WHO News and activities
trained staff are available. This method of management should be taken as far down the health care system as possible. * Ergometrine and oxytocin should be stored in the dark at 2-8°C, i.e., in the tropics they should be refrigerated. * In clinical practice, the birth attendant should react to postpartum bleeding before 500 ml of blood has been lost. Likewise, when bleeding cannot be controlled arrangements for transfer of the mother to a facility with more skilled workers should be made in good time. o Midwives should be trained in the manual removal of the placenta, especially if they are going to work in remote areas. o All trained health workers should be capable of managing shock from acute haemorrhage by administering intravenous fluids. * Referral and transfer systems must be planned in advance, and generally strengthened. o Pharmacological studies are needed: - to determine the stability of oxytocic drugs under different thermal and light conditions; and - to develop alternative oxytocic drug delivery systems; attempts to prepare and evaluate rectal suppositories containing ergometrine and oxytocin should be undertaken. * Research is needed: - to determine the incidence of postpartum haemorrhage and the associated mortality rates as well as the circumstances leading up to them; - to audit management practices during the third stage of labour; - to determine the effect of nipple stimulation on oxytocin release and uterine contractility; - to study the effect on blood loss and PPH rates of different timing of cord clamping; - to compare the relative value of oxytocin, ergometrine, and a combination of the two, when used as part of the active management of labour; and - to replicate a previously conducted study that compared physiological with active management of the third stage of labour in a unit where physiological management is the current routine practice. * More reliable methods of assessing postpartum blood loss are needed. * Operational field trials are required to test methods of controlling PPH in underprivileged areas. * WHO should consider developing a clinical trial service to facilitate the performance of appropriate research. * As a major cause of maternal death, PPH is a concern of many different groups of people: information about it should therefore be widely disseminated. WHO Bulletin OMS. Vol. 68 1990.
Neuropsychiatric aspects of HIV-1 infectionc A wide range of neurological and psychiatric disorders can occur in subjects with human immunodeficiency virus 1 (HIV-1) infection. By 1991 it is expected that the number of neurologically symptomatic patients with acquired immunodeficiency syndrome (AIDS) in the USA will be nearly half as many as the total number of patients with epilepsy and far exceed the number of subjects with Parkinson's disease. With the further spread of the AIDS epidemic, it is likely that an enormous burden of neuropsychiatric problems will face the health care systems of many countries. It is very important, therefore, to produce projections about the number of persons who will be suffering from these problems over the next 5-10 years, and to undertake action to train staff and to provide care for those who will be affected. Moreover, it would be extremely useful to develop algorithms for the management of the most frequent of such disorders that can be applied even where the availability of diagnostic tools and of medications is very limited. A consultation on the neuropsychiatric aspects of HIV-1 infection was held at WHO in Geneva from 11 to 13 January 1990. The purpose of the meeting was as follows: to review the scientific evidence on the neurological and psychiatric disorders that occur in subjects infected with HIV-1, paying special regard to information that has been reported since 1988; to discuss the research activities that have been undertaken or planned in this area within the WHO Global Programme on AIDS/Division of Mental Health collaborative programme; and to develop operational diagnostic criteria for the neurological and psychiatric disorders associated with HIV-1 for use in research and clinical practice. Below is a summary of the major topics discussed by participants and a summary of the recommendations for action to be taken at the country level. Currently available information about the neurological and psychiatric disorders associated with HIV-1 infection has mainly been obtained from studies carried out in Western countries and on samples of homosexual and bisexual men. The generalizability of the findings obtained is therefore uncertain, and well-designed investigations in other geographical and sociocultural contexts, as well as in other at-risk populations, are clearly needed. The WHO multicentric study on neuropsychiatric aspects of HIV-1 infection, which is currently at the pilot Based on an article by M. Maj, Division of Mental Health, World Health Organization, 1211 Geneva 27, Switzerland.
