 Pregnancy/PMTCT-related items

Drug and alcohol assessment (Tool 9.2)

Structured history: age/substance at first use; reasons for initiation (pain

relief, curiosity, peer pressure, pleasure, escapism, symptom-
suppression); substance-use progression and current pattern; route of
administration; injecting-specific risk (needle-sharing, cleaning practice);
treatment history; legal history. ICD-10 dependence guideline applied
by counsellor: ≥3 of the following co-occurring in the past year —
tolerance; withdrawal syndrome (or substance use to relieve it); strong
compulsion to use; impaired control over use; progressive neglect of other
interests; continued use despite clear harm. Explicitly motivational-
interviewing framed — assess readiness for change (Stages-of-Change
model, see §7) rather than pressuring toward detox.

Assessment/intervention for children — grief work (Tool 10.1)

Framed around embodied, expressive processing rather than verbal

insight alone (developmentally appropriate for children, who often
somatise grief).

 Expressive/externalising activities: "scream box," "mad box"

(physically destroying a box of anger-triggers), clay sculpting, worry
beads — channel affect through physical action.

 Memory-integration activities: paper chain of supportive people,

memory box/collage, "My Special One" structured worksheet
(documents the deceased, how the child learned of the death, what
they want to remember vs forget) — balances remembering with
permission to let go of painful details.

 Body-mapping: outline drawing, colouring in where grief is felt

physically — supports affect labelling in children who lack
vocabulary for internal states.

 For young children: physical/gross-motor activities (e.g., "fly like a

lion" — jumping from a safe height) reframed as reclaiming a sense
of power/agency lost during illness or bereavement.

 For teens: structured sentence-completion prompts ("I wish you

could tell me what your death was like...", "This is what helps me
 find meaning in my pain...") — supports more abstract, identity-level
grief processing appropriate to adolescent cognitive development.

 A guilt-specific group exercise: circle discussion normalising guilt

("it's not your fault"), followed by a physically cathartic release
(tearing up phone books) and a settling/discussion phase — pairs
affective discharge with cognitive reframing.

Family/caregiver-level intervention

 Partners/family sometimes struggle more than the patient with the

diagnosis (BMJ); individual counselling support needed for role
changes within the relationship.

 Joint patient-partner counselling only with explicit consent (see §2).

 Family caregiving concerns: social-support gaps, anticipatory grief,

and loss.

 Palliative/hospice models explicitly build in bereavement support

for family, not just symptom management for the patient (see §3).

5. Highly Active Antiretroviral Therapy (HAART)

Mechanism (UNICEF Tool 8.2)

HIV is a retrovirus (uses reverse transcriptase to convert RNA to DNA);

drugs against it are antiretrovirals (ARVs); correctly administered ARVs
with adherence support = ART.

Three major drug classes (each hits a different step of viral replication):

 NRTIs (nucleoside/nucleotide reverse transcriptase inhibitors) and

NNRTIs (non-nucleoside RTIs) — both block HIV from entering the
cell's genetic machinery, preventing new copies being made.

 PIs (protease inhibitors) — block the correct cutting/assembly of

new viral protein chains, so immature virions cannot mature into
infectious copies.

Why combination (≥3 drugs) therapy — "HAART":

1. HIV replicates extremely fast; a single drug slows this only modestly,
three drugs together far more.

2. Different drug classes hit different replication steps — hitting two

targets raises the odds of halting the virus.

3. Combination delays resistance (HIV needs only a small mutation to

escape one drug; escaping 2–3 simultaneously takes much longer).
"Bottle-with-a-hole" analogy used in patient education: the body is
a leaking bottle; missed/late doses let the drug level drop ("half-empty"),
and HIV can defend itself against low drug levels but not sustained high
levels — hence strict timing matters, not just correct dosing.

ART does not cure HIV — it blocks replication, halts further immune
damage, and lets the immune system partially recover, reducing
opportunistic infections.

Adherence counselling architecture (Tools 8.1, 8.3, 8.4, 8.5, 8.6,

8.7)

Pre-adherence checklist (8.1): reviews client's HIV/AIDS knowledge

(CD4/viral load understanding), anticipated barriers (communication,
literacy, disclosure fears, substance use, mental state, work/travel
constraints), the regimen itself (dummy-pill demonstration), and
adherence-promotion strategies (buddy/reminder systems) before
treatment starts.

Barriers to adherence (8.3) — three broad categories:

1. Individual-client barriers — subdivided into (a) understanding

(poor communication, language/literacy barriers, mistaken beliefs,
mistrust of ART efficacy); (b) motivation/remembering
(forgetfulness, depression/other psychiatric illness, active substance
use, difficulty with long-term goal-setting); (c) support/logistics
(disclosure fear, unstable living situation).

2. Health-system barriers (provider must advocate structurally).

3. Medication-related barriers (pill burden, side-effects, regimen

complexity).

Practical fixes emphasised: nonjudgemental, open discussion;

paraphrasing/repetition; dialect-matched counselling (avoid using family
members as interpreters — compromises honesty and accuracy); pictorial
materials and dummy-pill practice for low literacy.

