HIV DOF Dec15
- 1. World Mental Health Day and Black History Month Life on AL1 older adults ward Bethlem apple harvest and the power of nature + SLaMnews News from South Londonand Maudsley NHS Foundation Trust for staff and members Winter 2015/16 HIV, mental health and stigma
- 2. Stigma is what prevents people being tested for this now treatable condition. The fear of rejection and the baggage of the old days when AIDS equalled death and AIDS labelled you as socially undesirable - along with the cultural fantasy that HIV was able to make moral decisions about who it infected, based on their life choices. Through the work of the Global Fund for the Eradication of AIDS and Malaria, based in Geneva, and currently led by Microsoft's Bill Gates, these medications are increasingly available globally. Guy Burch's recent exhibition "Head Spaces" at the Menier Gallery addressed memories of the decimation of London's gay communities in the 1980s, and the issues for those who survived long enough to get cART. Many people from those days have lost so many people in their lives and, having assumed they would die young, are now entering middle age. But new problems arise that still seem to be relatively unknown among health professionals. I found John Walters installation, "Alien Sex Club" (www.aliensexclub.com), which was at the University of Westminster and is opening again in Liverpool this winter - as did DV8's phenomenal dance theatre work by Lloyd Newson, "John" (www.DV8.co.uk) both about HIV today, both addressing what to me, as a psychiatrist practising in HIV psychiatry, is the contemporary discourse. Forget the skull and crossbones and the falling gravestones, and enter a world where gay communities are living with the plethora of antiretroviral medications and some sections of the gay communities, as well as other communities, are being deeply affected by a tidal wave of "chemsex. For those who are unfamiliar with the term, chemsex refers to the use of probably 120 new psychoactive substances (often augmented with Viagra), which are compulsive to take, increasing sexual arousal and repressing shame, leading to the enactment of pornography. Also in a world of geo-social apps (for example, Grindr or Scruff) it can lead to drug-fuelled sessions that can go on for hours or days, in which safer sex is unlikely to be maintained. Cover story 20/21 The message is to get everyone tested for HIV, which is now SLaM policy and is extending across the NHS. What HIV means for mental health today In 1986 Professor Tony Maden wrote a feature in the Maudsley and Bethlem Gazette on AIDS and its implications on public health policy. At the time the UK was experiencing an epidemic following on from the initial outbreak in the early 1980s in the US. In the same year the UK Government launched the worlds first major government-sponsored national campaign with the slogan AIDS: Dont die of Ignorance. Tuesday 1 December is World Aids Day, the day aims to raise support and awareness for people living with HIV. What a difference over 30 years makes since the first cases of HIV disease were recognised in Los Angeles in 1981. If I were to design a poster now, it would be HIV Stigma Kills; get tested for HIV because HIV infection is treatable with long-term medication, and seemingly has no impact on people's life expectancy. There is even some evidence suggesting those who do not smoke, who are HIV positive and on treatment have extended life expectancy, probably due to close medical supervision. We know more about the treatment revolution which began in 1996 with the appearance of combination antiretroviral treatment (cART). In the early years, it transformed the prognosis for those living with infection; although with the early medications the side effect burden was high. We now know that people on treatment are not infectious as long as they have a reliably undetected viral load, meaning that physical care or the most intimate sexual contacts are without risk of transmission. In my weekly HIV/mental health clinic with CASCAID, I urge the men I see to use condoms more to protect themselves from, for example, hepatitis C and treatment-resistant gonorrhoea than to protect against the possibility of infecting others with HIV. We also now know that giving these medications in the 72 hours after possible exposure to HIV (post- exposure prophylaxis = PEP) vastly reduces the risk of transmission, and now there is evidence that using medication for HIV negative sexually active men who have sex with men reduces infection risk (pre- exposure prophylaxis = PREP). Consultant psychiatrist and HIV specialist Dr David OFlynn from our CASCAID HIV service looks back on the 30+ years since the first cases of HIV were detected and what the virus means for our population today. The message is to get everyone tested for HIV, which is now SLaM policy and is extending across the NHS. For example, Chelsea and Westminster Hospital have a long and well established programme of offering blood-borne virus (BBV) testing to all who present for care. Under the current philosophy of "normalisation", HIV and other BBV testing should just be seen as a routine test. Adding the bells and whistles of consent forms and health advisers just increases reluctance. We know from antenatal clinics that women have been strong uptakers of testing. It seems when testing is made easily accessible at any point of access to health care, people will go for it. Lambeth and Southwark have the highest rates of HIV prevalence in Europe (13 to 15 per 1000 residents). Broadly speaking, half are people of Black African origin, and half are men who have sex with men. In the experience of CASCAID, we have a number of people of African descent who present late with advanced HIV disease. Some present with psychosis or HIV-related neuro-cognitive disorder to our inpatient wards, a tragedy considering the cerebral damage is irreversible and treatment is so freely available locally.