c
671
WHO News and activMes
phase, represents an important step in this direction. The study has been implemented in the following centres: Bangkok, Thailand; Kinshasa, Zaire; Los Angeles, CA, USA; Munich, Federal Republic of Germany; Nairobi, Kenya; and Sao Paulo, Brazil. For this purpose a newly developed comprehensive instrument has been used to collect the neuropsychiatric data, which includes a battery of neuropsychological tests, designed to cover the functional domains affected by HIV-1 infection and to be, as far as possible, culturally nonspecific. At the meeting, the participants agreed that a group of conditions characterized by cognitive and motor impairment, which appear to be directly related to the infection of the brain with HIV-1, can now be reliably described. A new terminology was suggested, including a general term to encompass all the clinical entities (HIV-1-associated cognitive/ motor complex), and additional terms to segregate subsets of patients on the basis of the severity and the prominence of cognitive and myelopathic deficits (HIV-1-associated dementia, HIV-i-associated myelopathy, and HIV-1-associated minor cognitive/ motor disorder). In this scheme, the term cognitive/ motor complex replaces the previously used AIDS dementia complex (ADC); the term HIV-I-associated myelopathy covers the clinical syndrome corresponding to the pathologically identified vacuolar myelopathy; and the term HIV-1-associated minor cognitive/motor disorder corresponds to ADC stage 1 as well as to what was referred to as "neurobehavioural abnormalities other than dementia" in the report of the previous consultation on neuropsychiatric aspects of HIV infection, held in March 1988.d
After careful consideration of studies on performance in neuropsychological tests at the different stages of HIV-1 infection, the participants concluded that, according to the weight of available evidence, otherwise healthy individuals infected with HIV-1 (CDC groups II and III) are not more likely to present a clinically significant cognitive impairment than persons not infected with HIV-1. At present there is therefore no justification for carrying out serological screening of asymptomatic persons for HIV-1 as a strategy for detecting such impairment in the interest of public safety. However, this policy statement needs to be continually reviewed as fresh evidence becomes available. Hallucinations (either visual or auditory) and delusions (either persecutory or grandiose) are not Report of the Consultation on the Neuropsychiatric Aspects of HIV Infection, Geneva, 14-17 March 1988. Unpublished document
d
WHO/GPA/DIR/88.1. 672
infrequent in patients with AIDS or AIDS-related complex (ARC). They may occur within a context of cognitive impairment, which may sometimes be subtle or fluctuating, or they may be initially the only psychopathological manifestations, being followed later by symptoms such as disorientation, clouding of consciousness, or memory and concentration disturbances. In these circumstances, a diagnosis of organic brain syndrome (dementia or delirium) is usually warranted. There are, however, also patients who develop acute psychotic disorders without any evidence of cognitive impairment throughout the episode. The following interpretations for the disorders in the last-mentioned cases were proposed by the consultation: they may be a reaction to being diagnosed as having HIV-1 infection or AIDS; they may be produced by drugs used or abused by the patient; they may result from the chance association of psychosis and HIV-1 seropositivity; they may be precipitated by HIV-1 infection in predisposed subjects; or they may be directly related to HIV-1 infection of the brain. It was acknowledged that a depressive syndrome not fulfilling ICD-10 criteria for a severe depressive episode or DSM IIIR criteria for major depression may occur at any time in the course of HIV-1 infection, but more frequently in the period following the identification of HIV-1 seropositivity (adjustment disorder with predominant depression) or in the initial stage of HIV-1 dementia. It was emphasized that depressive symptoms may be difficult to differentiate from some manifestations of ARC (fatigue, anorexia, weight loss, loss of libido, or sleep disorders). On the other hand, the prevalence of severe or major depression in HIV-1-infected subjects is at present uncertain. The spectrum of mild and moderate reactions or disorders that occur as a reponse to the diagnosis of HIV-1 infection or AIDS, or more generally to the stress associated with the infection or disease, was extensively examined. It was confirmed that the appearance of such reactions or disorders may be conditioned by several factors, including the subject's coping strategies; previous history of psychiatric disorders; level of acceptance by the subject's family, work colleagues, and by society; and availability of adequate counselling, especially before and after HIV-1 serological testing. Several neuropsychiatric disorders caused by opportunistic processes in HIV-1-infected subjects were discussed and characterized. These included progressive multifocal leukoencephalopathy, cerebral
toxoplasmosis, cryptococcal meningitis, cytomegalovirus neuropathy, tuberculosis of the central nervous system, herpes zoster encephalitis, cytomegalovirus WHO Bulletin OMS. Vol. 68 1990.
WHO News and activities
encephalitis, varicella zoster radiculitis, and primary lymphoma of the central nervous system. The possible contribution of tropical diseases, such as malaria and trypanosomiasis, as opportunistic infections of the nervous system in patients infected with HIV-1 was also discussed. Several recommendations were made at the end of the consultation. Below are summarized those concerned with the action to be undertaken at country level. * Health workers should be made aware of the wide range of neuropsychiatric conditions associated with HIV-1 infection, and that, according to the weight of current information, otherwise healthy individuals who are HIV-1 seropositive are not more likely to present a clinically significant cognitive impairment than persons not infected with HIV-1. O Health services should prepare to deal with a large burden of neuropsychiatric illness, much of it severe, in patients with ARC or AIDS. * Governments should be made aware of the increased demand for neuropsychiatric care as the
WHO Bulletin OMS. Vol. 68 1990.
HIV-1 epidemic progresses, since they have the responsibility of ensuring that medical services receive proper support to cope with the increased work load, and that training programmes are implemented as soon as possible for key categories of health workers. * Those services that perform HIV-1 serological testing should in every case provide pre- and post-test counselling. * In planning the development of counselling services, the special needs of the families of subjects infected with HIV-1 and of the staff who deal with AIDS patients should be taken into account. * Governments and health workers should be aware of the high priority that needs to be given to research on the neurological and mental health aspects of HIV-1 infection, and of the immediate policy and care implications of the results: such research should be adequately encouraged, supported, and funded, taking into account that the uncertain generalizability of the research findings to different geographical and sociocultural contexts is at present a major difficulty.
673
Notes et activit6s OMS
* L'OMS devrait envisager de creer un service d'essais cliniques pour faciliter le travail des chercheurs. * L'HPP est une des principales causes de dce's maternels, et a ce titre elle interesse de nombreuses categories de personnes; les informations concernant cette complication devraient donc etre largement diffusees.