Further tools: 8.4 (pre-adherence screening), 8.5 (resistance education),

8.6 (side-effect management), 8.7 (structured problem-solving specific to
ART difficulties).

Counselling during combination ART (BMJ)

Long-term survival optimism has grown, but the daily regimen is a

constant reminder of infection, and side-effects can feel worse than
the disease itself. Counselling's role: realistic adherence assessment +
support for the psychological adjustment to a lifelong medication routine
— an important, ongoing task, not a one-time pre-treatment briefing.
6. Neuropsychological Findings at Different Stages of HIV
Infection

(Woods, Moore, Weber & Grant, 2009 — HAND = HIV-Associated

Neurocognitive Disorders)

Epidemiology and background

Clinically obvious mild neurologic disease appears in roughly 30% of

asymptomatic HIV infection and roughly 50% of AIDS cases (Heaton et al.,
1995, cited in Woods et al. 2009). Since combination ART (cART, from
1996), the most severe form (HAD) has declined, but milder HAND forms
have stayed roughly stable — and may even have risen slightly among
people who are not immunosuppressed.

Current diagnostic nomenclature (Antinori et al., 2007 criteria) —

three tiers

1. Asymptomatic Neurocognitive Impairment (ANI): >1 SD below

demographically-adjusted norms in ≥2 cognitive domains, no
functional impairment. Majority of HAND cases fall here; still
linked to increased mortality risk and neuropathological abnormality
despite lack of everyday-functioning impact.

2. Mild Neurocognitive Disorder (MND, formerly MCMD): same

cognitive threshold plus mild everyday-functioning impact (≥2 of:
IADL decline, unemployment/reduced job responsibility, vocational
decline, self/proxy-reported cognitive problems in daily life, or
impaired performance-based functional testing). Estimated 5–20%
of the HIV population; ~25% of AIDS patients.

3. HIV-Associated Dementia (HAD): ≥2 SD below norms in ≥2

domains plus marked ADL decline. Prevalence has fallen sharply in
the cART era — from an early-1990s range of 6–30% down to
roughly 1–2% of PLHIV in more recent estimates.

Diagnosis requires assessment across ≥5 domains (executive function,

episodic memory, processing speed, motor skills, attention/working
memory, language, sensoriperception) and explicit exclusion of confounds
— severe depression/psychosis/substance dependence/delirium must not
be the sole explanation.

Neural substrate

HIV crosses the blood-brain barrier via a "Trojan Horse" mechanism

inside monocytes/macrophages. It preferentially disrupts fronto-striato-
thalamo-cortical loops — basal ganglia (caudate, putamen), frontal
neocortex, and the white-matter tracts connecting them — though
temporal/parietal regions are also affected since the virus doesn't have a
single fixed site of entry the way some neurodegenerative diseases do. In
the cART era, classical HIV encephalitis (microglial nodules) has become
less common, but synaptodendritic/white-matter injury and chronic low-
grade neuroinflammation persist even with good virologic control.

Cognitive domain profile

Domain Key findings

Bradykinesia (slowed movement) + bradyphrenia

(slowed thinking) — argued by some to be the
Motor/
cardinal HAND symptoms. Seen in gait, finger-tapping,
processing
manual dexterity; worsens under divided-attention
speed
load. Predicts driving safety, adherence, everyday
QoL.

Impaired in 40–60% of PLHIV; profile is mixed

encoding/retrieval deficit (poor free recall,
relatively spared recognition) in ~30–40% — a
"subcortical" memory pattern, distinct from the rapid-
forgetting profile of cortical dementias (e.g.,
Alzheimer's). Reduced use of organisational strategies
like semantic clustering. Prospective memory
Episodic memory
("remembering to remember") is also impaired and
strongly predicts medication non-adherence — up to
6× higher non-adherence risk with time-based
prospective memory deficits. Meta-memory deficits
(over/under-estimating one's own impairment) present
in 35–60%; under-reporting is especially risky since it
discourages use of compensatory strategies.

Basic attention relatively preserved early; deficits

emerge with disease progression (esp. CD4 <200) and
increase with task "load" (divided attention, response
Attention/
inhibition). Debate over whether the deficit is centred
working memory
in the central executive vs. storage/maintenance
systems (Baddeley & Hitch model). Predicts driving
accidents and adherence.

Executive Present in nearly all HAND profiles;

function abstraction/problem-solving deficits (Wisconsin Card
Sort, Category Test), set-shifting (Trail Making B),
response inhibition (Stroop interference), and risky
decision-making (Iowa Gambling Task) — linked to
Domain Key findings

impulsivity and real-world risk behaviours like condom

non-use.

Long thought spared; subtler deficits now documented

in egocentric spatial tasks, global/local processing,
Visuoperception covert orienting, mental rotation — tied to fronto-
striato-parietal network integrity rather than pure
occipital/parietal damage.

