Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV Cost and Services Utilization Study

Depressive symptoms, quality of life, and neuropsychological performance in HIV/AIDS: the impact of gender and injection drug use

Limited attention has been paid to the potential impact of gender and injection drug use (IDU) on mood, quality of life, and neuropsychological performance in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Several studies that describe the natural history of HIV/AIDS in terms of mental health and neuropsychological ability have focused solely on men or have excluded injection drug users. Women and injection drug users are two groups for whom the incidence of HIV infection is increasing. Additionally, the National Academy of Sciences recently recommended that studies concerned with health-related research include males and females, and that researchers analyze their data for gender differences. The goals of the current study were to investigate possible relationships between HIV and IDU status and depressive symptoms, quality of life, and neuropsychological performance in women and men matched for age, race, and education. Overall, women reported more depressive symptoms than men, and this gender difference was most evident in women who were both infected with HIV and who were also injection drug users. Women and HIV-infected individuals reported the poorest quality of life scores. Women outperformed men on a measure of verbal memory and HIV(-) participants outperformed HIV(+) participants on a measure of perceptual speed. Finally, gender and HIV status interacted such that uninfected women performed the best, and infected men performed the worst, on a test of verbal memory. A better understanding of how men and women with different drug use profiles respond to HIV/AIDS may substantially improve survival, as well as aspects of daily functioning, of affected individuals. Thus, further study and development of treatment protocols targeted at including women and IDU are needed.

Approach to management of clinically localized prostate cancer in patients with human immunodeficiency virus

OBJECTIVES

To evaluate the approach to management of localized prostate cancer (PCa) in patients with human immunodeficiency virus (HIV) in the highly active antiretroviral therapy era.

METHODS

A retrospective analysis was performed on 10 HIV-positive patients who recently presented with elevated prostate-specific antigen levels and clinically localized PCa.

RESULTS

At the diagnosis of PCa, the average patient was 54.0 years old, had been HIV positive for 8.75 years, had a CD4 count of 417, a prostate-specific antigen level of 9.2 ng/mL, and a Gleason score of 6. Eight of the patients had risk factors for PCa--either African-American descent (n = 6) or a positive family history (n = 2). The treatment was laparoscopic radical prostatectomy in 1, potency-preserving androgen deprivation in 1, cryosurgery in 1, brachytherapy in 2, observation in 2, and external beam radiotherapy in 3.

CONCLUSIONS

Screening of all HIV-positive men should be initiated at age 40 if they have either a positive family history of prostate cancer or are of African-American descent. Asymptomatic HIV-positive patients should be offered all therapeutic PCa treatment options.

Impact of chronic viral hepatitis on health-related quality of life in HIV: results from a nationally representative sample

BACKGROUND

Little is known about the health burden of chronic viral hepatitis in HIV-infected patients. We compared health-related quality of life (HRQOL) of patients with HIV and hepatitis C virus (HCV) or HIV and hepatitis B virus (HBV) coinfection to those with HIV monoinfection.

METHODS

Using a nationally representative sample of 1,874 adults with HIV who completed a baseline and two follow-up interviews, we identified those with HIV monoinfection (n = 1,493), HIV-HCV coinfection (n = 279), and HIV-HBV coinfection (n = 122). We measured baseline and change over time scores for physical and mental health (PHS, MHS), overall quality of life (QOL), overall health, and disability days. To identify the independent effect of coinfection, we adjusted for demographic and clinical predictors of HRQOL using multivariable regression.

RESULTS

Despite significant differences in socio-demographic characteristics between groups, there were no differences in the baseline scores for PHS, MHS, overall QOL, overall health, or disability days between groups. The HRQOL did not decline significantly over time for the HIV patients with or without HCV or HBV coinfection. All groups reported similar longitudinal changes in the HRQOL scores for all measures.

CONCLUSIONS

We found no significant differences in disease burden as assessed by a generic HRQOL instrument between patients with HIV monoinfection and HIV-HCV or HIV-HBV coinfection. These data are relevant in counseling coinfected patients regarding the impact of coinfection on HRQOL, and are important in designing clinical trials and conducting cost-effectiveness analyses including this vulnerable cohort.

Assessing a conceptual framework of health-related quality of life in a HIV/AIDS population

With the recognition of health-related quality of life (HRQOL) as an important outcome in the course of HIV-disease, it is important to gain a better understanding of the complex relationships among the various factors that influence it. This study assesses a conceptual framework of HRQOL, consisting of disease status, socio-economic status (SES), behavioral variables, symptom status, role-specific functional status and HRQOL, among a multiethnic, economically disadvantaged population of individuals living with HIV/AIDS. Self-report data were collected from 348 patients receiving care at a large HIV/AIDS care center, serving residents of a large metropolitan area. The relationships between the study variables were examined using structural equation modeling. Results indicated that the hypothesized framework provided a well-fitted solution to the data, chi2(44df) = 57.62], p = 0.08 and root mean square error of approximation = 0.03, 90% confidence interval 0.01; 0.05. This framework suggests that health-related variables fall along a continuum, beginning with disease status and ending in generic HRQOL. In addition, the framework suggests that behavioral factors (i.e., smoking status, alcohol consumption, and illicit drug use) and SES exert significant effects along this continuum and should be carefully considered when analyzing and interpreting HRQOL data.

Herbal medicine use and quality of life among people living with HIV/AIDS in northeastern Thailand

Many people living with HIV/AIDS (PHA) use herbal medicine as one of alternative therapies, where curative options are limited. This study aimed to examine the association between the herbal medicine use and quality of life (QOL) among PHA in northeastern Thailand. Participants were 132 HIV-positive Thai adults who attended the PHA's self-help group meetings from June to July 2002. Health-related QOL scores were measured by self-administered questionnaire from the Medical Outcomes Study-HIV Health Survey. Dimensions of physical function (PF) and mental health (MH) in QOL were assessed. Additional data were collected on herbal medicine use, socio-demographic, psychosocial and HIV-related characteristics. The herbal medicine users had significantly better MH scores than the non-users, while the herbal medicine use was not statistically associated with PF scores. When stratified, herbal medicine users with the following characteristics had significantly better MH scores than the non-users: female, widowed, having no income, reporting any HIV-related symptom, having no instrumental support or receiving subsidies. In conclusion, herbal medicine use was associated with better MH especially among socially vulnerable PHA. This study suggests that herbal medicine has a potential to improve the MH aspect of QOL among socially vulnerable PHA who cannot easily receive antiretroviral therapy in Thailand.

Health-related quality of life of patients with HIV: Impact of sociodemographic, clinical and psychosocial factors

OBJECTIVES

This study aims to analyse how a wide group of clinical, social, demographic and psychological factors are related to both physical and mental quality of life in HIV + patients.

DESIGN

A cross-sectional study was carried out of 320 HIV + patients in antiretroviral treatment who attended infectious diseases units in four hospitals in the region of Andalusia (Spain).

METHODS

Health-Related Quality of Life was measured by the MOS-HIV. Included as independent variables were: sociodemographic variables, variables related to antiretroviral therapy, psychosocial variables like social support (Duke-UNC-11) and psychological morbidity (GHQ-28), variables related to main risk behaviours and clinical variables.

RESULTS

In the multiple linear regression analysis, a better PHS quality of life was found to be associated with the absence of mental illness, social support, not being an intravenous drug user and using more than one type of non-injectable drug. A better quality of life, in mental terms, was found to be associated with fewer years as a non-intravenous drug user, having social support, absence of mental illness, not being an intravenous drug user taking only one additional pill, not having any difficulty in taking the medication, and being female.

CONCLUSIONS

The study of other non-biological factors that may be related to quality of life has been limited practically to social support and the emotional state. This study highlights the importance of these factors independently from the clinical state, as well as the existence of other psychological and behavioural factors that are also related.

Mental health status of clients from three HIV/AIDS palliative care projects

Objective:To describe mental health status and its correlates among clients of three palliative care programs targeting underserved populations.

Methods:Mental Health Inventory (MHI-5) scores of clients from programs in Alabama (n= 39), Baltimore (n= 57), and New York City (n= 84) were compared.