- 3. I have recently been involved with colleagues from the trust in the making of a blood born virus (BBV) training video: http://intranet.slam.nhs.uk/bbv. In it one of my patients, portrayed by an actor, talks about his experiences as a young gay man in Jamaica, being horrendously beaten for a night by a homophobic mob. When I first met him, he was a refugee, experiencing overwhelming hallucinations of the crowd who beat him to kill him. He later became HIV positive. He has now psychologically much recovered but, as the actor captures in the video, although he says HIV is no longer a problem, the look in his eyes says there is a huge weight for those who are positive. I watched the video with the patient involved and he wept, saying: "It brings it all back to me. It is ok now - but it isnt". Approximately 37 million people are living with HIV globally - only 15 million are receiving treatment (Kate Thomson. Global Fund). For the others HIV disease is as it ever was. At South London and Maudsley we run a number of services that work with HIV diagnosed patients including a dedicated mental health and HIV service. Through our addictions services we provide needle exchange, advice and information and a specialist chemsex clinic. Please email hivteam@slam.nhs.uk for more information. If you would like to read Tony Maden's original article visit: www.slam.nhs.uk/media/our-newsletter and follow the link. Cover story Members update 22/23 Nearly 50 people attended the seminar where Professor Simon Wessely gave an informative and amusing talk about shellshock, Post traumatic stress syndrome (PSTS) , and the myths that surround the conditions. Shellshock was a diagnosis used for a fairly short period during the First World War, although there was a tendency to treat it as moral cowardice and an attempt by its victims to get out of fighting. In many countries it was a capital offence. Shellshock was characterised by both mental and physical symptoms such as blindness (when there was no physical damage to the eyes). One case became a media sensation in Australia, where a soldier with total memory loss remained unidentified for many years. Post-war, shellshock became a significant theme in fiction. The diagnosis of PSTS (post-traumatic stress syndrome) arose following the Vietnam war. Most of what is now seen in the media relating to PSTS is inaccurate or untrue. Prof Wessely treated us to a one minute talk in the style of The Unbelievable Truth in which every fact except one was untrue (that one being that we no longer shoot people for having PSTS). Prof Wessely then spoke about his - and others - research into PSTS, mostly relating to the Iraq war. Length of exposure to combat (as opposed to support roles) increases the risk of PSTS, but a much greater risk to health is the level of alcohol intake. Military from the USA have much higher rates of PSTS than those from the British or Canadian armies, something that he believes actually relates to differences in health services. The NHS and the Canadian health service provide free health care, but the USA only get free treatment if they have completed 25 years in the army or have a service-related illness. We are planning further talks in the coming months. The next one will feature c hief executive Dr Matthew Patrick, talking about the mortality gap the reduced life expectancy that people with mental health problems suffer. If you have any suggestions or feedback, please contact membership@slam.nhs.uk or phone 020 3228 2441. Members Seminar Post-traumatic stress syndrome Anyone can become a member of the trust, and by doing so you will have the chance to influence how we develop our services. You can get involved as much or as little as you like. You can sign up at www.slam.nhs. uk/membership Seminars are another chance for our members to benefit from their membership. by Carol Stevenson, membership officer Sfc. Al Chang, 1950 息 U.S. Army Korea - Department of Defense Above: 息 Jonathan Bassett, Alien Sex Club art exhibition Some men I have seen have said they have been relieved to have been infected so that they perversely do not need to worry about being infected. The unsafe injection of, particularly, crystal meth seems to be becoming epidemic. The use of these stimulant drugs are leading to psychotic episodes and in my clinic I have people, who have been injecting crystal meth, who have seemingly developed enduring psychoses with no other clear risk factors. Alien Sex Club also approaches another issue, that of the eroticisation of transmission, the so-called "bug chaser", men who fantasise or actively seek infection. Effective treatment has opened up a whole range of different attitudes to infection. Some men I have seen have said they have been relieved to have been infected so that they perversely do not need to worry about being infected. Others, such as the participants in the research for DV8's "John", reportedly said they did not worry about getting infected because it was so treatable now. But then there is a literature of people in gay communities rejected for being HIV positive. The other less talked about epidemic is of Hepatitis C, and the increasing appearance of highly successful treatment regimes for Hepatitis C will raise complex issues. As opposed to life-long HIV medication, these treatments are for a matter of weeks or months. They are highly expensive and raise the issue of whether we are able, as an NHS, to spend hundreds of thousands of pounds on eradicating someone's hepatitis C, for them to get re-infected in the context of chemsex and unprotected penetrative sexual contact. So, it is a more optimistic world than Tony Maden described in 1986 but, as I have tried to portray in this piece, a much more complex picture has emerged. Safer sex and safer needle use seem to be in the retreat. HIV testing is being normalised and hopefully there will be more uptake of testing and treatment leading to lower community or herd infection rates. But the epidemic of the new psychoactive substances, and their influence on the transmission of infections, seems from the view I have from my HIV / mental health clinic to be on the ascent. Chemsex may become both a public and mental health phenomenon we still have to see through.