Aphasia is rare (unless an opportunistic CNS infection

like PML causes a focal lesion). Verbal fluency is the
most consistently affected language function (~40%
of PLHIV) — driven by impaired switching between
semantic categories during word retrieval, not
Language
degraded vocabulary itself. Action (verb) fluency is
disproportionately impaired (~60% of HAND cases)
relative to noun fluency, and is a stronger, more
sensitive predictor of IADL dependence than standard
letter/category fluency.

Course over time

HAND is not inevitably progressive — unlike Alzheimer's or

Huntington's disease. Course can show recovery (with effective cART),
worsening, static impairment, or fluctuation. In one major cohort, of those
impaired at baseline, 44% no longer met impairment criteria at follow-up;
transition rates from unimpaired→impaired and impaired→unimpaired
were roughly symmetrical (~21–23%).

Clinical/functional relevance

Neurocognitive impairment — especially psychomotor slowing, memory,

attention/working memory, and executive dysfunction — reliably predicts
everyday functional decline: medication non-adherence, IADL dependence
(financial management, etc.), and driving safety. This is why routine
neurocognitive/functional screening (self-report scales like Lawton & Brody
ADL or PAOFI, supplemented by proxy report where insight is poor)
matters clinically, not just as a research exercise.

7. Prevention, Awareness, and Interventions in At-Risk

Populations

The Stages-of-Change (Transtheoretical) Model in HIV counselling

(UNICEF Tools 3.1–3.3)
Used to assess and build motivation for behaviour change (condom use,
substance reduction, disclosure, etc.), not just to impart information.

 Readiness ruler (Tool 3.1): client self-rates 0–10 on (i) importance

of changing the target behaviour, (ii) confidence to change, (iii)
likelihood of relapse — opens a Socratic conversation ("why are you
at X and not 0/10? what would move you higher?").

 Stage-of-change wheel: Pre-contemplation → Contemplation →

Determination/Preparation → Action → Maintenance → Relapse
(cyclical, not strictly linear) — counsellor marks the client's stage
post-session to guide the next intervention pitch.

 Decisional balance (Tool 3.2): client tabulates pros/cons of

changing vs. continuing current behaviour — classic motivational-
interviewing technique.

 Goal-setting/commitment (Tool 3.3): formalises specific target

behaviours (eliminate/modify/keep same/undecided) while explicitly
respecting client autonomy ("how you engage in certain behaviours
is your own personal decision") — motivational rather than coercive
framing throughout.

Direct prevention skills training

 Condom use (Tool 4.3): structured male- and female-condom

instructions (checking expiry, correct application timing — only on
an erect penis, before contact — lubrication rules: water-based only,
oil-based lubricants degrade latex; one condom per act; safe
disposal).

 Safe injecting — "3 x 2 x 6" method (Tool 4.4): rinse works with
water 3×, then bleach 2× (≥30 seconds contact each time — the
minimum needed to inactivate HIV; note hepatitis B needs ≥2
minutes contact, and bleach's efficacy against hepatitis C is
uncertain even at 2 minutes), then water 6× to clear residual
bleach. Also covers safe handling of cookers/spoons/filters and
front-/back-loading equipment.

Population-specific and structural prevention (NACP/NACO

framing)

 Targeted Interventions (TIs) for High-Risk Groups — sex workers,

MSM, transgender persons, PWID — delivered via NGOs/CBOs,
including harm-reduction (needle-syringe programmes, opioid
substitution).

 PPTCT integrated into ICTC services for pregnant women (see §1).
  NACP-V's 95-95-95 alignment makes case-finding (the first "95" —
knowing one's status) the current structural bottleneck nationally,
which is why ICTC decentralisation (stand-alone, facility-integrated,
PPP, mobile models) has been a recent priority.

The BMJ prevention framing

Effective one-to-one prevention counselling requires frank discussion of

sensitive material that other settings (routine medical visits) often can't
accommodate due to confidentiality/judgement concerns. Core
components: determining whether the client's lifestyle carries risk; helping
them understand that risk in personally meaningful terms; identifying the
meaning the risk behaviour holds for them (this is what differentiates
counselling from simple health education); assessing genuine potential for
change; sustaining that change over time.

Quick cross-reference index (for viva recall)

Syllabus topic Primary source(s)

Indian service model NACO web sources (external, cited)

UNICEF Tools 4.1–4.7; BMJ (Chippindale

Pre/post-test counselling
& French)

Unit 9 flowchart; BMJ psychological-

Psychosocial issues/resolution responses table; UNICEF palliative-care
tools

Assessment/intervention UNICEF Tools 5.1, 5.2, 6.1, 6.2, 9.2, 10.1;

(adults/children/family) Unit 9 CBGT/CBSM section

UNICEF Tools 8.1–8.7; BMJ combination-

HAART
therapy section

Neuropsychological findings Woods et al. (2009), full paper

UNICEF Tools 3.1–3.3, 4.3, 4.4; BMJ

Prevention/at-risk populations
prevention aims; NACP TI framing