Results:Mean MHI-5 scores did not differ among sites and were indicative of poor mental health. Significant differences were noted among sites with regard to client sociodemographics, physical functioning, and perceptions of interpersonal relations. Results of multivariate regression models estimated for each site suggest variation in the relative importance of potential predictors among sites. Whereas poorer mental health was primarily associated with history of drug dependence at Baltimore and more physical symptomatology at New York, better mental health was most strongly correlated with more positive perceptions of interpersonal relationships at Baltimore and increasing age and more positive perceptions of meaning and purpose in life at New York.

Significance of results:The data presented suggest the importance of assessing clients' history of and current need for mental health services. Evidence of a relationship between positive perceptions of meaning and purpose and better psychological function underscores the importance of existential issues for the overall well-being of those who are seriously ill.

A Comparison of the Clinical and Cost-Effectiveness of 3 Intervention Strategies for AIDS Wasting

OBJECTIVE

To compare oxandrolone (OX) or strength training with nutrition alone (NA) for AIDS wasting.

SUBJECTS

Fifty patients with AIDS; 47 completing the study.

INTERVENTIONS

Randomization to (1) NA with placebo pills, (2) nutrition with 10 mg of OX administered orally twice a day, or (3) nutrition with progressive resistance training (PRT) for 12 weeks.

MAIN OUTCOME MEASURES

Midthigh cross-sectional muscle area (CSMA), physical functioning (PF), costs, and cost-effectiveness in dollars/quality-adjusted life-years (dollars/QALYs).

RESULTS

The OX and PRT subjects had increases in CSMA (7.0% +/- 2.5%, P = 0.01; 5.0% +/- 2.0%, P = 0.04, respectively), although these increases did not differ significantly from the NA arm (NA: 1.0% +/- 1.0%; OX vs. NA: P = 0.09; PRT vs. NA: P = 0.26). Only PRT caused significant improvements in PF (mean +/- SE: 10.4 +/- 3.8 points on a 100-point scale) and 7 measures of strength (P values: 0.04 to <0.001). There were no overall differences between groups in PF change. Among patients with impaired baseline PF, however, OX was significantly less effective than NA and PRT was significantly better than NA. All treatments led to increases in protein intake and performance; NA and PRT also increased caloric intake. The institutional costs per subject in this trial were 983 dollars for NA, 3772 dollars for OX, and 3189 dollars for PRT. At a community-based level of intensity, the institutional costs per QALY were 45,000 dollars (range: 42,000 dollars-64,000 dollars) for NA, 147,000 dollars (range: 147,000 dollars-163,000 dollars) for OX, and 31,000 dollars (range: 21,000 dollars-44,000 dollars) for PRT.

CONCLUSIONS

OX and PRT induce similar improvements in body composition, but PRT improves quality of life more than nutrition or OX, particularly among patients with impaired PF. PRT was the most cost-effective intervention, and OX was the least cost-effective intervention.

Measuring validity of self-reported symptoms among people with HIV

Symptoms are important indicators of health and treatment for people with HIV. Symptoms are measured by patient self-report, but there has been little attention to what is the best method of elicitation. We compared three methods (presence, frequency, and bother) commonly used to measure HIV self-reported symptoms. CD4+ T lymphocyte count and health-related quality of life (HRQL) scales were used to test validity in 160 people with HIV. The average number of symptoms reported was 15.2 (standard deviation 8.4). Correlation coefficients of summary symptom scores using the three methods ranged from -0.30 to -0.36 with HRQL score and from -0.19 to -0.20 with CD4 count (p<0.05). Correlation coefficients of seven specific symptom items with CD4+ counts and HRQL scores for the same concepts were small to moderate (-0.08 to -0.58, p<0.05). For the three methods, the correlation coefficients in general tended to be greater with frequency or bother than presence. However, the differences among the three methods were not statistically significant. We conclude that no single method is superior to the others.

Gender differences in health-related quality of life in patients with HIV/AIDS

BACKGROUND

In studies evaluating the general US population, patients in primary care, and patients with chronic conditions, women consistently report poorer health-related quality of life (HRQoL) than men; however, studies evaluating HRQoL in patients with HIV/AIDS have not completely corroborated those findings. The objective of this study was to evaluate gender differences in HRQoL for participants in a large randomized trial comparing antiretroviral regimens.

METHODS

AIDS Clinical Trials Group (ACTG) 320 was a randomized, blinded, placebo-controlled trial comparing the 3-drug regimen of indinavir + zidovudine (or stavudine) + lamivudine with the 2-drug combination of zidovudine (or stavudine) + lamivudine in subjects with CD4 cell counts less than 200 cells/microl and no prior treatment with protease inhibitors. Nine quality of life domains scored on 0-100 scales were assessed using the ACTG QOL 601-602 Health Survey at 3 points in the trial: baseline, 24 weeks and 40 weeks. Differences between men and women in HRQoL scores were assessed using the Wilcoxon rank-sum test and generalized estimating equation (GEE) models.

RESULTS

Overall, 202 females and 976 males were randomized to one of two treatment arms. Female participants were more likely to be black or Hispanic and tended to be younger. At baseline, females reported lower HRQoL scores than males in all of the domains except social functioning, and at week 40, women scored lower in all of the domains except overall health. In repeated measures models, women were found to score lower in all HRQoL domains except overall health, with significant differences of 3.5-6.7 points in 3 of the 9 quality of life domains: physical functioning, pain, and energy/fatigue. HRQoL scores improved for participants in the study over time and in response to potent treatment, and the improvements were similar for men and women.

CONCLUSIONS

Women with HIV/AIDS report substantially poorer HRQoL than men with HIV/AIDS in several HRQoL domains. However, changes in domain scores over time and in response to treatment do not differ significantly by gender, implying that changes in domain scores may be better HRQoL outcomes to compare between HIV-infected men and women in clinical trials than mean domain scores.

Comparison of WHOQOL-BREF and SF-36 in patients with HIV infection

The purpose of the study was to evaluate the reliability and validity of the two generic instruments, the WHOQOL and the SF-36, for assessing health-related quality of life in 224 patients with HIV infection. The internal consistency ranged from 0.75 to 0.86 across the WHOQOL-BREF domains and from 0.72 to 0.93 across the SF-36 scales. The scores of all WHOQOL-BREF domains and SF-36 scales correlated positively with the measure of happiness, Sat-HRQOL and self-perceived health status, and correlated negatively with the number and intensity of symptoms. Patients with higher CD4 cell counts scored significantly higher on G4 (general health), three WHOQOL-BREF domains, seven SF-36 scales, and PCS (physical component summary). Patients with fewer symptoms and with less intensity of symptoms had significantly higher scores on all four domains of WHOQOL-BREF, eight scales, PCS, and MCS (mental component summary) of the SF-36 scale. The correlations between the physical, psychological, and social domains of the WHOQOL-BREF and PF (physical functioning), MH (mental health), and SF (social functioning) of the SF-36 were 0.51, 0.75, and 0.54, respectively. There is also good correlation between PCS of the SF-36 and the physical domain of the WHOQOL-BREF (r = 0.48), and between MCS and all four domains of the WHOQOL-BREF (r range = 0.60-0.75). The WHOQOL-BREF domains showed fewer floor or ceiling effect than the SF-36 scales. We concluded that both the WHOQOL-BREF and the SF-36 are reliable and valid health related quality-of-life instruments in patients with HIV infection.

Protease inhibitor combination therapy, severity of illness, and quality of life among children with perinatally acquired HIV-1 infection

OBJECTIVES

This study examines quality of life (QOL) among school-aged children with perinatally acquired HIV infection and compares QOL outcomes between treatment groups that differ according to the use of protease inhibitor (PI) combination therapy (PI therapy). To gain insights into how PI therapy might influence QOL, associations between severity of illness and QOL were also investigated.

