Health-related quality of life in persons with acquired immune deficiency syndrome

The fatigue experience: persons with HIV infection

Fatigue is a frequently reported symptom by persons with HIV infection and one that has an adverse impact on activities of daily living and overall quality of life. Although the concept of fatigue has been studied extensively and discussed in the literature, little is known about the experience of fatigue by persons with HIV infection. A hermeneutic phenomenological study was conducted to investigate the subjective experience of HIV-associated fatigue and to describe the management of fatigue in the context of daily life. In-depth interviews were done with 10 adult patients of an outpatient HIV/AIDS clinic. Thematic analysis identified three concerns that represented the meaning of fatigue for the participants. The first concern was 'Fatigue as a signal of AIDS'. A second concern was 'The mind, the body, the social experience of fatigue'. The third concern was 'Choosing ways to live with fatigue and addiction'. The findings provide insights for nursing practice regarding the subjective meaning of fatigue for patients with HIV and the need for nurses to explore this topic with patients.

Costs and outcomes of AIDS care: comparing a health maintenance organization with fee-for-service systems in the Boston Health Study

OBJECTIVE

A 4-month observational cohort study was performed to compare the performance of one health maintenance organization (HMO) with two fee-for-service (FFS) systems in Boston, Massachusetts in treating 255 patients with AIDS.

MAIN OUTCOME MEASURES

Total 4-month costs; cost subcomponents, including inpatient, outpatient, home care, and zidovudine costs; functional status (difficulties with activities of daily living); and satisfaction with care.

RESULTS

Compared with FFS patients, HMO patients were better educated, more often white, less often on Medicaid, and more often reported homosexual or bisexual behaviors as HIV risk factors (all factors, p = .001). Both groups had similar duration of AIDS, baseline hemoglobin levels, and leukocyte counts. Total 4-month costs at the HMO were significantly lower than those in the FFS settings ($4799 U.S. versus $8540 U.S.; p = .013), as were outpatient costs ($1131 U.S. versus $1614 U.S.; p = .001), after adjustment for sociodemographic factors, baseline functioning, main HIV risk factor, and other clinical variables. Adjusted physical functioning (p = .32) and patient satisfaction (p = .82). were similar between systems.

CONCLUSIONS

The HMO had significantly lower total costs without any observable decrement in functional outcomes or patient satisfaction. The largest component of these cost savings came from reduced spending on inpatient care, but the HMO also spent less on outpatient and home care. Better coordination of care at the HMO may have been responsible for these lower costs.

Functional status transitions and survival in HIV disease: evidence from the AIDS Costs and Service Utilization Survey

OBJECTIVE

The authors examined the prevalence of limitations in physical functioning in a large sample of people with human immunodeficiency virus (HIV) infection and the patterns of change in their functional status with time.

METHODS

Patients receiving treatment for HIV infection were sampled from 26 providers in 10 cities across the United States; the analytic sample included 1,784 adults with HIV infection. Functional status was measured three times during a 12-month period. Respondents indicated whether they were limited in their ability to perform six activities, ranging from vigorous activities to bathing and dressing. Responses to the six items were combined to form an index of physical functioning. Medical records were used to determine stage of HIV infection, and death records were used to determine vital status. Changes in functional status during a 1-year period were assessed; correlates of change were examined using multinomial logistic regression, with "deceased" included as an outcome state.

RESULTS

Limitation was most prevalent for vigorous activities (55%) and least prevalent for activities of daily living (12%). For each activity, the prevalence of limitations rose with increasing disease severity. During 1 year, 43% of respondents did not change in functional status, whereas 42% became worse and 15% reported improved functioning. Controlling for prior functional status, multivariate analyses showed that declines in functioning were related to developing acquired immunodeficiency syndrome (AIDS), to prior reports of fatigue, and to poor self-rated health. These same variables also predicted mortality.

CONCLUSIONS

Results suggest that the most prevalent types of home care assistance needed by those with HIV disease involve help with energy-demanding activities, such as shopping, and that nonuniform patterns of change in functioning necessitate flexible programs to meet frequently changing needs.

Reliability and validity of physical and mental health summary scores from the Medical Outcomes Study HIV Health Survey

OBJECTIVES

Health-related quality of life measures are used to evaluate patient outcomes in clinical trials of new treatments for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). Summary index scores, rather than profiles of scale scores, would simplify data analysis and interpretation of findings from clinical trials and comparison across studies.