Aspects neuropsychiatriques de l'infection A VIH-lC Une grande variete de troubles neurologiques et psychiatriques peuvent survenir chez les sujets ayant une infection a virus de l'immunodeficience humaine type 1 (VIH-1). En 1991, aux Etats-Unis d'Amerique, le nombre de porteurs du syndrome d'immunodeficience acquise ayant des symptomes neurologiques aura presque atteint la moitie du nombre des epileptiques et depasse de beaucoup le nombre des parkinsoniens. Avec la propagation de l'epidemie de SIDA, les systemes de soins de sante de nombreux pays risquent d'etre confrontes a une masse enorme de troubles neuropsychiatriques. II importe donc de calculer les projections du nombre de personnes atteintes dans les 5 a 10 prochaines annees et de prendre les mesures qui s'imposent pour former le personnel et assurer la prestation des soins. Il conviendrait en outre de mettre au point des arbres de decision applicables a la prise en charge des troubles les plus frequents malgre la limitation des moyens diagnostiques et therapeutiques. Une consultation sur les aspects neuropsychiatriques de l'infection a VIH-1 s'est tenue 'a Geneve du 11 au 13 janvier 1990. La consultation s'etait assignee plusieurs buts: passer en revue les donnees scientifiques sur les troubles neurologiques et psychiatriques des sujets infectes par le VIH-1, tout particulierement les observations rapportees depuis 1988; examiner les travaux de recherche realises ou prevus a ce sujet dans le cadre du programme conjoint Programme mondial OMS de lutte contre le SIDA/Division Sante mentale; definir des criteres operationnels de diagnostic des troubles neurologiques et psychiatriques associes au VIH-1 applicables 'a la recherche et a la pratique clinique. On trouvera resumees ci-dessous les principales questions envisagees par les participants et les recommandations concernant les mesures a prendre au niveau national. Ce que l'on sait aujourd'hui des troubles neurologiques et psychiatriques associes 'a l'infection 'a VIH-1 vient pour l'essentiel d'etudes realisees dans les pays occidentaux, sur des echantillons d'homo-
sexuels et de bisexuels. L'extrapolation des conclusions est par consequent contestable, et de toute evidence, des investigations bien conques dans d'autres contextes geographiques et socioculturels, comme dans d'autres populations 'a risque, s'imposent. L'etude multicentrique OMS sur les aspects neuropsychiatriques de l'infection a VIH-1 actuellement en phase pilote est un pas important dans cette voie. Elle a ete mise en ceuvre dans les centres de Bangkok (Thailande), Kinshasa (Zaire), Los Angeles, CA (Etats-Unis d'Amerique), Munich (Republique federale d'Allemagne), Nairobi (Kenya) et Sao Paulo (Bresil). La collecte des donnees neuropsychiatriques a fait appel a un outil recemment mis au point qui comporte notamment une batterie de tests neuropsychologiques, et est conqu pour couvrir l'ensemble des domaines fonctionnels touches par l'infection a VIH et etre autant que possible independant des caracteristiques culturelles. Lors de la reunion, les participants ont reconnu qu'il est maintenant possible de decrire avec certitude un groupe d'affections caracterisees par une atteinte cognitive et motrice qui semble directement liee 'a la presence du VIH-1 dans le cerveau. Une nouvelle terminologie a ete proposee, notamment un terme general pour englober l'ensemble des entites cliniques (complexe cognitif/moteur associe au VIH-1) et des termes nouveaux pour distinguer des sous-groupes de patients d'apres la gravite et l'importance des deficits cognitifs et myelopathiques (demence associee au VIH-1, myelopathie associee au VIH-1, trouble cognitif/moteur mineur associe au VIH-1). Dans le schema propose, le terme "complexe cognitif/moteur" remplace le terme auparavant utilise de "complexe dementiel du SIDA"; l'expression "myelopathie associee au VIH-1" coiffe le syndrome clinique correspondant 'a la description anatomopahologique de la myelopathie vacuolaire; l'expression "trouble cognitif/ moteur mineur associe au VIH-1" correspond au stade 1 du complexe dementiel du SIDA ainsi qu'aux troubles decrits sous le nom d'..anomalies neurocomportementales autres que la demence" dans le rapport de la consultation precedente sur les 'aspects neuropsychiatriques de l'infection 'a VIH de mars 1988.d Apres avoir examine avec attention les resultats des tests neuropsychologiques aux differents stades de l'infection a VIH-1, les participants sont arrives 'a la conclusion que d'apres les observations dont on dispose, la probabilite que les sujets contamines par le VIH-1 et par ailleurs en bonne sante (groupes II et III des CDC) presentent une atteinte cognitive clid
D'apres un article de M. Maj, Division de la Sante mentale, Organisation mondiale de la Sante, 1211 Gen6ve 27 (Suisse). c
680
Rapport de la consultation sur les aspects neuropsychiatriques de linfoction i VIH, Gen6ve, 14-17 mars 1988. (WHO/GPA/DIR/ 88.1). WHO Bulletin OMS. Vol. 68 1990.