METHODS

Cross-sectional data for 940 children, 5 to 18 years of age, who were enrolled in Pediatric AIDS Clinical Trials Group Late Outcomes Protocol 219 were used to examine domains of caregiver-reported QOL, as assessed with the General Health Assessment for Children, during 1999. The General Health Assessment for Children is an age-specific, modular, QOL assessment that was developed for the study with previously validated measures. QOL differences between treatment groups were estimated with linear and logistic regressions that controlled for sociodemographic characteristics (age, gender, race/ethnicity, maternal/caregiver education, and respondent) and severity-of-illness indicators related to receipt of PI therapy (AIDS status, log(10) CD4+ cell counts, and height-for-age z scores).

RESULTS

The mean age of participants was 9.7 years. Most children were non-Hispanic black (54%) or Hispanic (31%), and 49% of the participants were female. At the 1999 study visit, approximately 14% of children had severe immune suppression (<15% CD4+ cells), whereas 62% of children had > or =25% CD4+ cells, ie, no immune suppression. Participants did exhibit some lag in growth, with mean height and weight z scores of -0.70 and -0.20, respectively. Twenty-eight percent of the children were reported to have met criteria for AIDS at study entry (1993-1999). When treatment groups were compared, children receiving PI therapy (72%) were older, had lower CD4+ cell percentages, and had lower height and weight z scores than did those receiving non-PI therapies. They were also more likely to have met criteria for AIDS at study entry. The most commonly used PIs were ritonavir (46%) and nelfinavir (63%). Health perceptions ratings for most children were at the upper end of the scale, whereas ratings for 25% of the children ranged over the lower 70% of scale scores. Almost one half of the children had at least some limitations in physical functioning, with more frequent limitations in energy-demanding activities (46%) than in basic activities of daily living (32%). The Behavior Problems Index was used to assess psychologic functioning. The mean total Behavior Problems Index score (9.34) and the proportion of children with extreme scores (23%) were consistent with values reported for chronically ill children and those at social and economic risk. One or more limitations in social/school functioning were reported for 58% of children. More than one third of the children (38%) experienced > or =1 physical symptoms that were at least moderately distressing. Health perceptions, physical functioning, psychologic functioning, social/school functioning, and overall HIV symptom scores did not differ between treatment groups. However, receipt of PI therapy was associated with an increased rate of diarrhea (28 vs 13%; adjusted odds ratio: 2.59; 95% confidence interval: 1.74-3.85). Severity of illness was associated with QOL in all domains except psychologic functioning. Higher log(10) CD4+ cell counts, higher height-for-age z scores, and absence of AIDS at study entry were independently associated with fewer social/school limitations and better HIV symptom scores. Health perceptions and physical functioning scores were associated with log(10) CD4+ cell counts and height z scores, respectively.

CONCLUSIONS

QOL among children receiving PI therapy differed little from that among children receiving non-PI therapy, despite clinical indications of more advanced disease. Importantly, the study found no evidence of direct negative effects of PI therapy on QOL outcomes, other than an increased rate of diarrhea. Findings suggest that the effects of PI combination therapies to slow or to prevent disease progression and to increase CD4+ cell counts and height growth have the potential to improve QOL among children with HIV infection. However, many children do experience a constellation of functional impairments indicated by behavioral problems and clinical symptoms, with limitations in activities and in school performance. Comprehensive health services will continue to be required to minimize long-term illness and disability and to maximize children's potential as they move into adolescence and adulthood.

The association of health-related quality of life with survival among persons with HIV infection in the United States

OBJECTIVES

Both clinical trials and observational studies of persons with HIV infection commonly include health-related quality of life (HRQOL) measures, but less is known about the relation of HRQOL to survival among persons with HIV since the development of effective antiretroviral treatment.

DESIGN/PARTICIPANTS

Prospective cohort study of a national probability sample of 2,864 adults receiving HIV care.

INDEPENDENT VARIABLES

The main independent variables were derived from the HIV Cost and Services Utilization Study (HCSUS) HRQOL measure, and include physical and mental HRQOL summary scores (divided into quartiles) constructed from the following items administered at baseline: physical functioning (9 items, alpha=0.91), role functioning (2 items, alpha=0.85), pain (2 items, alpha=0.84), general health perceptions (3 items, alpha=0.80), emotional well-being (7 items, alpha=0.90), social functioning (2 items, alpha=0.82), energy (2 items, alpha=0.74), and a single-item measure of disability days (days in bed for at least 0.5 day due to health).

MAIN OUTCOME VARIABLE

Death between January 1996 and December 1999.

ANALYSIS

Descriptive and multivariate adjusted Cox proportional hazards regression analysis of survival by physical and mental HRQOL.

RESULTS

By December 1999, 17% of the sample had died. In unadjusted analysis, persons in the higher quartiles of physical HRQOL, as well as those in the higher quartiles of mental HRQOL at baseline, had significantly better survival than those in lower quartiles. In multiple regressions controlling for a number of sociodemographic and clinical variables, the hazard of death for those in the highest quartile of physical HRQOL was one quarter of that for those in the lowest quartile. This difference was similar in magnitude to that observed for being on highly active antiretroviral therapy versus no antiretrovirals in this population. By contrast, there was no unique association of mental HRQOL with survival.

CONCLUSIONS

Physical HRQOL added prognostic information over and above the sociodemographic and routinely available clinical data such as CD4 count and stage of HIV infection. Measurement of HRQOL, which is often performed to identify problems or assess outcomes, is also useful prognostically.

Abuse in the close relationships of people with HIV

We estimated the proportion of adults receiving HIV care who are involved in abusive close relationships and identified factors associated with abuse perpetration and victimization. A nationally representative sample of 1,421 persons in care for HIV included 51% who reported having a close relationship (a spouse or a primary relationship partner) during a 6-month period. Of those in a close relationship, 26.8%reported the presence of abuse. Forty-eight percent of all abuse was mutual, and abuse perpetration and victimization occurred equally often. Age, substance abuse, and psychiatric disorder, as well as characteristics of relationships (e.g., both partners seropositive) predicted perpetration and/or victimization. After adjusting for these factors, females were not found to differ from gay men in their likelihood of being perpetrators of abuse or victims. However, African Americans were more likely than Whites to be involved in an abusive relationship. Interventions for people with HIV must address the presence of abuse in close relationships, regardless of gender or sexual orientation, but may benefit from targeting people of color.

Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection

BACKGROUND

There is little evidence to support the widely accepted assertion that better physician-patient relationships result in higher rates of adherence with recommended therapies.

OBJECTIVE

To determine whether and which aspects of a better physician-patient relationship are associated with higher rates of adherence with antiretroviral therapies for persons with HIV infection.

DESIGN

Cross-sectional analysis.

SETTING

Twenty-two outpatient HIV practices in a metropolitan area.

PARTICIPANTS

Five hundred fifty-four patients with HIV infection taking antiretroviral medications.

MEASUREMENTS

We measured adherence using a 4-item self-report scale (alpha= 0.75). We measured core aspects of physician-patient relationships using 6 previously tested scales (general communication, HIV-specific information, participatory decision making, overall satisfaction, willingness to recommend physician, and physician trust; alpha > 0.70 for all) and 1 new scale, adherence dialogue (alpha= 0.92). For adherence dialogue, patients rated their physician at understanding and solving problems with antiretroviral therapy regimens.

RESULTS

Mean patient age was 42 years, 15% were female, 73% were white, and 57% reported gay or bisexual sexual contact as their primary HIV risk factor. In multivariable models that accounted for the clustering of patients within physicians' practices, 6 of the 7 physician-patient relationship quality variables were significantly (P < .05) associated with adherence. In all 7 models worse adherence was independently associated (P < .05) with lower age, not believing in the importance of antiretroviral therapy, and worse mental health.

CONCLUSIONS

This study showed that multiple, mutable dimensions of the physician-patient relationship were associated with medication adherence in persons with HIV infection, suggesting that physician-patient relationship quality is a potentially important point of intervention to improve patients' medication adherence. In addition, our data suggest that it is critical to investigate and incorporate patients' belief systems about antiretroviral therapy into adherence discussions, and to identify and treat mental disorders.