METHODS

Baseline MOS HIV Health Survey scores from two clinical trials of new antiretroviral medications in HIV/AIDS patients (total n = 2253) and an observational study (n = 162) were used to develop physical health summary (PHS) and mental health summary (MHS) scores. Exploratory and confirmatory factor analysis were used to identify the factor structure of the summary scores based on MOS HIV Health Survey scales. Physical health summary and MHS scores were derived and the factor structure proved invariant across the two groups.

RESULTS

Reliability of the PHS score was 0.90 to 0.92 and MHS score was 0.91 to 0.94. Mean PHS and MHS scores differed in patient groups defined by HIV disease stage, HIV disease severity, Karnofsky performance status scores, and global ratings of health status. Mean PHS and MHS scores in patient reporting worsening health status were significantly lower than scores of patients reporting stable or improving health status.

CONCLUSIONS

The PHS and MHS were reproducible across different samples of HIV/AIDS patients and are reliable and valid measures for demonstrating treatment impact on patient functioning and well-being.

A new HIV/AIDS-targeted quality of life (HAT-QoL) instrument: development, reliability, and validity

OBJECTIVES

The objectives of this study were to identify quality-of-life concerns, as reported by human immunodeficiency virus (HIV) seropositive individuals, and to develop a measure to assess these concerns.

METHODS

The HIV/acquired immunodeficiency syndrome (AIDS)-targeted measure was developed in two linked studies. In study one, group discussions with 42 HIV seropositive individuals were used to generate item content for the new measure. In study two, 201 HIV seropositive individuals were cross-sectionally studied to identify dimensions and to reduce the number of items of the quality of life questionnaire resulting from study one.

RESULTS

Study one subjects (76% male; 66% white; 55% gay/bisexual) identified concerns captured by 76 items. Factor analysis indicated that responses of study two subjects (78% male; 42% white; 55% gay/bisexual) could be summarized by nine dimensions. Overall function, sexual function, disclosure worries, health worries, financial worries, HIV mastery, life satisfaction, medication concerns, and provider trust dimensions were refined by removing items using methods to maximize internal consistency and to minimize item redundancy. No substantial ceiling/floor effects existed, except for the provider trust dimension (43% received the highest score possible). All internal consistency coefficients were > or = 0.70, except those for the HIV mastery (0.57) and medication concerns (0.51) dimensions, as well as the sexual function dimension (0.56) in the non-AIDS subsample. Multitrait/multiitem assessment indicated scaling success rates that were high (> or = 91%) for eight of nine dimensions (HIV mastery revealed a lower but modest success rate of 79%). Validity assessments, using self-reported HIV disease severity and sociodemographic variables, indicated expected relationships for all dimensions.

CONCLUSIONS

Five dimensions of the new HIV/AIDS-targeted quality of life instrument (overall function, disclosure worries, health worries, financial worries, and life satisfaction) exhibited good psychometric properties, including low ceiling/floor effects, good internal consistency, and evidence for construct validity.

Health-related quality of life in chronic disorders: a comparison across studies using the MOS SF-36

The purpose of this report is to examine health-related quality of life (HRQoL) as measured by the Medical Outcomes Study Short Form-36, across patient populations with chronic disorders and to compare quality of life (QoL) in these subjects with normative data on healthy persons. Six studies, within the Center for Research in Chronic Disorders at the University of Pittsburgh School of Nursing, in patients with urinary incontinence, prostate cancer, chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), fibromyalgia and hyperlipidaemia provided the data for analysis. The results demonstrated that not only did the prostate cancer and hyperlipidaemia patients have the highest QoL across the chronic disorders, but their QoL was comparable to normative data on healthy persons. Homebound, elderly, incontinent patients had the lowest QoL for physical functioning, whereas patients hospitalized with AIDS had the lowest QoL in general health and social functioning. Patients with COPD had the lowest QoL in role-physical, role-emotional and mental health. Patients with fibromyalgia had the lowest QoL in bodily pain and vitality. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia generally had lower QoL. Prostate cancer and hyperlipidaemia patients had QoL comparable to normative data. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia had more variability for role-emotional. AIDS patients had more variability on physical functioning, bodily pain and social functioning compared to the normative data. These data suggest that patients with various chronic disorders may have QoL that is lower in most domains compared to a healthy population. However, there may be differences in the domains affected as well as the extent of variation across specific chronic disorders.