Notes et activit6s OMS
niquement importante n'est pas plus elevee qu'en l'absence d'infection a VIH-1. L'interet de la securite publique ne justifie donc pas a l'heure actuelle la recherche de l'infection a VIH-1 par le depistage serologique des sujets aysmptomatiques. II faut neanmoins que cette option soit continuellement r&eexaminee a la lumiere des faits nouveaux. Les hallucinations (visuelles ou auditives) et le delire (de persecution ou des grandeurs) ne sont pas rares en cas de SIDA ou d'ARC (para-SIDA). Ils peuvent survenir dans un contexte d'atteinte cognitive parfois discrete ou fluctuante ou etre au debut les seules manifestations psychopathologiques, suivies ulterieurement de symptomes tels que desorientation, obnubilation et troubles de la memoire et de la concentration. Un diagnostic de syndrome cerebral organique (demence ou delire) est alors generalement justifie. Il arrive cependant qu'apparaissent des troubles psychotiques aigus sans signe d'atteinte cognitive tout au long de l'episode. Ces troubles ont ete interpretes de la fa$on suivante par les participants: il peut s'agir d'une reaction a l'annonce du diagnostic d'infection a VIH-1 ou de SIDA; ils peuvent etre dus a la consommation ou a l'abus de drogues; ils peuvent resulter de l'association fortuite d'une psychose et de la seropositivite au VIH-1; leur survenue peut etre accleree par l'infection a VIH-1 chez les sujets predisposes; ils peuvent etre directement lies a la presence du VIH-1 dans le cerveau. On admet qu'un syndrome depressif ne repondant pas aux criteres de l'episode depressif severe de la CIM-10 ou a ceux de la depression majeure de la DSM IIIR peut survenir a n'importe quel moment de l'infection a VIH-1, mais plus souvent dans la periode qui suit la decouverte de la seropositivite au VIH-1 (trouble de l'adaptation a dominante depressive) ou au debut de la demence a VIH-1. On souligne qu'il est parfois difficile de distinguer les symptomes depressifs de certains manifestations de l'ARC (fatigue, anorexie, perte de poids, perte de la libido ou troubles du sommeil). La prevalence de la depression majeure ou severe chez le sujet infecte par le VIH-1 n'est par contre pas bien connue. Le spectre des reactions et des troubles benins et moderes resultant de l'annonce du diagnostic d'infection a VIH ou de SIDA, et plus generalement du stress associe a l'infection ou a la maladie, a ete longuement examine. On confirme que l'apparition de ces manifestations est sous l'influence de plusieurs facteurs, notamment des strategies de resistance mises en ceuvre par le sujet, des antecedents de troubles psychiatriques, de l'attitude des proches, des collegues de travail et de la societe en general, de la possibilite d'obtenir un soutien psychologique approprie, en particulier avant et apres le serodiagnostic du VIH-1. WHO Bulletin OMS. Vol. 68 1990.
Plusieurs troubles neuropsychiatriques d'etiologie opportuniste chez le sujet contamine par le VIH ont ete examines et caracterises. II s'agit de la leucoencephalopathie multifocale progressive, de la toxoplasmose cerebrale, de la meningite cryptococcique, de la neuropathie a cytomegalovirus, de la tuberculose du systeme nerveux central, de l'encephalite zonateuse, de l'encephalite a cytomegalovirus, de la radiculite varicello-zonateuse, du lymphome primitif du systeme nerveux central. L'intervention eventuelle de maladies tropicales comme le paludisme ou la trypanosomiase en tant qu'infections opportunistes du systeme nerveux chez les sujets contamines par le VIH a egalement ete discutee. Un certain nombre de recommandations ont ete formulees a la fin de la consultation. On trouvera resumees ci-dessous les recommandations concernant les mesures a mettre en ceuvre au niveau national.
Informer les personnels de sante de la grande variete des affections neuropsychiatriques associees a l'infection a VIH-1 et de ce que, d'apres les donn&ees existantes, la probabilite d'observer une atteinte cognitive cliniquement importante chez les seropositifs au VIH-1 en bonne sante n'est pas plus elevee qu'en l'absence de contamination par le VIH-1. * Les services de sante doivent se preparer a affronter une masse enorme de maladies neuropsychiatriques, la plupart severes, chez les SIDA et les paraSIDA. * Informer les pouvoirs publics de la demande accrue de soins neuropsychiatriques, au fur et a mesure que progresse l'epidemie de VIH-1, car il leur appartient de faire en sorte que les services medicaux recoivent l'aide appropriee pour repondre a l'augmentation de la charge de travail et que les programmes de formation soient mis en ceuvre au plus tot pour les categories de personnel concernees: O Les services qui pratiquent le depistage serologique du VIH-1 doivent dans tous les cas assurer egalement un soutien psychologique avant et apres le test. * Tenir compte, quand on planifie le developpement des services d'aide, des besoins propres aux familles des sujets contamines par le VIH-1 et aux personnels qui s'occupent des SIDA. o Informer les pouvoirs publics et les travailleurs de sante du rang eleve de priorite qu'il convient d'accorder a la recherche sur les aspects neurologiques et psychiatriques de l'infection a VIH-1 et de l'impact immediat des resultats sur les orientations et les soins: une incitation, un soutien et un financement appropries s'imposent, sans oublier que la generalisation discutable des resultats a des contextes geographiques et socioculturels differents est actuellement une des principales difficultes. O
