The psychosocial impact of HIV infection in men with haemophilia: controlled investigation and factors associated with psychiatric morbidity

Prevalence and associated factors of low vigor in patients living with HIV and hemophilia in Japan: A cross-sectional observational study

People living with human immunodeficiency virus (HIV) are at high risk of mental health problems. However, little is known about this risk in HIV-infected patients with hemophilia (HPH) who contracted the virus through blood products. This cross-sectional, observational study assessed patients' mood states and the factors associated with them among Japanese HPH to evaluate the need for psychosocial support. HPH completed self-administered questionnaires (Profile of Mood States [POMS] and General Health Questionnaire-28), neuropsychological tests, and brain magnetic resonance imaging (MRI) and fluorodeoxyglucose positron emission tomography/computerized tomography scans. HIV-infected patients with no hemophilia (HPnH) completed POMS and neuropsychological tests. Socio-demographic characteristics and HIV- and hemophilia-related data were obtained from participants' medical records and interviews. A Mann-Whitney U test and chi-squared analyses were conducted. Fifty-six HPH and 388 HPnH completed the questionnaires and neuropsychological tests. HPH had a significantly lower prevalence of tension-anxiety (HPH, 7%; HPnH, 18%; p = 0.049) and a significantly higher prevalence of low vigor (HPH, 63%; HPnH, 32%; p < 0.001). Low vigor in HPH was significantly associated with impaired executive function (low vigor, 66%; high vigor, 33%; p = 0.019) and a social dysfunction score ≥ 3 (moderate; low vigor, 26%; high vigor, 5%; p = 0.047). Our results highlight the high prevalence of low vigor among HPH, leading to impairments in executive and social functions. Therefore, healthcare workers need to pay attention to the vigor, executive function, and social function of HPH.

Health Related Quality of Life and Psychopathological Symptoms in People with Hemophilia, Bloodborne Co-Infections and Comorbidities: An Italian Multicenter Observational Study

Background

The health-related quality of life (HRQoL) of people with hemophilia (PWH) is an important issue, especially considering people suffering from chronic diseases beyond hemophilia. The principal aim of this study was to investigate the presence and relevance of psychological symptoms, both internalizing and externalizing, lifestyle, and HRQoL in a group of Italian PWH with chronic bloodborne co-infections and comorbidities. Furthermore, the research describes the association between psychological aspects and the impact of disease-related characteristics (type of hemophilia, presence of co-infections, and comorbidities) on them.

Methods

Seventy patients (mean age 46.77±11.3), 64 with severe hemophilia A (Factor VIII: C < 1 IU/dL) and 6 with severe hemophilia B (Factor IX <1 IU/dL), were consecutively recruited from seven Hemophilia Centers in Italy of Italian Association of Hemophilia Centers (AICE). In order to assess psychological symptoms, HRQoL, and lifestyle, three psychological questionnaires were administered (the SCL-90-R, SF-36, and PSQ, respectively).

Results

A general decline in the quality of life and an increase in the tendency to adopt a lifestyle characterized by hyperactivity emerged. Inverse correlations were found between HRQoL and psychological distress. Although the SCL-90-R did not reveal symptoms above the clinical cut-off, co-infections significantly increased anxiety, depression, somatizations, paranoia, and social withdrawal. Lastly, HRQoL is impaired by co-infections as well as comorbidities.

Conclusion

Our preliminary results must be confirmed to deepen the findings between mental health and hemophilia.

Mental health disorders in haemophilia: Systematic literature review and meta-analysis

AIM

Despite significant advances in morbidity and mortality outcomes, quality of life for people with haemophilia (PWH) remains compromised. Underrecognized and undertreated mental health disorders decrease quality of life; however, reports are inconsistent regarding the true prevalence of mental health disorders in PWH.

METHODS

We conducted a systematic literature search of Ovid MEDLINE, EMBASE, Psychinfo and the Cochrane Library, and hand searched the journal Haemophilia to identify records and subsequently conducted a meta-analysis to determine the prevalence of depression, anxiety and attention deficit hyperactivity disorder (ADHD) in patients with congenital haemophilia.