Disease-related factors associated with health-related quality of life in people with nonadvanced HIV disease assessed using an Italian version of the MOS-HIV Health Survey

OBJECTIVE

This study was intended to present evidence for the reliability and validity of an Italian version of the MOS-HIV Health Survey and to identify important disease-related factors associated with health-related quality of life (HRQoL) in people with nonadvanced HIV.

DESIGN

In this cross-sectional study, HRQoL was measured using an Italian version of the MOS-HIV Health Survey questionnaire in 213 HIV-infected people without previous opportunistic infections or neoplasms attending an outpatient clinic in a university hospital. Distribution of scores, reliability, and validity were calculated, and presence and frequency of HIV-related symptoms were recorded and transformed into a score. The relation of HRQoL values to sociodemographic, epidemiologic, and clinical data was assessed.

RESULTS

The level of internal consistency of the Italian version of the MOS-HIV Health Survey was high (Cronbach's alpha, 0.80-0.93), and items demonstrated acceptable discrimination across scales. At linear regression analysis, all domains of HRQoL correlated with symptom score (r2 range, 0.07-0.41), but only the pain and physical-functioning scores showed a significant correlation with CD4 cell count. A weighted sum of single domains of HRQoL, TOTQoL, is also strongly correlated with symptom score (r2 = 0.57; p < .0001) but not with CD4 cell count (r2 = 0.01; p = .1). Using multivariate analysis, only symptom score (p < .0001) and total number of daily pills (p = .03) showed significant association with HRQoL. The same results were observed when analysis was performed only on people with CD4 levels <200/microl.

CONCLUSIONS

This study presents the first evidence for the reliability and validity of a HRQoL instrument in Italian for people with HIV. Results also suggest a strong impact of symptoms on all measured dimensions of health status. The number of pills required to be taken daily is the only other significant factor associated with a lower HRQoL, whereas no relations were found with CD4 cell count or Karnofsky performance status values. To improve HRQoL in persons with nonadvanced HIV disease, symptom control could be a crucial element of medical treatment.

Clinical predictors of declines in physical functioning in persons with AIDS: results of a longitudinal study

OBJECTIVE

This study was performed in an attempt to determine clinical correlates of declines in physical functioning in people with AIDS.

DESIGN

An 8-month longitudinal cohort study was performed at three sites in Boston, Massachusetts: a private academic group practice, an AIDS clinic at a public teaching hospital, and a staff-model health maintenance organization. Intermediate activities of daily living (IADLs), 10 symptoms and symptom complexes, mental health, and weight loss were assessed by interview in 201 persons with AIDS. Clinical diagnoses, comorbidities, laboratory results, and use of selected medications were assessed by chart review.

RESULTS

Participants were young (mean age, 36 years), 92% were male, 35% were nonwhite, and 27% had a history of injection drug use. The mean 8-month decrement in physical functioning was 9.6 points on a 100-point scale, and mean weight loss was 2.3 kg. After adjusting for baseline functioning, age, sex, race, and educational level, independent predictors of the 8-month IADL score included worsening fatigue (p = .0002), worsening neurologic symptoms (p = .001), weight loss (p = .0001), Candida esophagitis (p = .020), hypertension (p = .0005), depression (p = .004), and gastrointestinal (GI) disease (p = .018, model R2 = 0.56).

CONCLUSIONS

Two symptom complexes (fatigue and neurologic symptoms), three comorbidities (hypertension, depression, and GI disease), and weight loss were significant independent predictors of 8-month IADL scores after statistically controlling for baseline IADL score and sociodemographic variables. These clinical factors are potential targets for interventions designed to improve physical functioning.

Psychosocial predictors of life satisfaction among persons living with HIV infection and AIDS

As AIDS becomes a more chronic but manageable illness, understanding quality of life issues among persons living with this disease has become an important goal of health care researchers. However, most quality of life investigations of persons living with HIV disease have relied heavily on clinical samples (e.g., hospitalized patients, psychiatric outpatients). The present study sought to identify psychosocial predictors of general life satisfaction in a community sample of 275 persons living with HIV/AIDS in a large midwestern state. Principal components and multiple regression analyses revealed that improved physical/functional well-being, increased social support, more frequent use of active coping strategies, and fewer incidents of AIDS-related discrimination and stigma predicted higher levels of general life satisfaction (R2 = 39). Intervention strategies likely to produce higher levels of life satisfaction among persons living with HIV disease are discussed.