681
trained staff are available. This method of management should be taken as far down the health care system as possible. * Ergometrine and oxytocin should be stored in the dark at 2-8°C, i.e., in the tropics they should be refrigerated. * In clinical practice, the birth attendant should react to postpartum bleeding before 500 ml of blood has been lost. Likewise, when bleeding cannot be controlled arrangements for transfer of the mother to a facility with more skilled workers should be made in good time. o Midwives should be trained in the manual removal of the placenta, especially if they are going to work in remote areas. o All trained health workers should be capable of managing shock from acute haemorrhage by administering intravenous fluids. * Referral and transfer systems must be planned in advance, and generally strengthened. o Pharmacological studies are needed: - to determine the stability of oxytocic drugs under different thermal and light conditions; and - to develop alternative oxytocic drug delivery systems; attempts to prepare and evaluate rectal suppositories containing ergometrine and oxytocin should be undertaken. * Research is needed: - to determine the incidence of postpartum haemorrhage and the associated mortality rates as well as the circumstances leading up to them; - to audit management practices during the third stage of labour; - to determine the effect of nipple stimulation on oxytocin release and uterine contractility; - to study the effect on blood loss and PPH rates of different timing of cord clamping; - to compare the relative value of oxytocin, ergometrine, and a combination of the two, when used as part of the active management of labour; and - to replicate a previously conducted study that compared physiological with active management of the third stage of labour in a unit where physiological management is the current routine practice. * More reliable methods of assessing postpartum blood loss are needed. * Operational field trials are required to test methods of controlling PPH in underprivileged areas. * WHO should consider developing a clinical trial service to facilitate the performance of appropriate research. * As a major cause of maternal death, PPH is a concern of many different groups of people: information about it should therefore be widely disseminated. WHO Bulletin OMS. Vol. 68 1990.
Neuropsychiatric aspects of HIV-1 infectionc A wide range of neurological and psychiatric disorders can occur in subjects with human immunodeficiency virus 1 (HIV-1) infection. By 1991 it is expected that the number of neurologically symptomatic patients with acquired immunodeficiency syndrome (AIDS) in the USA will be nearly half as many as the total number of patients with epilepsy and far exceed the number of subjects with Parkinson's disease. With the further spread of the AIDS epidemic, it is likely that an enormous burden of neuropsychiatric problems will face the health care systems of many countries. It is very important, therefore, to produce projections about the number of persons who will be suffering from these problems over the next 5-10 years, and to undertake action to train staff and to provide care for those who will be affected. Moreover, it would be extremely useful to develop algorithms for the management of the most frequent of such disorders that can be applied even where the availability of diagnostic tools and of medications is very limited. A consultation on the neuropsychiatric aspects of HIV-1 infection was held at WHO in Geneva from 11 to 13 January 1990. The purpose of the meeting was as follows: to review the scientific evidence on the neurological and psychiatric disorders that occur in subjects infected with HIV-1, paying special regard to information that has been reported since 1988; to discuss the research activities that have been undertaken or planned in this area within the WHO Global Programme on AIDS/Division of Mental Health collaborative programme; and to develop operational diagnostic criteria for the neurological and psychiatric disorders associated with HIV-1 for use in research and clinical practice. Below is a summary of the major topics discussed by participants and a summary of the recommendations for action to be taken at the country level. Currently available information about the neurological and psychiatric disorders associated with HIV-1 infection has mainly been obtained from studies carried out in Western countries and on samples of homosexual and bisexual men. The generalizability of the findings obtained is therefore uncertain, and well-designed investigations in other geographical and sociocultural contexts, as well as in other at-risk populations, are clearly needed. The WHO multicentric study on neuropsychiatric aspects of HIV-1 infection, which is currently at the pilot Based on an article by M. Maj, Division of Mental Health, World Health Organization, 1211 Geneva 27, Switzerland.