RESULTS

Our search strategy identified 2315 records, and 28 studies met eligibility criteria. Meta-analysis demonstrated that PWH are at increased risk of depression (odds ratio (OR) 2.45; 95% confidence interval (CI) 1.64-3.68), anxiety (OR 1.74, 95% CI 1.01-3.00), anxiety/depression (OR 2.60, 95% CI 2.35-2.87) and ADHD (OR 3.48, 95% CI 1.74-6.96). We found considerable heterogeneity among the studies likely due to differences in assessment tools, populations studied and year of publication. This suggests that standardized tools to diagnose mental health disorders in PWH are needed. Additionally, high-quality studies investigating mental health disorders in PWH are necessary to adequately document the prevalence of these disorders.

CONCLUSION

Overall, our meta-analysis suggests that the prevalence of depression, anxiety and ADHD across decades is significantly increased in PWH compared to the general population.

"Development in well-being and social function among Danish hemophilia patients with HIV: a three-wave panel study spanning 24 years"

Background

Between 1975 and 1985 a total of 91 Danish patients with moderate and severe hemophilia (PWH) was infected with HIV constituting a major scandal in the Danish health care system. This study describes the burden of HIV infection among Danish PWH by evaluating changes from 1988 to 2012 in well-being, social function, experiencing stigma and openness about disease among Danish HIV⁺ PWH.

Methods

Three anonymous surveys were conducted in 1988, 2001 and 2012 targeting all Danish patients with moderate to severe hemophilia. Survey responses were received from 53, 21 and 18 HIV⁺ PWH respectively. A matched comparison sample of HIV⁻ PWH was identified for each survey-year, using propensity score matching. Differences for each survey-year and trends over time were analyzed using ordinal logistic regression.

Results

In 1988, HIV⁺ PWH had more psychosomatic symptoms than HIV⁻ PWH, but in 2001 life satisfaction was higher among HIV⁺ PWH than among HIV⁻ PWH. Tests of differences in trend over time showed larger improvements in life satisfaction among HIV⁺ PWH than HIV⁻ PWH, while HIV⁻ PWH showed an increase in educational level compared to HIV⁺ PWH. Analysis restricted to HIV⁺ PWH showed an increase in perceived stigmatization.

Conclusions

Differences between Danish HIV⁺ and HIV⁻ PWH regarding well-being and psychosomatic symptoms seem to have evened out between 1988 and 2012. However, results suggest that HIV⁺ PWH still experience stigmatization and lower levels of education.

A structural equation model of perceived and internalized stigma, depression, and suicidal status among people living with HIV/AIDS

Background

Previous studies have shown positive association between HIV-related stigma and depression, suicidal ideation, and suicidal attempt among people living with HIV/AIDS (PLWH). But few studies have examined the mechanisms among HIV-related stigma, depression, and suicidal status (suicidal ideation and/or suicidal attempt) in PLWH. The current study examined the relationships among perceived and internalized stigma (PIS), depression, and suicidal status among PLWH in Guangzhou, China using structural equation modeling.

Methods

Cross-sectional study by convenience sampling was conducted and 411 PLWH were recruited from the Number Eight People’s Hospital from March to June, 2013 in Guangzhou, China. Participants were interviewed on their PIS, depressive symptoms, suicidal status, and socio-demographic characteristics. PLWH who had had suicidal ideation and suicidal attempts since HIV diagnosis were considered to be suicidal. Structural equation model was performed to examine the direct and indirect associations of PIS and suicidal status. Indicators to evaluate goodness of fit of the structural equation model included Chi-square Statistic, Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), Standardized Root Mean Square Residual (SRMR), and Weighted Root Mean Square Residual (WRMR).

Results

More than one-third (38.4%) of the PLWH had depressive symptoms and 32.4% reported suicidal ideation and/or attempt since HIV diagnosis. The global model showed good model fit (Chi-square value = 34.42, CFI = 0.98, RMSEA = 0.03, WRMR = 0.73). Structural equation model revealed that direct pathway of PIS on suicidal status was significant (standardized pathway coefficient = 0.21), and indirect pathway of PIS on suicidal status via depression was also significant (standardized pathway coefficient = 0.24). There was a partial mediating effect of depression in the association between PIS and suicidal status.

Conclusions

Our findings suggest that PIS is associated with increased depression and the likelihood of suicidal status. Depression is in turn positively associated with suicidal status and plays a mediating role between PIS and suicidal status. Therefore, to reduce suicidal ideation and attempt in PLWH, targeted interventions to reduce PIS and improve mental health status of PLWH are warranted.