Fatigue, Depression, and Quality of Life in HIV-Positive Men

1. Fatigue is a real symptom of HIV infection, and up to two thirds of clients with HIV report symptoms of depression. 2. Depression and fatigue, besides being closely related in HIV cases, have an adverse effect on quality of life. 3. Treating depression and underlying causes of fatigue will improve the quality of life for patients with HIV, who now have an extended life span.

Measuring quality of life in early HIV disease: the modular approach

RATIONALE

to examine the reliability and validity of the General Health Self-assessment, a modular questionnaire for self-assessment of quality of life (QoL) in human immunodeficiency virus (HIV) clinical trials and to describe the baseline QoL of participants in a large HIV clinical trial.

DESIGN

the domains assessed include health perceptions, physical, psychological and role/social functioning, health care utilization and symptom distress.

METHOD

1,694 subjects with early HIV infection enrolled in the AIDS Clinical Trials Group Protocol 175 completed the scale at baseline.

RESULTS

the domains demonstrated reliability, construct and discriminant validity. A worse QoL was associated with recent hospitalization and symptomatic status. Prior antiretroviral therapy was associated with higher health perceptions and well-being. The presence of symptom distress was related to lower QoL on the other scales. There was no relationship between QoL scales and the baseline CD4 count. Women showed a lower QoL than men on all scales, while ethnicity was related to differences in health perceptions and physical and psychological functioning.

CONCLUSIONS

the General Health Self-assessment shows excellent potential as a measure of QoL for HIV-infected patients in clinical trials. Further research is necessary to determine the responsiveness of the scale to clinical and immunological changes in HIV-infected individuals.

Performance of a new, HIV/AIDS-targeted quality of life (HAT-QoL) instrument in asymptomatic seropositive individuals

OBJECTIVE

To evaluate the psychometric performance of a new human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS)-targeted quality of life (QoL) instrument in asymptomatic HIV-seropositive individuals.

METHODS

201 urban and rural, HIV-seropositive subjects were recruited to complete a 76-item pilot QoL measure developed using content provided in group process by seropositive individuals. Questionnaire responses from the full sample (n = 201) were used to identify dimensions and to reduce the number of items to 42. The responses to the retained items were then analysed for the asymptomatic subsample (n = 106).

RESULTS

9 multi-item dimensions were identified: overall function (OF), sexual function (SF), disclosure worries (DW), health worries (HW), financial worries (FW), HIV mastery (HM), life satisfaction (LS), medication concerns (MC) and provider trust (PT). The responses by asymptomatic subjects (74% male, 64% non-White and 63% homosexual/bisexual) revealed no substantial floor or ceiling effects, except for the PT dimension (where 44% were found to have scored the highest score). The internal consistency coefficients (Cronbach's alphas) were between 0.80 and 0.89 for six dimensions. The coefficients were lower for the SF (0.52), HM (0.67) and MC (0.48) dimensions. Construct validity assessments, using self-reported HIV disease-severity and sociodemographic variables, revealed some significant relationships (p < or = 0.05) for all dimensions except SF, MC and PT.

CONCLUSIONS

The results suggested that five dimensions (OF, DW, HW, FW and LS) from the new instrument have good psychometric properties for asymptomatic HIV-seropositive individuals. These dimensions may be useful in the study of asymptomatic, seropositive individuals' QoL. Four dimensions (SF, HM, MC and PS) require additional refinement for this subpopulation.

Applications of the Medical Outcomes Study health-related quality of life measures in HIV/AIDS

The leading health status instruments in human immunodeficiency virus (HIV) research are based on the pool of items developed as part of the Medical Outcomes Study (MOS). The measures include the SF-20, MOS-HIV, SF-36, SF-12, SF-56, SF-38 (Patient Reported Status and Experience Survey (PARSE)), SF-21 and HIV Cost and Service Utilization Study (HCSUS) questionnaires. The instrument length ranges from 12 to 56 items, covering two to 11 dimensions. Completion requires from 2 to 14 minutes. Subscales are scored on a 0-100 scale (a higher score indicates better health); physical and mental health or overall summary scores are available for most of the measures. Three of the instruments are available in multiple languages. The instruments have been administered to over 20,000 persons with HIV in descriptive studies and clinical trials and there is substantial evidence for their reliability, construct and predictive validity and responsiveness. In several studies the measures have shown important differences between treatments. Although existing measures do not assess all domains relevant to HIV disease, additional subscales are available from the MOS pool. Some of the subscales may be prone to floor and ceiling effects. However, summary scales that encompass all of the subscales reduce this issue. Selection among MOS measures should be dictated by specific questions, the balance of available time and resources, and practical concerns.