c
671
WHO News and activMes
phase, represents an important step in this direction. The study has been implemented in the following centres: Bangkok, Thailand; Kinshasa, Zaire; Los Angeles, CA, USA; Munich, Federal Republic of Germany; Nairobi, Kenya; and Sao Paulo, Brazil. For this purpose a newly developed comprehensive instrument has been used to collect the neuropsychiatric data, which includes a battery of neuropsychological tests, designed to cover the functional domains affected by HIV-1 infection and to be, as far as possible, culturally nonspecific. At the meeting, the participants agreed that a group of conditions characterized by cognitive and motor impairment, which appear to be directly related to the infection of the brain with HIV-1, can now be reliably described. A new terminology was suggested, including a general term to encompass all the clinical entities (HIV-1-associated cognitive/ motor complex), and additional terms to segregate subsets of patients on the basis of the severity and the prominence of cognitive and myelopathic deficits (HIV-1-associated dementia, HIV-i-associated myelopathy, and HIV-1-associated minor cognitive/ motor disorder). In this scheme, the term cognitive/ motor complex replaces the previously used AIDS dementia complex (ADC); the term HIV-I-associated myelopathy covers the clinical syndrome corresponding to the pathologically identified vacuolar myelopathy; and the term HIV-1-associated minor cognitive/motor disorder corresponds to ADC stage 1 as well as to what was referred to as "neurobehavioural abnormalities other than dementia" in the report of the previous consultation on neuropsychiatric aspects of HIV infection, held in March 1988.d
After careful consideration of studies on performance in neuropsychological tests at the different stages of HIV-1 infection, the participants concluded that, according to the weight of available evidence, otherwise healthy individuals infected with HIV-1 (CDC groups II and III) are not more likely to present a clinically significant cognitive impairment than persons not infected with HIV-1. At present there is therefore no justification for carrying out serological screening of asymptomatic persons for HIV-1 as a strategy for detecting such impairment in the interest of public safety. However, this policy statement needs to be continually reviewed as fresh evidence becomes available. Hallucinations (either visual or auditory) and delusions (either persecutory or grandiose) are not Report of the Consultation on the Neuropsychiatric Aspects of HIV Infection, Geneva, 14-17 March 1988. Unpublished document
d
WHO/GPA/DIR/88.1. 672
infrequent in patients with AIDS or AIDS-related complex (ARC). They may occur within a context of cognitive impairment, which may sometimes be subtle or fluctuating, or they may be initially the only psychopathological manifestations, being followed later by symptoms such as disorientation, clouding of consciousness, or memory and concentration disturbances. In these circumstances, a diagnosis of organic brain syndrome (dementia or delirium) is usually warranted. There are, however, also patients who develop acute psychotic disorders without any evidence of cognitive impairment throughout the episode. The following interpretations for the disorders in the last-mentioned cases were proposed by the consultation: they may be a reaction to being diagnosed as having HIV-1 infection or AIDS; they may be produced by drugs used or abused by the patient; they may result from the chance association of psychosis and HIV-1 seropositivity; they may be precipitated by HIV-1 infection in predisposed subjects; or they may be directly related to HIV-1 infection of the brain. It was acknowledged that a depressive syndrome not fulfilling ICD-10 criteria for a severe depressive episode or DSM IIIR criteria for major depression may occur at any time in the course of HIV-1 infection, but more frequently in the period following the identification of HIV-1 seropositivity (adjustment disorder with predominant depression) or in the initial stage of HIV-1 dementia. It was emphasized that depressive symptoms may be difficult to differentiate from some manifestations of ARC (fatigue, anorexia, weight loss, loss of libido, or sleep disorders). On the other hand, the prevalence of severe or major depression in HIV-1-infected subjects is at present uncertain. The spectrum of mild and moderate reactions or disorders that occur as a reponse to the diagnosis of HIV-1 infection or AIDS, or more generally to the stress associated with the infection or disease, was extensively examined. It was confirmed that the appearance of such reactions or disorders may be conditioned by several factors, including the subject's coping strategies; previous history of psychiatric disorders; level of acceptance by the subject's family, work colleagues, and by society; and availability of adequate counselling, especially before and after HIV-1 serological testing. Several neuropsychiatric disorders caused by opportunistic processes in HIV-1-infected subjects were discussed and characterized. These included progressive multifocal leukoencephalopathy, cerebral
toxoplasmosis, cryptococcal meningitis, cytomegalovirus neuropathy, tuberculosis of the central nervous system, herpes zoster encephalitis, cytomegalovirus WHO Bulletin OMS. Vol. 68 1990.
WHO News and activities
encephalitis, varicella zoster radiculitis, and primary lymphoma of the central nervous system. The possible contribution of tropical diseases, such as malaria and trypanosomiasis, as opportunistic infections of the nervous system in patients infected with HIV-1 was also discussed. Several recommendations were made at the end of the consultation. Below are summarized those concerned with the action to be undertaken at country level. * Health workers should be made aware of the wide range of neuropsychiatric conditions associated with HIV-1 infection, and that, according to the weight of current information, otherwise healthy individuals who are HIV-1 seropositive are not more likely to present a clinically significant cognitive impairment than persons not infected with HIV-1. O Health services should prepare to deal with a large burden of neuropsychiatric illness, much of it severe, in patients with ARC or AIDS. * Governments should be made aware of the increased demand for neuropsychiatric care as the
WHO Bulletin OMS. Vol. 68 1990.
HIV-1 epidemic progresses, since they have the responsibility of ensuring that medical services receive proper support to cope with the increased work load, and that training programmes are implemented as soon as possible for key categories of health workers. * Those services that perform HIV-1 serological testing should in every case provide pre- and post-test counselling. * In planning the development of counselling services, the special needs of the families of subjects infected with HIV-1 and of the staff who deal with AIDS patients should be taken into account. * Governments and health workers should be aware of the high priority that needs to be given to research on the neurological and mental health aspects of HIV-1 infection, and of the immediate policy and care implications of the results: such research should be adequately encouraged, supported, and funded, taking into account that the uncertain generalizability of the research findings to different geographical and sociocultural contexts is at present a major difficulty.
673
Notes et activit6s OMS
* L'OMS devrait envisager de creer un service d'essais cliniques pour faciliter le travail des chercheurs. * L'HPP est une des principales causes de dce's maternels, et a ce titre elle interesse de nombreuses categories de personnes; les informations concernant cette complication devraient donc etre largement diffusees.