Health-related quality of life among men with HIV infection: effects of social support, coping, and depression

In a prospective cohort study, baseline data were collected on 226 males with HIV infection attending three infectious disease clinics in a southern state. As a result of advances in HIV treatment, understanding the association between psychosocial factors and health-related quality of life has become an important area of study. The purpose of this study was to assess the total effects of social support and coping as well as the direct and indirect effects of these factors through depression on health-related quality of life. Subjects were interviewed and answered the following standardized questionnaires: The HIV Cost and Services Utilization Study tool, Coping with HIV Questionnaire, Social Support Appraisals Scale, and Centers for Epidemiological Studies Depression instrument. Path models with strictly ordered relationships were fitted to study the effects of the psychosocial variables on each quality of life subscale. We found that coping and social support had total effects on some, but not all dimensions of health-related quality of life, whereas depression was associated with all dimensions of health-related quality of life. Furthermore, the effects of both social support and coping were mainly through the intermediate variable, depression. In the era of highly active antiretroviral therapy (HAART), when quality of life issues are of paramount importance, strategies to improve social support, coping, and particularly, depressive symptoms are strongly encouraged.

Predictors of major depression in recently diagnosed patients with HIV/AIDS in South Africa

There is increasing evidence that major depression impacts the course of HIV infection, yet few studies have explored demographic and clinical predictors of depression in people who with HIV/AIDS. This study investigated predictors of depression (e.g., demographic and clinical variables, negative life events, and coping response) among outpatients with recently diagnosed HIV/AIDS patients in South Africa. One hundred forty-nine recently diagnosed HIV/AIDS patients (44 males and 105 females; mean time since diagnosis = 5.8, standard deviation [SD] 4.1) were evaluated. Subjects were assessed using the Mini International Neuropsychiatric Interview (MINI), the Carver Brief COPE coping scale, and the Sheehan Disability Scale. In addition, previous exposures to trauma and past risk behaviors were assessed. Three variables: gender (odd ratio [OR] = 1.23; 95% confidence interval [CI] 1.56, 1.93), impact of negative life events (OR = 1.13; CI, 1.03, 1.23), and disability (OR = 1.51, CI, 1.28, 1.80) predicted current major depression. It is well known from non-HIV populations that female gender and increased negative life events predict depression. These data also emphasize the importance of these links in HIV.

Impact of indinavir on the quality of life in patients with advanced HIV infection treated with zidovudine and lamivudine

OBJECTIVE

In AIDS Clinical Trial Group (ACTG) study 320, triple-combination antiretroviral therapy including indinavir significantly slowed progression to acquired immunodeficiency syndrome or death, compared with treatment with dual nucleoside reverse-transcriptase inhibitors (NRTIs) alone, in zidovudine-experienced patients with advanced human immunodeficiency virus (HIV) infection. We examined the impact of indinavir on quality of life in participants from this study.

METHODS

A total of 1156 protease inhibitor- and lamivudine-naive patients stratified by CD4 cell count (<or=50 and 51-200 cells/mm(3)) were randomized to receive zidovudine (or stavudine) and lamivudine, with or without indinavir. Health-related quality of life was measured using the ACTG QoL601-602 questionnaire, which assesses general health status measured on a visual analogue scale and 8 specific health-related domains. Quality-adjusted survival time was estimated using the visual analogue scale for general health.

RESULTS

Mean changes in general health scores after 24 weeks were +2.9 in the triple-therapy group versus -0.2 in the dual-therapy group (P=.018). By week 24, scores in all specific domains were higher with triple-drug therapy than dual-drug therapy, with statistically significant differences in role function, energy, and pain scores. Benefits of triple-drug therapy were largely confined to patients with CD4 cell counts of <or=50 cells/mm(3). Quality-adjusted survival time did not differ significantly between the 2 treatment groups.

CONCLUSIONS

Triple-drug therapy with indinavir and 2 NRTIs resulted in a significant improvement in general health status after 24 weeks, especially in patients with low CD4 cell counts. Patients receiving triple-drug therapy also had significantly better role function, energy, and pain scores than did patients treated with dual-drug therapy.

Panic disorder and pain in a national sample of persons living with HIV

Research to date has focused on depression and co-existing pain in HIV with relatively little attention devoted to the study of anxiety disorders and concurrent pain. We therefore examined the relationships among panic disorder, posttraumatic stress disorder (PTSD), major depression and pain in a US national sample of persons with HIV, controlling for key sociodemographic and clinical variables, including HIV disease status. The study sample comprised 1489 HIV+ individuals (representing 219 667 persons). In multivariate analyses, panic disorder showed a strong association with pain ( beta= -15.70; 99% confidence interval [CI]=-21.33 to -10.08; P<0.001, which was significantly greater than PTSD (P=0.002) but only marginally greater than major depression (P=0.002). Longitudinal analyses of the three psychological disorders revealed that increasing pain from baseline to follow-up (an approximately 6-month period) was associated with panic disorder only (relative risk ratio=2.18, 99% CI=1.02-4.69; P<0.01), after controlling for baseline pain scores, baseline HIV disease status and change in disease stage across time. We discuss specific mechanisms by which clinical anxiety and chronic pain may be mutually maintained in HIV+ individuals. Our findings suggest that panic disorder, as well as PTSD and major depression are associated with greater pain in HIV patients.

Association between diarrhea and quality of life in HIV-infected patients receiving highly active antiretroviral therapy

Diarrhea is a common symptom that many HIV patients experience either as a consequence of HIV infection or of highly active antiretroviral therapy (HAART). A multicenter, prospective observational study was conducted in 11 AIDS clinics in Italy to determine the effect of diarrhea on health-related quality of life among patients receiving HAART. The study enrolled 100 consecutive HIV positive patients who had diarrhea while on HAART. For each enrolled patient a control patient with matching disease stage who did not have diarrhea was identified using existing data from another prospective observational study conducted in 34 AIDS clinics (including the 11 in current study). Quality of life was measured by MOS-HIV Health Survey (MOS-HIV). Paired t-test and multiple regression analysis were used to compare the quality of life among patients with and without diarrhea. Mean patient age was 40 +/- 7 years; 69% were male. Mean CD4 cell count was 342 +/- 239 cells/mm3; 59% had AIDS. Of the cases, 49 patients had severe diarrhea (> 5 bowel movements or > 3 watery per day) and 46 patients had moderate diarrhea (3-5 bowel movements). Compared to matched control patients, cases experiencing diarrhea while on HAART had significantly lower MOS-HIV scores in all domains. The significant adverse effect of diarrhea on quality of life should be considered when choosing the appropriate antiretroviral drugs regimen.

Disparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients

BACKGROUND

Current HIV treatment guidelines recommend delaying antiretroviral therapy for nonadherent patients, which some fear may disproportionately affect certain populations and contribute to disparities in care.

OBJECTIVES

To examine the relationship of physician's attitude toward prescribing protease inhibitors (PIs) to nonadherent patients with disparities in PI use and with health outcomes.

DESIGN

Prospective cohort study.

PATIENTS AND SETTING

A national probability sample of HIV-infected adults in the United States and their health care providers was surveyed between January 1996 and January 1998. We analyzed data on 1717 patients eligible for PI treatment and the 367 providers who cared for them.

MEASUREMENTS

Providers' attitude toward prescribing PIs to nonadherent patients, time until patients' first receipt of PIs, mortality, and physical health status.

MAIN RESULTS

Eighty-nine percent of providers agreed that patient adherence is important in their decision to prescribe PIs (Selective) while 11% disagreed (Nonselective). Patients who had a Selective provider received PIs later than those with a Nonselective provider (P =.05). Adjusting for patient demographics and health characteristics and provider demographics, HIV knowledge, and experience, Latinos, women, and poor patients received PIs later if their provider had a Selective attitude but as soon as others if their provider had a Nonselective attitude. African-American patients received PIs later than whites, irrespective of their providers' prescribing attitude. Patients with Selective providers had similar odds of mortality than those with Nonselective providers (odds ratio, 1.1; 95% confidence interval, 0.6 to 2.0), but had slightly worse adjusted physical health status at follow-up (49.1 vs 50.4, respectively; P =.04), after controlling for baseline physical health status and other patient and provider covariates.