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument

OBJECTIVES

This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival.

METHODS

Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained.

RESULTS

Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61).

CONCLUSIONS

Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.

Physicians' assessments of the utility of health states associated with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infection

An understanding of quality of life (QOL) with human immunodeficiency virus (HIV) is important because the merits of prevention and treatment alternatives may depend substantially on how these interventions affect QOL. Physicians' views about QOL are important, because they influence the therapeutic options that physicians consider or offer, the recommendations that physicians make, and because they are important for the analysis of certain policy questions. We assessed physicians' utilities of health states associated with HIV infection, and hepatitis B virus (HBV) infection; assessment of utilities for HBV was induced to provide a comparison with HIV utilities. We surveyed 200 housestaff and staff physicians in an academic medical centre by anonymous paper-based questionnaire and used the time-tradeoff method to assess physicians' utilities of the health states. On a scale in which 0 was equivalent to death, and 1 was equivalent to good health, the median utilities for asymptomatic HIV infection, symptomatic HIV infection, and AIDS were 0.833, 0.417, and 0.167, respectively (p < 0.01 or each two-way comparison). Median utilities for asymptomatic HBV infection, mildly symptomatic HBV infection, and severely symptomatic HBV infection were 0.917, 0.667, and 0.167, respectively (p < 0.01 for each two-way comparison). Although physicians varied substantially in the ratings of health states, they assessed the utility of life with HIV disease, including asymptomatic infection, as severely reduced. Studies of the effectiveness and cost-effectiveness of preventive and therapeutic interventions for HIV should evaluate the effect of the intervention on utility-based assessments of QOL. Studies that do not assess such effects may significantly underestimate or overestimate the value of these interventions, depending on the intervention's effect on QOL.

A behavioral medicine intervention in persons with HIV

This study used a pretest-posttest preexperimental design to examine the effect of a 10-week behavioral medicine support group intervention in a sample of persons with HIV. Using Solomon's psychoneuroimmunologic framework, the 10-week behavioral medicine program focused on the mind/body interaction, the relaxation response, coping with illness, hardiness, and nutrition. Pearson correlation coefficients and t tests were performed on the pre- and postintervention measures of hardiness, social support, immune function, and perceived health status. Results of the study indicated that hardiness (preintervention) and CD4 counts (pre- and postintervention) were significantly correlated with health status; however, CD4 counts decreased over the course of the behavioral medicine program. Implications for nursing and recommendations for further research are discussed.

The influence of health-related quality of life and social characteristics on hospital use by patients with AIDS in the Boston Health Study

OBJECTIVES

The authors examine whether health-related quality of life (HRQL) and social factors were independent predictors of future hospital use for persons with acquired immunodeficiency syndrome (AIDS).

METHODS

A panel of 305 patients with AIDS treated at three provider settings in the Boston, Massachusetts area were enrolled during 1990 and 1991. Data were collected at baseline study enrollment and again 4 months later. Patient interviews, hospital bills, and medical charts were used to measure hospital use (admissions and days during the 4 months after enrollment), sociodemographic characteristics (age, gender, race, education, insurance, homelessness, alcohol use, and AIDS risk factors), disease burden (patient severity and a three-level opportunistic diseases and complications score), HRQL (patient-reported symptoms, activities of daily living, neuropsychological status, and global health assessment), system of care, and use of prophylactic drugs. Logistic regression was used to estimate the odds of admission. Total days of hospital care by patients with at least one admission were analyzed using multiple linear regression. Clinical models of hospital use were developed first from the variables measuring disease burden and system of care. Models estimating the associations between hospital use and all other predictor variables measured at baseline then were estimated using stepwise techniques, controlling for variables in the core model.

RESULTS

Patients were more likely than their reference groups to be hospitalized if they had serious opportunistic diseases (adjusted odds ratio [OR] = 2.7), had poorer neuropsychological status (OR = 1.9), were non-white (OR = 2.0), or were homeless (OR = 3.3) (all P < or = 0.05). Activities of daily living were associated moderately (OR = 1.3; P = 0.07). Only system of care and neuropsychological status predicted total hospital days.