Aspects neuropsychiatriques de l'infection A VIH-lC Une grande variete de troubles neurologiques et psychiatriques peuvent survenir chez les sujets ayant une infection a virus de l'immunodeficience humaine type 1 (VIH-1). En 1991, aux Etats-Unis d'Amerique, le nombre de porteurs du syndrome d'immunodeficience acquise ayant des symptomes neurologiques aura presque atteint la moitie du nombre des epileptiques et depasse de beaucoup le nombre des parkinsoniens. Avec la propagation de l'epidemie de SIDA, les systemes de soins de sante de nombreux pays risquent d'etre confrontes a une masse enorme de troubles neuropsychiatriques. II importe donc de calculer les projections du nombre de personnes atteintes dans les 5 a 10 prochaines annees et de prendre les mesures qui s'imposent pour former le personnel et assurer la prestation des soins. Il conviendrait en outre de mettre au point des arbres de decision applicables a la prise en charge des troubles les plus frequents malgre la limitation des moyens diagnostiques et therapeutiques. Une consultation sur les aspects neuropsychiatriques de l'infection a VIH-1 s'est tenue 'a Geneve du 11 au 13 janvier 1990. La consultation s'etait assignee plusieurs buts: passer en revue les donnees scientifiques sur les troubles neurologiques et psychiatriques des sujets infectes par le VIH-1, tout particulierement les observations rapportees depuis 1988; examiner les travaux de recherche realises ou prevus a ce sujet dans le cadre du programme conjoint Programme mondial OMS de lutte contre le SIDA/Division Sante mentale; definir des criteres operationnels de diagnostic des troubles neurologiques et psychiatriques associes au VIH-1 applicables 'a la recherche et a la pratique clinique. On trouvera resumees ci-dessous les principales questions envisagees par les participants et les recommandations concernant les mesures a prendre au niveau national. Ce que l'on sait aujourd'hui des troubles neurologiques et psychiatriques associes 'a l'infection 'a VIH-1 vient pour l'essentiel d'etudes realisees dans les pays occidentaux, sur des echantillons d'homo-
sexuels et de bisexuels. L'extrapolation des conclusions est par consequent contestable, et de toute evidence, des investigations bien conques dans d'autres contextes geographiques et socioculturels, comme dans d'autres populations 'a risque, s'imposent. L'etude multicentrique OMS sur les aspects neuropsychiatriques de l'infection a VIH-1 actuellement en phase pilote est un pas important dans cette voie. Elle a ete mise en ceuvre dans les centres de Bangkok (Thailande), Kinshasa (Zaire), Los Angeles, CA (Etats-Unis d'Amerique), Munich (Republique federale d'Allemagne), Nairobi (Kenya) et Sao Paulo (Bresil). La collecte des donnees neuropsychiatriques a fait appel a un outil recemment mis au point qui comporte notamment une batterie de tests neuropsychologiques, et est conqu pour couvrir l'ensemble des domaines fonctionnels touches par l'infection a VIH et etre autant que possible independant des caracteristiques culturelles. Lors de la reunion, les participants ont reconnu qu'il est maintenant possible de decrire avec certitude un groupe d'affections caracterisees par une atteinte cognitive et motrice qui semble directement liee 'a la presence du VIH-1 dans le cerveau. Une nouvelle terminologie a ete proposee, notamment un terme general pour englober l'ensemble des entites cliniques (complexe cognitif/moteur associe au VIH-1) et des termes nouveaux pour distinguer des sous-groupes de patients d'apres la gravite et l'importance des deficits cognitifs et myelopathiques (demence associee au VIH-1, myelopathie associee au VIH-1, trouble cognitif/moteur mineur associe au VIH-1). Dans le schema propose, le terme "complexe cognitif/moteur" remplace le terme auparavant utilise de "complexe dementiel du SIDA"; l'expression "myelopathie associee au VIH-1" coiffe le syndrome clinique correspondant 'a la description anatomopahologique de la myelopathie vacuolaire; l'expression "trouble cognitif/ moteur mineur associe au VIH-1" correspond au stade 1 du complexe dementiel du SIDA ainsi qu'aux troubles decrits sous le nom d'..anomalies neurocomportementales autres que la demence" dans le rapport de la consultation precedente sur les 'aspects neuropsychiatriques de l'infection 'a VIH de mars 1988.d Apres avoir examine avec attention les resultats des tests neuropsychologiques aux differents stades de l'infection a VIH-1, les participants sont arrives 'a la conclusion que d'apres les observations dont on dispose, la probabilite que les sujets contamines par le VIH-1 et par ailleurs en bonne sante (groupes II et III des CDC) presentent une atteinte cognitive clid
D'apres un article de M. Maj, Division de la Sante mentale, Organisation mondiale de la Sante, 1211 Gen6ve 27 (Suisse). c
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Rapport de la consultation sur les aspects neuropsychiatriques de linfoction i VIH, Gen6ve, 14-17 mars 1988. (WHO/GPA/DIR/ 88.1). WHO Bulletin OMS. Vol. 68 1990.