CONCLUSIONS

Most providers consider patient adherence an important factor in their decision to prescribe PIs. This attitude appears to account for the relatively later use of PI treatment among Latinos, women, and the poor. Given the rising HIV infection rates among minorities, women, and the poor, further investigation of this treatment strategy and its impact on HIV resistance and outcomes is warranted.

Social support and quality of life over time among adults living with HIV in the HAART era

Stability in perceived social support and associations between social support and health-related quality of life for a sample of 41 adult outpatients living with HIV/AIDS (PHA) in Canada were assessed longitudinally. Construct-specific dimensions of the Medical Outcomes Study Social Support Survey (SSS), the Physical and Mental components of the Short-Form-36 (SF-36) quality of life measure, as well as clinical factors (i.e., symptomatology, immunologic/virologic variables), were measured in three waves: initial consecutive registration (T1, 1997), 2-year (T2, 1999) and 4-year (T3, 2001) follow-up, and evaluated for changes using repeated-measures analysis of variance, supplemented by Friedman tests for SSS and SF-36 ratings. Proportions of the PHA sample with clinically significant SSS changes (i.e., greater than 0.5 standardized effect size) were also calculated. Effects of improvement versus deterioration in SSS ratings on SF-36 ratings, and vice versa, were explored. Associations between SSS and SF-36 ratings, as well as between changes in SSS ratings and SF-36 ratings, were assessed using multiple regression analyses controlling for clinical factors. Cross-lagged analyses were conducted to examine predictive potential between SSS and SF-36 ratings. Clinical outcomes suggested immunologic improvement tempered by symptoms and/or treatment side effects. SSS and SF-36 mean ratings were moderately stable over time, but clinically significant 4-year decrements in SSS ratings occurred for approximately 40% of patients. A trend occurred in which poorer SF-36 mental outcomes portended poorer emotional and informational support. Otherwise, relations between SSS and SF-36 ratings appeared to be reciprocal. Cross-sectional associations between SSS and SF-36 ratings were more pronounced at T2 compared to baseline and T3. Changes in SSS and SF-36 ratings were somewhat related over the consecutive 2-year periods but not over the long term. T1-T2 SSS changes were associated with changes in the SF-36 mental component. T2-T3 SSS changes were associated with changes in the SF-36 physical component. Cross-lagged analyses yielded little explanation concerning direction of causation in terms of associations between social support and quality of life for the PHA in this study.

Stability of anxiety and depression in a national sample of adults with human immunodeficiency virus

We examined the stability of anxiety and depression in a national sample of patients with human immunodeficiency virus (HIV) using data from the HIV Cost and Services Utilization Study. We also investigated risk factors for developing new cases of anxiety and depression. Analyses were conducted using multiple logistic regressions to control for key demographic and clinical factors. Our results showed a general stability of these psychiatric conditions across 6 months, with no dramatic increase in new cases. Overall prevalence declined over time, but a subgroup of patients, particularly those with major depression, evidenced persistent psychopathology. Having a high baseline HIV symptom count and a growing number of HIV symptoms significantly increased the likelihood of anxiety and depression persisting to follow-up and of developing new such cases. Our findings indicate that living with HIV does not necessarily lead to increased psychiatric distress but that palliation of HIV symptoms is paramount to patients' mental health.

Health-related quality of life of patients with HIV disease: impact of hepatitis C coinfection

Health-related quality of life (HRQOL) is diminished in patients infected with both hepatitis C virus (HCV) and human immunodeficiency virus (HIV), but the effect of HIV/HCV coinfection on HRQOL is unknown. We compared the HRQOL of urban HIV/HCV coinfected patients with that of patients infected with either HCV or HIV alone. We then compared the 3 groups with a US population sample, adjusting for demographic characteristics. HRQOL for the group of HIV/HCV coinfected patients was statistically similar to that of HRQOL in patients with either HCV or HIV alone, but the 3 groups had a significantly decreased HRQOL than did the adjusted US population. Using multivariate techniques, we determined that age, unemployment, injection drug use, and depression were associated with impaired HRQOL. These findings underscore the importance of a multidisciplinary approach to the treatment of these patient populations.

Difficulty Swallowing and Lack of Receipt of Highly Active Antiretroviral Therapy Predict Acute Weight Loss in Human Immunodeficiency Virus Disease

In human immunodeficiency virus (HIV) disease, symptoms of underlying illness may promote weight loss through decreased caloric intake, increased metabolic needs, or nutrient malabsorption. We evaluated disease symptoms as predictors of acute weight loss (i.e., loss of > or =5% of weight). HIV-infected men and women (n=415) were telephoned every 5 weeks to obtain information about weight and recent symptoms. Weight change between each pair of consecutive calls (telephone intervals, 2814) was calculated. Acute weight loss occurred across 4.5% of intervals and among 24% of individuals. Patients reported > or =1 symptom before 58% of telephone intervals. The most common symptoms or symptom complexes before intervals were diarrhea (21% of patients), anorexia (17%), upper respiratory symptoms (16%), skin symptoms (12%), and abdominal pain (12%). Trouble swallowing (6%) and oral symptoms (7%) were less common. Risk of acute weight loss was significantly increased when oral symptoms or trouble swallowing were present, and it was decreased when highly active antiretroviral therapy (HAART) was used or when diarrhea was not present. Even when HAART is being administered, clinicians should remain vigilant regarding weight loss, oral symptoms, and trouble swallowing.

Neurocognitive function in HIV-infected patients with low weight and weight loss

OBJECTIVE

To determine neurocognitive function in HIV-infected subjects with low weight and weight loss.

DESIGN

Cross-sectional cohort.

METHODS

Baseline data from male and female participants in longitudinal treatment studies of AIDS wasting were analyzed. Fifty-seven HIV-infected women (age: 38 +/- 5 years, education level: 12.3 +/- 2.3 years) and 24 HIV-infected men (age: 37 +/- 5 years, education level: 13.5 +/- 2.9 years) with weight <90% IBW or loss of >10% of preillness weight maximum underwent standardized neurocognitive testing to measure intellectual functioning, attention, memory, and fine motor dexterity. The z scores were determined using age- and gender-specific normative data.

RESULTS

Among women, IQ (87 +/- 13, z score: -0.8 +/- 0.8 SD) and executive functioning scores (-0.7 +/- 1.2 SD) were below average but within normal limits. In contrast, performance (z scores) on measures of verbal learning (-2.5 +/- 1.5 SD), visuospatial abilities (-2.5 +/- 2.0 SD), and motor coordination (-2.3 +/- 3.3 SD) fell significantly below normal limits. Among men, IQ score was 96 +/- 13 SD (z score: -0.3 +/- 0.8 SD). Performance was below average on measures of verbal learning (-1.0 +/- 1.7 SD) and visual construction (-1.6 +/- 1.7 SD) but within normal limits on executive functioning (-0.1 +/- 1.0 SD).

CONCLUSIONS

HIV-infected women at low weight demonstrate significantly reduced verbal learning, memory, and motor function, whereas HIV-infected men at low weight demonstrate more moderate impairment in verbal learning and other measures of neurocognitive function.

The impact of HIV on oral health and subsequent use of dental services

OBJECTIVE

This study examined differences in health and access to dental services among a nationally representative sample of patients with HIV using Andersen's Behavioral Model of Health Services Use.

METHODS

This investigation is a longitudinal study that used structural equation modeling to analyze data from the HIV Cost and Services Utilization Study, a probability sample of 2,864 adults under treatment for HIV infection. Key predisposing variables included sex, drug use, race/ethnicity, education, and age. Enabling factors included income, insurance, and regular source of care. Need factors included mental, physical, and oral health. Dependent variables included whether a respondent utilized dental services and number of visits.

RESULTS

More education, dental insurance, usual source of dental care, and poor oral health predicted a higher probability of having a dental visit. African Americans, Hispanics, those exposed to HIV through drug use or heterosexual contact, and those in poor physical health were less likely to have a dental visit. Of those who visited dental professionals, older persons, those with dental insurance, and those in worse oral health had more visits. African Americans and persons in poor mental health had fewer visits.