CONCLUSIONS

The results indicate that future hospital use by persons with AIDS may be influenced by social and other health-related factors in addition to the more clinically related characteristics that are recorded in a medical chart. It therefore may be appropriate to assess these factors when considering options for intervention or when comparing patterns of use among patient groups or settings.

Pilot randomized controlled trial of Chinese herbal treatment for HIV-associated symptoms

We wished to determine the short-term safety and efficacy of a Chinese medicinal herb preparation in treating symptoms of human immunodeficiency virus (HIV) infection in a 12-week randomized, double-blind, placebo-controlled clinical trial in a University-affiliated acquired immunodeficiency syndrome (AIDS) clinic at a public general hospital. Thirty adults with symptomatic HIV infection, no previous AIDS-defining diagnosis, and CD4+ counts of 0.200-0.499 x 10(9)/L (200-499/mm3) received 28 tablets each day of either a standardized oral preparation of 31 Chinese herbs or a cellulose placebo. Primary outcome measures were changes in life satisfaction, perceived health, and number and severity of symptoms. Other outcomes included adherence, and changes in weight, CD4+ count, depression, anxiety, physical and social function, and mental health. Two placebo- and no herb-treated subjects had mild adverse events (AE). Subjects on both arms reported taking 94% of prescribed tablets. No differences between treatment groups reached the p < 0.05 level. Life satisfaction improved in herb-treated [+0.86, 95% confidence interval (CI): +0.29, +1.43] but not in placebo-treated subjects (+0.20, 95% CI -0.35, + 0.75). Number of symptoms was reduced in subjects receiving herbs (-2.2, 95% CI -4.1, -0.3) but not in those receiving placebo (-0.3, 95% CI -3.2, +2.7). There were trends toward greater improvements among herb-treated subjects on all symptom subscales except dermatologic. Believing that one was receiving herbs was strongly associated with reporting that the treatment had helped (p < 0.005), but not with changes in life satisfaction or symptoms. There were improvements in life satisfaction and symptoms among subjects receiving the herbal therapy. Whether Chinese herbs are effective in the management of symptomatic HIV infection can be adequately addressed only by larger trials of longer duration.

Clinical predictors of functioning in persons with acquired immunodeficiency syndrome

To help clinicians better assess and treat functional disabilities in persons with acquired immunodeficiency syndrome (AIDS), the authors estimate empirical relations among biologic and physiologic variables, symptoms, and physical functioning in persons with AIDS. The sample of 305 persons with AIDS for this cross-sectional analysis came from three sites in Boston, Massachusetts: a hospital-based group practice, a human immunodeficiency virus clinic at a city hospital, and a staff-model health maintenance organization. Physical functioning, 10 AIDS-specific symptoms, and mental health were assessed by interview. Clinical diagnoses, comorbidities, health habits such as smoking, laboratory results, and selected medication use were assessed by chart review. Significant predictors of physical functioning P < 0.01, R2 = .58) in a multivariable regression model included energy/fatigue, neurologic symptoms, fever symptoms, a lower hemoglobin level, and current non-pneumonia bacterial infection. Ninety-six percent of the explained variance in physical functioning was accounted for by three symptom complexes: energy/fatigue, neurologic symptoms, and fever symptoms. Significant predictors of energy/fatigue in multivariable models included poorer mental health, lower white blood cell count, longer time since diagnosis, and weight loss (P < 0.01, R2 =.36). Significant predictors of neurologic symptoms included poorer mental health, weight loss, and no zidovudine use (P < 0.001, R2 = .30). Predictors of fever symptoms included poorer mental health, no zidovudine use, weight loss, and history of asthma or chronic obstructive pulmonary disease (P < 0.05, R2 = .25). In conclusion, symptom reports were strong predictors of physical functioning. Poorer mental health and weight loss were correlated consistently with worse symptoms, and not using zidovudine was correlated with worse neurologic and fever symptoms. These variables, and the others the authors identified, may represent mutable determinants of physical functioning in persons with AIDS, and potential targets for specific clinical interventions.

HIV-related neurological disability and prospects for rehabilitation

The worldwide epidemic of acquired immunodeficiency syndrome (AIDS) continues to expand. Modest progress in prolonging survival has focused attention on the issue of quality of life among persons living with AIDS. Physical functional status (disability) is one of the most important determinants of quality of life. This paper outlines a conceptual approach to AIDS disability and provides new data examining the epidemiology of physical functional deficits in the population. In addition, the common neuromuscular and central neurological impairments encountered in AIDS are discussed with suggestions for potential rehabilitation interventions. The paper concludes with the author's view of the future of rehabilitation in persons with AIDS and human immunodeficiency virus infection.