Prevalence and Predictors of Substance Use Disorders Among HIV Care Enrollees in the United States

Prior efforts to estimate U.S. prevalence of substance use disorders (SUDs) in HIV care have been undermined by caveats common to single-site trials. The current work reports on a cohort of 10,652 HIV-positive adults linked to care at seven sites, with available patient data including geography, demography, and risk factor indices, and with substance-specific SUDs identified via self-report instruments with validated diagnostic thresholds. Generalized estimating equations also tested patient indices as SUD predictors. Findings were: (1) a 48 % SUD prevalence rate (between-site range of 21-71 %), with 20 % of the sample evidencing polysubstance use disorder; (2) substance-specific SUD rates of 31 % for marijuana, 19 % alcohol, 13 % methamphetamine, 11 % cocaine, and 4 % opiate; and (3) emergence of younger age and male gender as robust SUD predictors. Findings suggest high rates at which SUDs occur among patients at these urban HIV care sites, detail substance-specific SUD rates, and identify at-risk patient subgroups.

'Now and Again It Really Hits Me'

Quantitative and qualitative data were gathered from a sample of 66 seropositive and 67 seronegative men and women about the impact of an HIV diagnosis upon psychosocial well-being. No significant differences between seropositives and seronegatives were found on any of the psychosocial measures except hopelessness. Nor was there significant variation by disease progression (but this may be due to the restricted size of the sample). The qualitative data are used to illustrate these findings and explore their meaning. It is concluded that, with the exception of a hopeless future orientation, psychosocial disturbance of seropositives tends to be episodic and short-lived and thereby difficult to measure.

Determinants of Safer Sexual Behavior in a Long-term HIV-seropositive Population

Determinants of safer sexual behaviors among HIV-infected adult men with hemophilia were examined. A model was proposed that personal adjustment, communication skills, self-efficacy, and perceived advantages of condom use would influence safer sex practices. The model was tested with 181 men with hemophilia and HIV infection from 27 hemophilia treatment centers across the United States. The hypothesized model was tested using LISREL and explained 35 percent of the variance in safer sexual behaviors. Personal adjustment was significantly associated with general communication skills. General communication was linked with communication about safer sex which, in turn, influenced self-efficacy and perceived advantages of condom use. Communication about safer sex, efficacy and perceived advantages of condom use were all directly related to safer sexual behaviors.

Psychological status of men with haemophilia and HIV infection: two-year follow-up

This study aimed to assess the psychological status of men with haemophilia and HIV infection and to monitor changes in psychlogical status over time, in order to evaluate the need for psychological support. The study included 24 HIV seropositive men and a control group of 21 HIV seronegative men who attended the Haemophilia Centre in Bari (Italy). Subjects underwent psychological tests (STAl-Y: State and Trait Anxiety Inventory; SDS: Self-Rating Depression Scale) and completed a questionnaire on the emotional impact of AIDS. Assessment was repeated at 6-monthly intervals over a 2-year period. Contrary to expectation, HIV seronegative men with haemophilia had worse anxiety and depression scores, reported more confusion and fear, and had more reluctance towards the use of blood products (despite their present safety) than HIV seropositives. Possible reasons for these findings are considered, and their implications for clinical practice discussed.

Sexual dysfunction in HIV-positive men is multi-factorial: a study of prevalence and associated factors

To establish the prevalence of sexual dysfunction amongst HIV-positive men and to determine the factors associated with dysfunction we conducted a cross-sectional study in seven European HIV treatment centres. Data on medical history, antiretroviral treatment and laboratory results were collected by interview and case record review. Sexual function was evaluated by the participant self-completion of a questionnaire based on the International Index of Erectile Function (IIEF) 711/929. Seventy-seven percent of participants returned the questionnaire. Data from 668 (72%) respondents were included. Thirty-three percent (95%CI: 29.4-36.5%) had moderate/severe erectile dysfunction (EDF) and 24% (95%CI: 20.9-27.3%) had moderate to severe impairment of sexual desire. Variables significantly associated with EDF in multivariable analysis were older age (greater than 40 years), heterosexual status, non-alcohol drinking status, depression, antidepressants, psychotropic medications and duration of ARV therapy. Low sexual desire (LSD) was associated with older age (greater than 40 years), depression and black African ethnicity. We establish that EDF and LSD are common in both ARV naïve and ARV experienced, HIV-positive individuals. Erectile dysfunction was associated with long duration of ARV treatment, with a significantly increased risk of dysfunction in the quartile with the longest period of exposure. No significant association was seen with specific classes of anti-retrovirals. Older age, and depression were the variables most consistently associated with both EDF and LSD.