CONCLUSIONS

Persons with more HIV-related symptoms and a diagnosis of AIDS have a greater need for dental care than those with fewer symptoms and without AIDS, but more pressing needs for physical and mental health services limit their access to dental services. Providers should better attend to the oral health needs of persons with HIV who are in poor physical and mental health.

Commentary on using the SF-36 or MOS-HIV in studies of persons with HIV disease

The purpose was to compare and comment on use of the SF-36 and MOS-HIV instruments in studies of persons with HIV disease. Three medical information databases were searched to identify examples of HIV studies that included the MOS-HIV or SF-36. Thirty-nine and 14 published articles were identified for illustration in comparing the use of the MOS-HIV and SF-36 in HIV disease, respectively. Support for the reliability and construct validity of the MOS-HIV and SF-36 was found. Ceiling and floor effects were reported for both the MOS-HIV and SF-36; however, ceiling effects were more common for the MOS-HIV, in part due to fewer items in the physical, social, and role functioning domains. The MOS-HIV measures three domains hypothesized to be associated with the health deterioration of HIV disease not measured by the SF-36; however, these domains may not assess aspects of HIV disease that typify the majority of the persons with HIV disease today. National norms for the U.S. adult population (and other nations) are available for the SF-36. In addition, the SF-36 has been used in a wide variety of patient populations, enabling comparisons of HIV-infected persons with persons with other health conditions. No national norms for the MOS-HIV are available. We conclude that there is currently insufficient evidence in the literature to recommend the use of the MOS-HIV over the SF-36 in HIV-infected persons. Although the SF-36 is not targeted at HIV, it may be preferable to use the SF-36 over the MOS-HIV due to fewer ceiling effects, availability of national norms, and the vast amount of data for other populations in the U.S. and around the world. Head-to-head comparisons demonstrating the unique value of the MOS-HIV over the SF-36 are clearly needed. More importantly, additional work needs to be directed at comparing the MOS-HIV and other putatively HIV-targeted instruments to one another to help demarcate aspects of HRQOL that are truly generic versus specific to HIV disease. Using both a generic and targeted HRQOL measure is a good general strategy, but this has not been a typical practice in studies of HIV because the MOS-HIV is so similar in content to the SF-36.

Quality of generalist vs. specialty care for people with HIV on antiretroviral treatment: a prospective cohort study

OBJECTIVES

To describe health-care use by persons with HIV in an urban area of Switzerland (Zurich). Further, to compare the different health-care settings.

DESIGN

A 1-year prospective cohort study recruiting 60 patients at general practices and 60 patients at a specialized university outpatient clinic.

METHODS

Patients and their treating physicians were interviewed or answered questionnaires, respectively, at baseline, month 6 and 12.

RESULTS

During the study period, five patient groups were identified among the 106 enrolled patients, of whom (i) 42% saw a general practitioner exclusively, (ii) 31% were treated at the specialized outpatient clinic, (iii) 8% were in shared care, (iv) 10% changed health-care model, and (v) 9% were lost to follow-up. Baseline demographic, psychosocial and clinical data were similar among patient groups. At study end, the proportion of patients with HIV-1 RNA < 400 copies/mL was 72%, 74%, 88%, 55% among groups (i) to (iv), respectively (ns), and 22% at month 6 among those lost to follow-up. Indicators for quality of care were similarly good among all patient groups.

CONCLUSIONS

A well-working system offers high-quality healthcare to persons living with HIV, where existing teams of specialty and primary health-care professionals efficiently and effectively co-operate.

Social support, distress, and well-being in older men living with HIV infection

Older men with HIV infection/AIDS, having often lived with the condition longer, are more likely to confront the stress of managing more advanced HIV disease than their younger counterparts. Meanwhile, they also are more likely to have less social support and experience more distress than younger persons with HIV infection. The moderating effect of social support on health functioning and distress is unknown for persons with HIV infection, particularly those who are older. Study objectives were to assess whether the association between perceived health functioning and psychological distress and well-being is moderated (or influenced) by social support and age and if the impact of social support on distress and well-being is more pronounced for older than for younger men living with HIV infection/AIDS. In this cross-sectional study of HIV-positive adult men (n = 199) who have sex with men, participants completed self-report assessments of perceived health functioning, social support, and psychological distress and well-being. Measures of health functioning and overall social support were significantly associated with outcome measures of distress and positive affect (all p < .05). However, the main effect for social support was qualified by a significant age-by-social support interaction for both outcomes (beta = -.190, p < .01 for distress; beta = .172, p < .05 for positive affect), indicating that the impact of social support on decreasing distress and increasing well-being was more pronounced in older men. The relationships between perceived health functioning and distress and well-being were not moderated by social support or age. The influence of social support on negative and positive moods in this population of HIV-infected men who have sex with men was significantly greater among older than among younger participants. With an increasing number of older people with HIV infection/AIDS, special efforts to create effective and sustainable social support interventions may be particularly beneficial to older persons living with HIV infection.

Personal and psychosocial characteristics associated with psychiatric conditions among women with human immunodeficiency virus

This study presents information on correlates of mental health and substance abuse problems among women with human immunodeficiency virus (HIV), a particularly vulnerable, poor and minority population. Data are from 847 women in the HIV Cost and Services Utilization Study, a national probability sample of adults with known human immunodeficiency virus infection. Fifty-five percent of women manifested a probable psychiatric condition. Results indicated that increased risk for psychiatric conditions among these women was associated with younger age, having acquired immunodeficiency virus (rather than asymptomatic), using avoidant coping strategies, reporting increased conflict with others, and prior physical abuse, needing income assistance, and putting off going to the doctor because of caring for someone else. Findings suggest we need to address women's need for safety from assaultive partners and that we may need special programs for women burdened with having to care for others.

Self-reported health-related quality of life in persons with HIV infection: results from a multi-site interview project

BACKGROUND

To examine demographic and behavioral associations with self-reported health-related quality of life (HRQOL) among persons with HIV infection or AIDS.

METHODS

Analysis of interviews with persons > or = 18 years of age reported through routine disease surveillance with HIV infection or AIDS to nine state and local health departments from January 1995 through December 1996. Scales were constructed from validated measures of HRQOL, and mean scores were calculated (lower scores signified poorer HRQOL). Measures of HRQOL included Overall Health, Pain, Physical Functioning, Role Functioning, Social Functioning, Mental Health, Energy/Fatigue, and Cognitive Functioning. Differences in HRQOL were examined by various demographic and behavioral factors, including taking antiretroviral medication.

RESULTS

HRQOL data were available for 3778 persons. Factors associated with lower HRQOL scores included older age, female sex, black or Hispanic race/ethnicity, injection drug use, lower education and income, no private health insurance, and lower CD4 count. In multivariate analysis, lower CD4 count was the factor most consistently associated with lower HRQOL. Taking antiretroviral medication was not associated with differences in HRQOL regardless of CD4 count.

CONCLUSIONS

Perception of HRQOL varied in a population with HIV infection or AIDS. On most HRQOL measures, lower CD4 count was associated with lower HRQOL. Measurement of HRQOL can assist in understanding the long-term effects of disease and treatment on persons with HIV.

Functional status and overall quality of life in a multiethnic HIV-positive population

The objective of this study was to examine the sociodemographic and behavioral variables associated with quality of life (QOL) among multiethnic, economically disadvantaged patients with HIV/AIDS. A cross-sectional survey was conducted in a large inner-city HIV/AIDS clinic serving medically indigent residents of Houston, Texas, and the surrounding area. On arrival at the clinic, patients were systematically approached and asked to complete a questionnaire, offered in both English and Spanish. Demographic characteristics, stage of disease, and behavioral variables were assessed in addition to work-role functioning and overall health-related QOL. Multiple regression analysis was conducted to assess the relationships between the variables of interest. Of 617 patients approached and asked to participate in the study, 385 (62.4%) consented to complete the questionnaire. Demographic composition of the sample was as follows: 78% male, 25% white, 44% black, and 29% Hispanic. Forty-five percent of the participants were infected through men having sex with men (MSM), 35% through heterosexual contact, and 11% through injection drug use. Racial/ethnic minorities reported significantly (p < 0.05) poorer physical functioning and work-role functioning. Participants with higher nadir CD4 cell counts (> 500 per cubic millimeter), MSM HIV exposure, and more education (beyond high school) reported better physical functioning and work-role functioning. Overall QOL and work-related functioning were significantly impaired in this patient population. The impaired functional status findings hold for every social, demographic, and behavioral subgroup examined. Findings suggest that the influence of social inequality persist even among a universally disadvantaged population.