Determinants of health-related quality of life after temporal lobe epilepsy surgery

Temporal lobectomy appears to be an effective treatment for medically intractable epilepsy. However, the influences of pre-operative health status and post-operative reductions in seizure activity on post-surgical health-related quality of life (HRQOL) are not well understood. We used the Epilepsy Surgery Inventory 55 (ESI-55) to evaluate changes between pre- and post-operative HRQOL in 47 temporal lobectomy patients. Patients exhibited significantly improved scores in five HRQOL domains: health perceptions; energy fatigue; social function; cognitive function and role limitations due to physical problems. Although significant improvements in HRQOL were observed, this was not the case for all patients. Specifically, patients with low or medium pre-operative HRQOL scores were found to have the greatest degree of improvement post-operatively. Patients with high pre-operative scores did not exhibit these same improvements, although they continued to report high scores. The results indicate that the ESI-55 is a satisfactory instrument to measure change in HRQOL but also emphasizes that the magnitude of change in post-operative HRQOL scores tends to vary according to baseline scores. The outcome of temporal lobectomy is not entirely based upon the procedure's ability to reduce the frequency of seizures, but is also influenced by level of HRQOL prior to surgery.

Correlates of fatigue in HIV infection prior to AIDS: a pilot study

Fatigue is widely recognized as a significant source of morbidity in persons with human immunodeficiency virus (HIV) infection, yet there are few data examining fatigue in this population. We present pilot data assessing the relationship between fatigue and various physical and psychosocial measures in 20 men with HIV infection prior to the clinical development of acquired immunodeficiency syndrome (AIDS). Fatigue was measured by a visual analogue scale (VAS) and the Fatigue Assessment Inventory (FAI). No statistically significant associations were found between fatigue measures and physical parameters including haemoglobin, haematocrit, albumin, total protein, and physical dimension score of the Sickness Impact Profile (SIP). The FAI correlated well with Beck's Depression Inventory and SIP-Psychosocial Dimension (r = 0.72 and 0.81, respectively; p < 0.001.) Both the FAI and VAS held moderate associations with the total SIP score. The SIP profile was similar to that observed in a sample of persons with chronic fatigue but without HIV infection, reported previously. Although the sample size is small, our data suggest a stronger association with psychosocial, rather than physical, parameters among persons with HIV infection and fatigue. The implications for clinical management and further research are discussed.

Health values of patients infected with human immunodeficiency virus. Relationship to mental health and physical functioning

To assess the health values of patients infected with human immunodeficiency virus (HIV) and examine the relationships between their health values and health status at two points in time, the authors sought to determine whether patients' physical and mental health statuses were good predictors of how they valued their current state of health. One hundred thirty-nine patients with various stages of HIV infection were interviewed in a prospective cohort study based in a primary care practice of a community-based teaching hospital. Patients were interviewed twice at 6-month intervals using three health value measures--the time trade off, rating scale, and Quality of Well-being Scale--and three health status measures: the 18-item Mental Health Inventory, the Dyspnea-Fatigue Index, and the Medical Outcomes Study SF-36 Health Survey. The health status of HIV-infected patients was compromised and, with the exception of mental health, generally was worse among patients with more advanced HIV-infection. Rating scale and Quality of Well-being Scale scores were related inversely to disease stage, but time-trade off scores generally were higher regardless of disease stage. Health value measures showed moderate relationships with measures of physical functioning (r = 0.34-0.68) but only a fair relationship with mental health (r = 0.00-0.48). The health status of HIV-infected patients who remained asymptomatic or remained symptomatic but without developing acquired immunodeficiency syndrome (AIDS) changed little over 6 months, whereas the health status of patients with AIDS and of patients manifesting progression of HIV-infection deteriorated over time. In contrast, health values, particularly time-tradeoff scores, remained stable even in the face of changes in health status and disease progression. With the exception of mental health, the impact of HIV infection on health status tends to parallel the clinical stage of disease. Health values of HIV-infected patients, however, generally are high and correlate better with physical functioning than with mental health.

Threshold analysis and programs for prevention of HIV infection

BACKGROUND

Measuring the economic effectiveness of HIV-infection prevention activities poses special challenges in terms of behavioral change and health outcomes assessment.