Hope is forked: hope, loss, treatments, and AIDS dementia

In the HIV epidemic hope and loss are temporally structured according to pre, and post highly active antiretroviral therapies (HAART). AIDS dementia is a neurological condition on which HAART has had an important impact, yet this form of dementia has received little sociocultural attention. In this article, the author explores ethnographically personal hope from the perspective of "Matthew," a significant other to a person with AIDS dementia, and how treatments influence this. Hope is present in Matthew's narrative, but its nature is complex and fluctuates with the arrival and perceived failure of HAART. The author concludes by suggesting that hope in this context is forked, which is suggestive of the tenacious nature of hope in the context of AIDS dementia in the era of HAART.

Screening for major depression in persons with HIV infection: the concurrent predictive validity of the Profile of Mood States Depression-Dejection Scale

Major Depressive Disorder (MDD) is among the most prevalent but underdiagnosed psychiatric disorders in persons with HIV infection. Given the known adverse impact of comorbid MDD on HIV disease progression and health-related quality of life, it is important both for research and for efficient, effective clinical care, to validate existing screening measures that may discriminate between MDD and the somatic symptoms of HIV (such as fatigue). In the current study, we evaluated the concurrent predictive validity of the Profile of Mood States (POMS) Depression-Dejection scale in detecting current MDD in 310 persons with HIV infection. The Structured Clinical Interview for DSM-IV (SCID) diagnosis of MDD and the Cognitive-Affective scale from the Beck Depression Inventory (BDI-CA) served as comparative diagnostic and severity measures of depression, respectively. Results demonstrated that the POMS Depression-Dejection scale accurately classified persons with and without MDD SCID diagnoses, with an overall hit rate of 80%, sensitivity of 55%, specificity of 84%, and negative predictive power of 91% using a recommended cutpoint of 1.5 standard deviations above the normative mean. Moreover, the POMS performed comparably to the BDI-CA in classifying MDD. Findings support the predictive validity of the POMS Depression-Dejection scale as a screening instrument for MDD in persons with HIV disease.

The effect of serostatus on HIV risk behaviour change among women sex workers in Miami, Florida

HIV prevention and risk reduction are especially salient and timely issues for women, particularly among those who are drug-involved or who exchange sex for drugs or money. Studies suggest that HIV-prevention measures can be effective with highly vulnerable women, and have the potential to produce significant reductions in risk behaviours among both HIV-negative and HIV-positive women. Within this context, this paper examines risk behaviours and HIV serostatus among 407 drug-involved women sex workers in Miami, Florida, and investigates the effects of participation in HIV testing, counselling, and a risk-reduction intervention on subsequent behavioural change among this population. Overall, at follow-up, the HIV-positive women were 2.4 times more likely than the HIV-negative women to have entered residential treatment for drug abuse, 2.2 times more likely to have decreased the number of their sex partners, 1.9 times more likely to have decreased the frequency of unprotected sex, 1.9 times more likely to have reduced their levels of alcohol use, and 2.3 times more likely to have decreased their crack use. These data support the importance of HIV testing and risk-reduction programmes for drug-involved women sex workers.

Despair and hopelessness in the context of HIV - a meta-synthesis on qualitative research findings

AIM

The aim of the study was to explore the concepts of despair and hopelessness in the context of human immunodeficiency virus based on previous studies.

BACKGROUND

Some of the consequences of living with human immunodeficiency virus or as a significant other to a person with human immunodeficiency virus include despair and hopelessness.

METHODS

The study is based on five earlier studies describing the dynamics of hope (including despair and hopelessness) in adult persons living with human immunodeficiency virus.