Depression and HIV infection: impact on immune function and disease progression

Can psychological factors, such as depression, affect human immunodeficiency virus progression? HIV infection is viewed as a chronic illness in which those infected often confront a number of emotional challenges and physical health and disease-related issues. Over the past 20 years, there has been increasing evidence that depression and other mood-related disturbances are commonly observed among HIV-positive individuals. There is also mounting data showing that depressive symptoms might further impact upon specific elements of immune system functioning and influence quality of life and health status. This paper will highlight studies examining the prevalence of depression during HIV infection and review some of the evidence examining the impact of depressive symptoms on immune function and HIV disease progression.

Health-related quality of life after 1 year of highly active antiretroviral therapy

OBJECTIVE

We investigated the impact of the first year of highly active antiretroviral therapy (HAART) on health-related quality of life (HRQL).

METHODS

Medical data for patients in the French APROCO cohort were collected at enrollment (M0) and month 12 (M12). A self-administered questionnaire gathered information about HRQL (Medical Outcome Study 36-Item Short Form Health Survey) and toxicity-related symptoms. Using the twenty-fifth percentile of HRQL scales in the French population as a threshold, patients with normal values in at least three mental and three physical scales were considered to have a "normal HRQL." RESULTS. Of the 1053 patients followed through M12, HRQL data at M0 and M12 were available for 654. Among the 233 patients with a normal baseline HRQL, 63 (27.0%) experienced a deterioration of HRQL at M12. Among the 421 patients with a low baseline HRQL, 121 achieved a normal HRQL at M12. Logistic regression showed that factors independently associated with a normal HRQL at M12 were normal baseline HRQL, baseline CD4 count <500 cells/mm, time since HIV diagnosis <8 years, undetectable HIV-RNA at M12, and lower number of self-reported symptoms at M12.

CONCLUSION

An assessment of HRQL should be integrated to efficacy outcomes to evaluate and compare long-term strategies properly and to optimize the durability of response to antiretroviral therapy.

HIV patients' experiences with inpatient and outpatient care: results of a national survey

CONTEXT

Little is known about HIV patients' care experiences.

OBJECTIVE

To assess HIV patients' experiences with inpatient and outpatient care, and to assess the relationship and relative influence of patient characteristics and site of care on care experiences.

DESIGN

Cohort study.

SETTING

Patients with HIV receiving care outside of emergency rooms, prisons, or the military throughout the continental United States. One thousand seventy-four patients provided ratings of an inpatient stay and 2204 rated an outpatient visit; 818 patients provided evaluations of both inpatient and outpatient care.

PATIENTS

A national probability sample of persons in care for HIV from the HIV Cost and Services Utilization Study.

MEASUREMENTS

Outcome variables were rates of problems with, and global ratings of, inpatient and outpatient care.

RESULTS

Mean problem rates were 20.9% and 8.4% (lower score means fewer problems) for inpatient and outpatient care, respectively. On 9 of 10 of the individual inpatient report items, 15% or more of respondents reported problems. Global ratings of inpatient and outpatient care were 65.3 and 75.0 (0-100 scale, higher scores indicate better ratings), respectively. In multivariable models that controlled for site effects, the only patient characteristic that was consistently associated with problem rates and global ratings of care was mental health (P <0.0001 for both inpatient and outpatient care). Models including site effects explained two to four times as much variance as models excluding site effects.

CONCLUSIONS

Inpatients with HIV reported higher problem rates with inpatient than outpatient care. Better provider-patient communication during inpatient stays is needed. For both inpatient and outpatient care, quality improvement efforts may be most productively focused on providers and processes of care at sites rather than on specific patient subgroups.

Validation of the World Health Organization quality of life instrument in patients with HIV infection

We studied the reliability and validity of the World Health Organization quality of life (WHOQOL) assessment instrument in patients with human immunodeficiency virus (HIV) infection. WHOQOL-BREF was used to assess 136 HIV-infected outpatients. The results were analyzed and compared with data from 213 healthy persons. The Cronbach's alpha for internal consistency ranged from 0.74 to 0.85 across domains in HIV-infected patients. The test-retest reliability ranged from 0.64 to 0.79 across domains at average 4-week retest interval. Factor analysis identified four major factors: social, psychological, environment, and physical, consistent with the four domains of the instrument. The scores of all four domains correlated positively with self-evaluated health status and happiness (r range: 0.52-0.60 and 0.55-0.73 across domains, respectively), and correlated negatively with the number and severity of symptoms (r range: -0.40 to -0.47 and -0.41 to -0.52, respectively). The scores of physical, psychological and social domains, but not the environment domain, discriminated between healthy persons and HIV-infected patients (all p < 0.01). We conclude that the WHOQOL-BREF can be a useful quality-of-life instrument in patients with HIV infection.

Use of the SF-36 and other health-related quality of life measures to assess persons with disabilities

This article evaluates the appropriateness of existing approaches to the assessment of health-related quality of life (HRQOL) for persons with disabilities. We compare the conceptual model of HRQOL from the Medical Outcomes Study with the World Health Organization's International Classification of Functioning, Disability and Health. In addition, we examine the attitudes toward disease "burden" that arise from these 2 models. We note how values or the importance attached to domains of health can change with fluctuations in physical health. Further, we summarize arguments in favor of developing targeted measures of persons with disabilities. Finally, we discuss some methodologic issues in assessing physical functioning, attributions to health versus disability, and mode of administration. We conclude that users of "standard" HRQOL measures need to be aware of their limitations for assessing persons with disabilities.

A prospective study of predictors of adherence to combination antiretroviral medication

OBJECTIVE

Adherence to complex antiretroviral therapy (ART) is critical for HIV treatment but difficult to achieve. The development of interventions to improve adherence requires detailed information regarding barriers to adherence. However, short follow-up and inadequate adherence measures have hampered such determinations. We sought to assess predictors of long-term (up to 1 year) adherence to newly initiated combination ART using an accurate, objective adherence measure.

DESIGN

A prospective cohort study of 140 HIV-infected patients at a county hospital HIV clinic during the year following initiation of a new highly active ART regimen.

MEASURES AND MAIN RESULTS

We measured adherence every 4 weeks, computing a composite score from electronic medication bottle caps, pill count and self-report. We evaluated patient demographic, biomedical, and psychosocial characteristics, features of the regimen, and relationship with one's HIV provider as predictors of adherence over 48 weeks. On average, subjects took 71% of prescribed doses with over 95% of patients achieving suboptimal (<95%) adherence. In multivariate analyses, African-American ethnicity, lower income and education, alcohol use, higher dose frequency, and fewer adherence aids (e.g., pillboxes, timers) were independently associated with worse adherence. After adjusting for demographic and clinical factors, those actively using drugs took 59% of doses versus 72% for nonusers, and those drinking alcohol took 66% of doses versus 74% for nondrinkers. Patients with more antiretroviral doses per day adhered less well. Participants using no adherence aids took 68% of doses versus 76% for those in the upper quartile of number of adherence aids used.

CONCLUSIONS

Nearly all patients' adherence levels were suboptimal, demonstrating the critical need for programs to assist patients with medication taking. Interventions that assess and treat substance abuse and incorporate adherence aids may be particularly helpful and warrant further study.

Psychological and existential issues and quality of life in people living with HIV infection

This paper focuses on psychological and existential issues and their impact on psychological functioning and quality of life in adults living with HIV. Further, it suggests that many of the issues that people with HIV face today are similar to those that were on the pre-HAART agenda.