METHODS

One way to address this difficulty is to employ threshold analysis to determine a level of cost per HIV infection averted above which society would seem unwilling to pay. The authors employ a cost-utility analytic framework to determine a monetary threshold for HIV prevention programs, subject base-case results to sensitivity analyses, and apply these results to the Centers for Disease Control and Prevention's fiscal year 1993 budget for extramural HIV prevention programs.

RESULTS

The monetary threshold for cost per HIV infection averted was calculated to be $417,000 in 1993 dollars, and ranged from $185,000 to $648,000 depending upon the dollar amount society would be willing to pay per quality-adjusted life year gained.

CONCLUSIONS

Economic evaluations of particular HIV-infection prevention activities at least can begin by determining whether their levels of effectiveness are above or below this derived monetary threshold, and refinements beyond this dichotomous evaluation can proceed as further data become available.

The role of reluctance to give up life in the measurement of the values of health states

Questions that involve willingness to risk or give up life often are used to measure the values of health states. In the Boston Health Study, interviews with 291 patients who had AIDS included questions about health status and current desire for resuscitation, and a series of hypothetical questions about desire for life-extending efforts if the patients found themselves in undesirable states, such as being chronically nauseous or blind. An index, "reluctance to give up life" was made from five such questions. The desire for resuscitation was related to current health status, but the general reluctance to give up life was not. Desire to be resuscitated was significantly related to current health status only when "reluctance to give up life" was "low." For people reluctant to say they will give up any life at all, questions that involve risking or trading life seem likely to be poor measures of the values of health states.

The cost effectiveness of preoperative autologous blood donations

BACKGROUND

Since the recognition that human immunodeficiency virus is transmissible by blood transfusion there has been increasing public and professional support for autologous blood donations before elective surgery. Autologous blood donation is, however, a more expensive process than the donation of allogeneic blood by community volunteers. Furthermore, there have been recent improvements in the safety of the volunteer blood supply.

METHODS

We used a decision-analysis model to assess the cost effectiveness of donating autologous blood for four surgical procedures. Cost data were collected from the observation of transfusion practice at the University of California, Los Angeles, in 1992. Estimates of the risks of transfusion-associated diseases and the costs of treating them came from the medical literature. Cost effectiveness was expressed in dollars per quality-adjusted year of life saved. We performed sensitivity analyses of the variables in our model and examined the effect of strategies suggested to reduce costs.

RESULTS

Substituting autologous for allogeneic blood resulted in little expected health benefit (0.0002 to 0.00044 quality-adjusted year of life saved) at considerable additional cost ($68 to $4,783 per unit of blood). The additional cost of autologous blood was primarily a function of the discarding of units that were donated but not transfused and of a more labor-intensive donation process. The cost-effectiveness ratios ranged from $235,000 to over $23 million per quality-adjusted year of life saved.

CONCLUSIONS

Given the improved safety of allogeneic transfusions today, the increased protection afforded by donating autologous blood is limited and may not justify the increased cost.

Lentiviral infection, immune response peptides and sleep

The aberrant sleep documented in subjects with human immunodeficiency virus (HIV) infection is uniquely important because of the contribution this poor quality sleep makes to the fatigue, disability, and eventual unemployment that befalls these patients. Especially given this importance in clinical care, the research on the prominent sleep changes described in HIV infection remains modest in quantity. The chronic asymptomatic stage of HIV infection is associated with the most intriguing and singular sleep structure changes. Especially robust is the increase in slow wave sleep, particularly in latter portions of the sleep period. This finding is rare in other primary or secondary sleep disorders. The sleep structure alterations are among the most replicable of several pathophysiological sequelae in the brain associated with early HIV infection. It is unlikely that these sleep architecture changes are psychosocial in etiology, and they occur before medical pathology is evident. They are not associated with stress, anxiety, or depression. Evidence is accumulating to support a role for the somnogenic immune peptides tumor necrosis factor (TNF)alpha and interleukin (IL-1 beta) in the sleep changes and fatigue commonly seen in HIV infection. These peptides are elevated in the blood of HIV-infected individuals, and are somnogenic in clinical use and animal models. The peripheral production of these peptides may also have a role in the regulation of normal sleep physiology. The lentivirus family contains both HIV and the feline immunodeficiency virus (FIV). The use of the FIV model of HIV infection may provide a way to further investigate the mechanism of a neurotropic, neurotoxic virus initiating the immune acute phase response and affecting sleep. Neurotropic lentivirus infection is a microbiological probe facilitating neuroimmune investigation.