RESULTS

Despair consists of two sub-processes. The downward sub-process of despair refers to stopping and being stuck in a situation, losing grip and sinking into a narrowing existence, focusing on impossibility and losing perspective of the future. Furthermore, the downward orientation means questioning the possibility of hope. The upward sub-process of despair implies fighting against sinking and fighting to rise back up with a glimmer of hope. Hopelessness is the polar opposite of hope and includes sub-processes of helplessly giving up everything (including hope) and living in emptiness in the face of an assumed non-existing future, collapsing mentally, and becoming paralyzed without reason to live.

CONCLUSIONS

The results of this study support the findings of previous studies revealing that despair and hopelessness are possible elements in the life situation of persons living with human immunodeficiency virus and significant others to persons living with human immunodeficiency virus. The results of this study help to define the contents of despair and hopelessness, and help us to distinguish one from the other. The dual-dimensionality of despair has not been pointed out in previous studies and in this way the present study offers new information about the phenomenon of despair.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study offer clinical guidelines on a conceptual level about how to detect these phenomena in persons living with human immunodeficiency virus and their significant others. Furthermore, the findings offer a starting point for interventions used to alleviate despair and hopelessness. Suggestions for suitable interventions are offered. The results of this study underline the clinical relevance of these phenomena in adding new information to the previously documented consequences of despair and hopelessness.

Sexuality and sexual risk behavior in HIV-positive men who have sex with men

The purpose of this study was to examine the psychological processes pertaining to sexuality and sexual risk behavior among HIV-positive men who have sex with men (MSM). The authors analyzed transcripts of 30 semistructured interviews. Findings suggest that sexual problems in HIV-positive MSM might be primarily caused by the perceived risk of transmitting HIV to others. Furthermore, safer sexual behavior seems to be related to feelings of personal responsibility for safer sex. This study illustrates that although some men might have a clear notion of personal responsibility for safer sex, contextual factors can influence whether behavior is consistent with their norms of personal responsibility. The implications of the study are discussed for the practice of HIV prevention for HIV-positive MSM.

Depression in people living with HIV/AIDS attending primary care and outpatient clinics

OBJECTIVE

Our aim was to gain an estimate of the rate of depressive disorder in patients with HIV/AIDS attending general practice and to investigate factors associated with depression. A further objective was to determine the ability of non-mental health medical practitioners to detect depressive symptoms in their patients with HIV/AIDS. METHODS Participants comprised 322 persons living with HIV/AIDS ( (PLWHA); 13 females, 309 males; mean age 41.4, SD = 8.9) who were recruited from four general practice clinics specializing in HIV medicine and from an infectious diseases clinic. Medical, psychiatric and sociodemographic data were obtained. In addition, participants completed the Inventory to Diagnose Depression (IDD), a self-report measure to detect depression.

RESULTS

Twenty-two per cent of the sample met criteria for a current Major Depressive Episode (DSM-IV defined) on the IDD. Overall, there was moderate agreement between treating doctors' diagnosis of depression and patients' self-report of depressive symptoms. A multivariate model indicated that being in a current relationship was associated with lowered odds of depression (OR = 0.43; CI = 0.23-0.81). The factors strongly associated with increased odds of depression were a past history of illicit drug use (OR = 2.98; CI = 1.60-5.54) and a diagnosis of 'stress' by treating doctors (OR = 5.65; CI = 2.50-12.77). HIV-related medical variables such as immune function, use of antiretro-viral medication and duration of HIV infection were not associated with depression.

CONCLUSIONS

There was a high rate of self-reported depression in this group of PLWHA which was also recognized by treating clinicians. Being in a relationship appeared to afford protection against depression while having a history of illicit drug use and current 'stress' were highly associated with depression. Interestingly, HIV-related medical variables including laboratory markers of HIV disease, duration of illness and antiretroviral medication regimen were not related to depression.

Male sexual dysfunction associated with antiretroviral therapy

To determine whether treatment with protease inhibitors (PIs) is associated with male sexual dysfunction, we conducted a retrospective, cohort study of 254 adult male PI recipients who received care from the staff-model division of a large managed care organization in New England between 1993 and 1998. After a median of 5.0 years of observation, 80 incident cases of sexual dysfunction were observed. Relative to unexposed individuals, the rate of sexual dysfunction adjusted for confounding was most elevated with use of ritonavir (hazard ratio [HR], 2.83; 95% confidence interval [CI], 1.34-5.97; p =.006) followed by indinavir (HR, 1.69; 95% CI, 0.84-3.37; p =.14), nelfinavir (HR, 1.53; 95% CI, 0.66-3.54; p =.32) and saquinavir (HR, 1.25; 95% CI, 0.53-2.96; p =.60). We conclude that PIs, especially ritonavir, appear to increase the risk of sexual dysfunction.