Notes et activit6s OMS
niquement importante n'est pas plus elevee qu'en l'absence d'infection a VIH-1. L'interet de la securite publique ne justifie donc pas a l'heure actuelle la recherche de l'infection a VIH-1 par le depistage serologique des sujets aysmptomatiques. II faut neanmoins que cette option soit continuellement r&eexaminee a la lumiere des faits nouveaux. Les hallucinations (visuelles ou auditives) et le delire (de persecution ou des grandeurs) ne sont pas rares en cas de SIDA ou d'ARC (para-SIDA). Ils peuvent survenir dans un contexte d'atteinte cognitive parfois discrete ou fluctuante ou etre au debut les seules manifestations psychopathologiques, suivies ulterieurement de symptomes tels que desorientation, obnubilation et troubles de la memoire et de la concentration. Un diagnostic de syndrome cerebral organique (demence ou delire) est alors generalement justifie. Il arrive cependant qu'apparaissent des troubles psychotiques aigus sans signe d'atteinte cognitive tout au long de l'episode. Ces troubles ont ete interpretes de la fa$on suivante par les participants: il peut s'agir d'une reaction a l'annonce du diagnostic d'infection a VIH-1 ou de SIDA; ils peuvent etre dus a la consommation ou a l'abus de drogues; ils peuvent resulter de l'association fortuite d'une psychose et de la seropositivite au VIH-1; leur survenue peut etre accleree par l'infection a VIH-1 chez les sujets predisposes; ils peuvent etre directement lies a la presence du VIH-1 dans le cerveau. On admet qu'un syndrome depressif ne repondant pas aux criteres de l'episode depressif severe de la CIM-10 ou a ceux de la depression majeure de la DSM IIIR peut survenir a n'importe quel moment de l'infection a VIH-1, mais plus souvent dans la periode qui suit la decouverte de la seropositivite au VIH-1 (trouble de l'adaptation a dominante depressive) ou au debut de la demence a VIH-1. On souligne qu'il est parfois difficile de distinguer les symptomes depressifs de certains manifestations de l'ARC (fatigue, anorexie, perte de poids, perte de la libido ou troubles du sommeil). La prevalence de la depression majeure ou severe chez le sujet infecte par le VIH-1 n'est par contre pas bien connue. Le spectre des reactions et des troubles benins et moderes resultant de l'annonce du diagnostic d'infection a VIH ou de SIDA, et plus generalement du stress associe a l'infection ou a la maladie, a ete longuement examine. On confirme que l'apparition de ces manifestations est sous l'influence de plusieurs facteurs, notamment des strategies de resistance mises en ceuvre par le sujet, des antecedents de troubles psychiatriques, de l'attitude des proches, des collegues de travail et de la societe en general, de la possibilite d'obtenir un soutien psychologique approprie, en particulier avant et apres le serodiagnostic du VIH-1. WHO Bulletin OMS. Vol. 68 1990.
Plusieurs troubles neuropsychiatriques d'etiologie opportuniste chez le sujet contamine par le VIH ont ete examines et caracterises. II s'agit de la leucoencephalopathie multifocale progressive, de la toxoplasmose cerebrale, de la meningite cryptococcique, de la neuropathie a cytomegalovirus, de la tuberculose du systeme nerveux central, de l'encephalite zonateuse, de l'encephalite a cytomegalovirus, de la radiculite varicello-zonateuse, du lymphome primitif du systeme nerveux central. L'intervention eventuelle de maladies tropicales comme le paludisme ou la trypanosomiase en tant qu'infections opportunistes du systeme nerveux chez les sujets contamines par le VIH a egalement ete discutee. Un certain nombre de recommandations ont ete formulees a la fin de la consultation. On trouvera resumees ci-dessous les recommandations concernant les mesures a mettre en ceuvre au niveau national.
Informer les personnels de sante de la grande variete des affections neuropsychiatriques associees a l'infection a VIH-1 et de ce que, d'apres les donn&ees existantes, la probabilite d'observer une atteinte cognitive cliniquement importante chez les seropositifs au VIH-1 en bonne sante n'est pas plus elevee qu'en l'absence de contamination par le VIH-1. * Les services de sante doivent se preparer a affronter une masse enorme de maladies neuropsychiatriques, la plupart severes, chez les SIDA et les paraSIDA. * Informer les pouvoirs publics de la demande accrue de soins neuropsychiatriques, au fur et a mesure que progresse l'epidemie de VIH-1, car il leur appartient de faire en sorte que les services medicaux recoivent l'aide appropriee pour repondre a l'augmentation de la charge de travail et que les programmes de formation soient mis en ceuvre au plus tot pour les categories de personnel concernees: O Les services qui pratiquent le depistage serologique du VIH-1 doivent dans tous les cas assurer egalement un soutien psychologique avant et apres le test. * Tenir compte, quand on planifie le developpement des services d'aide, des besoins propres aux familles des sujets contamines par le VIH-1 et aux personnels qui s'occupent des SIDA. o Informer les pouvoirs publics et les travailleurs de sante du rang eleve de priorite qu'il convient d'accorder a la recherche sur les aspects neurologiques et psychiatriques de l'infection a VIH-1 et de l'impact immediat des resultats sur les orientations et les soins: une incitation, un soutien et un financement appropries s'imposent, sans oublier que la generalisation discutable des resultats a des contextes geographiques et socioculturels differents est actuellement une des principales difficultes. O
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