State AIDS Drug Assistance Programs: equity and efficiency in an era of rapidly changing treatment standards

BACKGROUND

The 54 state AIDS Drug Assistance Programs (ADAP) provide medications to HIV-infected persons with limited resources. Eligibility and coverage vary, raising concerns about health inequities.

OBJECTIVE

To compare the relative clinical and economic performance of ADAP programs.

RESEARCH DESIGN

A state-transition simulation model of HIV disease was used to explore the clinical consequences and lifetime costs associated with selected state policies. Clinical data came from the Multicenter AIDS Cohort Study, AIDS Clinical Trials Group Protocol 320, and other published randomized trials. Cost data came from the national AIDS Cost and Services Utilization Survey, and the 1999 Red Book. ADAP data came from National Association of State and Territorial AIDS Directors reports and interviews.

MEASURES

Projected life expectancy, quality-adjusted life expectancy, total lifetime direct medical costs, cost-effectiveness in dollars per quality-adjusted life year (QALY) gained.

RESULTS

ADAPs vary considerably in terms of formulary policies, health outcomes, expected costs, and cost-efficiency. Conservative projections, based on a cohort with starting mean CD4 count of 250 cells/microL, yield life expectancies ranging from 5.36 to 6.81 life years (4.69-6.01 quality-adjusted life years [QALYs]). Total per person lifetime direct medical costs range from $81,200 to $112,700; higher costs reflect increased spending on medications. Expected costs per QALY gained range from $7000 to $28,000. Under pessimistic assumptions regarding initial CD4 counts, drug efficacy, and discounting, the most comprehensive policy remains below $33,000/QALY.

CONCLUSIONS

Even the most comprehensive ADAPs constitute a cost-effective use of HIV care resources. A uniform, national ADAP formulary warrants consideration.

Effectiveness of a home-based exercise intervention for HIV-infected adults: a randomized trial

The authors conducted a randomized controlled trial to assess the impact of a 15-week (20 minutes three times per week) home-based aerobic exercise intervention versus usual care on the physical endurance, immune status, and self-reported health status of 99 HIV-infected adults. In the exercise group, there was no improvement in physical endurance or health-related quality of life (HRQOL), except in the Medical Outcomes Study-HIV Health Survey Overall Health subscale (difference = 12.1, 95% confidence interval = 2.0-22.2, p = .02). Although physical endurance levels were maintained at baseline levels in the intervention group and declined in the control group, differences between the groups were small and not significant. There were also no significant changes in CD4+ T-lymphocyte counts. Exercise appears to be safe in HIV-infected patients. Improvements in physical endurance and HRQOL might result if the exercise protocol is longer or progressive. Further research is needed to establish guidelines for exercise in patients on highly active antiretroviral therapy.

Comparison of health state utilities using community and patient preference weights derived from a survey of patients with HIV/AIDS

OBJECTIVES

The authors compare health state utilities derived from a national survey of patients with HIV/AIDS to represent community-based preferences with utilities derived from the same survey representing patient preferences; explore the relationships between these utilities and the dimensions of the SF-6D health state classification; and examine the implications of differences in the source of utilities for a cost-effectiveness analysis of early treatment of patients with HIV/AIDS.

METHODS

The authors derived community-based standard gamble (SG) utilities using an algorithm developed for the SF-6D health state classification system. The authors derived patient SG utilities from HIV/AIDS patient rating scale self-assessments using a power transformation. Data were from the HIV Cost and Services Utilization Study, a probability sample of 2864 HIV-infected adults receiving care in the United States in 1996.

RESULTS

Patient SG utilities were higher than community SG utilities by 4% to 9% (0.979 vs. 0.937, 0.910 vs. 0.841, and 0.845 vs. 0.778; P < 0.001 for all comparisons). In regression analyses, patient SG utilities were less influenced by physical functioning, pain, and mental health dimensions of the SF-6D. The base case results of a cost-effectiveness analysis comparing early antiretroviral therapy to deferred therapy were unaffected by the choice between community ($20,100 per quality-adjusted life year) and patient ($18,400 per quality-adjusted life year) perspectives. The impact of the choice of utilities remained small in sensitivity analyses that varied the influence of treatment side effects on utilities and the initial symptom status of patients.

CONCLUSION

There are differences between community and patient utilities for HIV/AIDS health states, although even when treatment side effects are important, these differences may not affect cost-effectiveness ratios.

The effect of changes in depression on health related quality of life (HRQoL) in HIV infection

This study prospectively evaluated the effect of treatment of major depression on psychosocial functioning (health-related quality of life (HRQoL)). Previously, we reported on a trial of 75 HIV+ patients who were blindly randomized to receive treatment with drug or placebo (N=25 to each of paroxetine, imipramine, or placebo). Forty-one individuals completed the entire trial (placebo = 14, antidepressant = 27). In this study, we assessed HRQoL using the Quality of Life Enjoyment and Satisfaction Questionnaire (QLESQ) and the Social Adjustment Scale (SAS) at baseline and the end of the trial (12 weeks) using a random effects model to estimate treatment effects. HIV/AIDS patients with a major depressive disorder who completed the clinical trial demonstrated a reduction in depression with response to treatment and a significant improvement in HRQoL with the exception of work and financial functioning. Effective management of depression in HIV/AIDS patients is important, especially with the importance of adherence in current HIV/AIDS antiviral therapy. HRQoL improved in patients regardless of drug or response group and as a function of being in this trial suggesting that medications may not be required to affect HRQoL outcomes and that disease management aspects of care are important.

Importance of mental health assessment in HIV-infected outpatients

HIV infection, even when well controlled, may be associated with important mental health problems. We sought to investigate anxiety, depression, and health-related quality of life using screening measurements in patients with HIV infection and to examine their dependency on biosocial parameters relating to HIV. Prospective clinical, virologic, and immunologic data were obtained in a cross-sectional study within the Swiss HIV Cohort Study. Four self-reported questionnaires were used in 397 HIV-infected individuals. The scores for anxiety and depression were high as measured by the Hospital Anxiety and Depression Scale (HADS) and the State Trait Anxiety Inventory (STAI). Half the population scored <75 on a visual analog scale (VAS) Patients were also affected in their quality of life as measured by the HIV Medical Outcome Study (HIV-MOS). Almost all scores were significantly worse for intravenous drug users compared with other transmission groups. People who were employed, with a higher education or with higher CD4 count tended to score better, whereas those who had been hospitalized within the last 6 months, infected for a longer time, with higher viral load, or loss of weight scored significantly worse. A multivariate analysis showed higher education, being employed, low viral load, female gender, and shorter HIV disease duration to be associated with better scores. This study highlights the importance of mental health assessment regardless of HIV-disease parameters.

The RAND-36 measure of health-related quality of life

The RAND-36 is perhaps the most widely used health-related quality of life (HRQoL) survey instrument in the world today. It is comprised of 36 items that assess eight health concepts: physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/fatigue, pain, and general health perceptions. Physical and mental health summary scores are also derived from the eight RAND-36 scales. This paper provides example applications of the RAND-36 cross-sectionally and longitudinally, provides information on what a clinically important difference is for the RAND-36 scales, and provides guidance for summarizing the RAND-36 in a single number. The paper also discusses the availability of the RAND-36 in multiple languages and summarizes changes that are incorporated in the latest version of the survey.

Measurement of fatigue in HIV-positive adults: reliability and validity of the Global Fatigue Index

Fatigue is among the most common and distressing symptoms in patients with HIV/AIDS. Little is known about the clinical assessment of fatigue, especially in patients using highly active antiretroviral regimens. The purpose of this study was to evaluate the psychometric properties of the Global Fatigue Index (GFI) in a community-based sample of 209 patients with HIV/AIDS. The GFI is a measure that quantifies five dimensions of fatigue from the Multidimensional Assessment of Fatigue instrument into one score. To assess construct validity, the study included measures of depression, perceived stress, activities of daily living (ADLs), health behaviors, and clinical markers. Cronbach's alpha was calculated for internal consistency reliability, and factor analysis and bivariate correlations were conducted. The GFI was found to be easily self-administered, reliable, and a valid measure of overall fatigue burden in an HIV population. This instrument may be used by clinicians and researchers for assessing fatigue.