Hope, despair and hopelessness in living with HIV/AIDS: a grounded theory study

BACKGROUND

Hope, despair or hopelessness have been detected in several research reports as important elements of the lives of persons living with human immunodeficiency virus (HIV) (PLWH) or acquired immunodeficiency syndrome (AIDS) (PLWA). However, there is an obvious gap in the literature suggesting a need to study the overall dynamics of hope (including both hope and despair or hopelessness) along the HIV spectrum from PLWHs' and PLWAs' perspective.

AIM

The purpose of this study was to describe the dynamics of hope in living with HIV/AIDS.

METHODS

The data were collected through interviewing 10 PLWHs/PLWAs and analysed using a grounded theory method.

FINDINGS

The dynamics of hope is a multifaceted and complex combination of 'hope', 'despair' and 'hopelessness'. It comprises balancing between 'believing life to be worth living at the present and in the future', 'losing one's grip and sinking into narrowing existence vs. fighting against sinking' and 'giving up in the face of belief in nonexisting future'. A dynamic alternation between hope, despair and hopelessness takes place in the presence of factors that contribute to the 'folding' and 'unfolding' possibilities in everyday life. Factors contributing to the folding possibilities include 'losing', 'fear', 'uncertainty', 'problems in care', 'HIV/AIDS in close ones', 'difficulties in relationships' and 'negative public images and attitudes concerning HIV'. Factors contributing to the unfolding possibilities are 'constructive life experiences', 'wishing not to have HIV while uncertain', 'constructive relationships', 'ability to control one's life', 'finding the meaning of life and zest for life', 'caring', 'noticing one's improved health and the continuance of life', 'increasingly positive attitudes concerning HIV-positive people' and 'protection by law'.

CONCLUSIONS

The dynamics of hope discovered in this study present new conceptualization, where hope, despair and hopelessness are viewed in relation to each other. The emerged definitions may be used in clinical practice to identify these phenomena in individuals with HIV/AIDS. The discovered factors contributing to the folding and unfolding possibilities can be used in clinical practice to help the individuals along the dynamics of hope.

Pharmacokinetic interactions between sildenafil and saquinavir/ritonavir

AIMS

To investigate the effect of the antiretroviral protease inhibitors saquinavir (soft gelatin capsule) and ritonavir on the pharmacokinetic properties and tolerability of sildenafil and to investigate the effect of sildenafil on the steady-state pharmacokinetics of saquinavir and ritonavir.

METHODS

Two independent, 8 day, open, randomized, placebo-controlled, parallel-group studies (containing a double-blind crossover phase) were conducted at Pfizer Clinical research units (Canterbury, UK. and Brussels, Belgium). Twenty-eight healthy male volunteers entered each study. In each study, volunteers were randomized (n = 14 per group) to receive sildenafil on day 1 followed by a 7-day treatment period (days 2-8) with saquinavir or placebo (Study I) or ritonavir or placebo (Study II). Sildenafil or placebo (Study I and Study II) was administered alternately on day 7 or day 8, depending on initial randomization. The effect of saquinavir and ritonavir on the pharmacokinetics of sildenafil and its primary circulating metabolite (UK-103, 320) and the effect of single-dose sildenafil on the steady-state pharmacokinetics of saquinavir (1200 mg three times daily) and ritonavir (500 mg twice daily) were determined. The safety and tolerability of sildenafil coadministered with saquinavir or ritonavir were also assessed.

RESULTS

Both protease inhibitors significantly increased Cmax, AUC, tmax and t(1/2) values for both sildenafil and UK-103, 320. Ritonavir showed a significantly greater effect than saquinavir with increases in sildenafil AUC and Cmax of 11-fold (95% CI: 9.0, 12.0) and 3.9-fold (95% CI: 3.2, 4.9), respectively. This compared with increases of 3.1-fold (95% CI: 2.5, 4.0) and 2.4-fold (95% CI: 1.8, 3.3) for coadministration with saquinavir. In contrast, the steady-state pharmacokinetics of saquinavir and ritonavir were unaffected by sildenafil. The increases in systemic exposure to sildenafil and UK-103, 320 were not associated with an increased incidence of adverse events or clinically significant changes in blood pressure, heart rate or ECG parameters.

CONCLUSIONS

These results indicate that both saquinavir and ritonavir modify the pharmacokinetics of sildenafil presumably through inhibition of CYP3A4. The more pronounced effect of ritonavir may be attributed to its additional potent inhibition of CYP2C9. No change in safety or tolerability was observed when sildenafil was coadministered with either protease inhibitor. However, given the extent of the interactions, a lower sildenafil starting dose (25 mg) should be considered for patients receiving saquinavir and it is recommended not to exceed a maximum single dose of 25 mg in a 48 h period for patients receiving ritonavir.

HIV-positive people, risk and sexual behaviour

For a long time, the sexual behaviour of HIV-infected persons did not receive any serious attention for a variety of reasons. Initially, diagnosis of HIV-infection appeared to imply a death sentence. In this context, the sex life of those infected seemed a secondary issue making prevention focused on sexual behaviour hard to imagine. Furthermore, the conviction that stigmatisation should be avoided also precluded an interest in the sexual behaviour of HIV-infected persons. From an epidemiological perspective and in the context of the developments in the medical treatment of AIDS it is important to address the sexuality of HIV-infected people. The scarce research done until now shows that there are various ways in which an HIV-infection affects people's sexuality. It seems that the sexuality of HIV-infected people can be compromised by their infection, inducing various sexual problems. Research also shows that there are HIV-infected people who do engage in unprotected sex, just as there are HIV-negative people or people with unknown serostatus who do so. Studies into the determinants of unsafe sex in HIV-infected people suggest that to some extent the same determinants are operative as among people in general. These include intention and self-efficacy regarding safe sex. Recreational drug use also affects safe sex regardless of serostatus. However, safe sex as well as sex in general is different for seropositive persons than for people who are seronegative or have an unknown serostatus. Among seropositive people, sex is also related to dilemma's involving disclosing their serostatus to potential sex partners, and their motivation to protect their partners as well as themselves against surinfection and STD. Furthermore, having to cope with a serious disease induces negative mood states (particularly depression) and may compromise sexual functioning. Comprehensive prevention aimed at HIV infected persons should address these various issues and should be an integrated part of general HIV-prevention.

Health status and satisfaction of asymptomatic HIV-positive haemophiliacs in Kyushu, Japan

The purpose of this study was to elucidate the effects of human immunodeficiency virus (HIV) on haemophiliacs with physical functional disabilities induced by haemophilia in Kyushu, Japan. The subjects were 38 adult haemophiliacs who were selected from 129 patients registered with the North Kyushu Haemophilia Centre. They were divided into 21 asymptomatic HIV-positive and 17 HIV-negative adult haemophiliacs. Coagulation factor levels, modified DePalma classification, Arthritis Impact Measurement Scale 2 (AIMS 2), and a satisfaction in daily life (SDL) questionnaire were used to investigate the clinical severity of their haemophilia and arthropathy, physical functional disabilities, and satisfaction. Although there were no significant differences in the objective assessments of health status between the HIV-positive and -negative haemophiliacs, the HIV-positive haemophiliacs were significantly more dissatisfied with their social activities and mood, according to AIMS 2, and with social intercourse, job, self-development, and social security and pension according to SDL assessment. These dissatisfactions were due to the effects of HIV, in addition to the physical functional disabilities that were caused by haemophilia. Dissatisfaction with social security and pension may be a specific feature in HIV-positive haemophiliacs in Japan resulting from the origin of HIV infection.

Psychiatric disorder in HIV infection

OBJECTIVE

This study aimed to investigate rates of psychiatric disorder in human immunodeficiency virus (HIV) infection, in an Australian sample of homosexual and bisexual men.

METHOD

A cross-sectional study of a total of 65 HIV sero-negative (HIV-) and 164 HIV sero-positive men (HIV+) (79 CDC stage II/III and 85 CDC stage IV) was conducted in three centres. Lifetime and current prevalence rates of psychiatric disorder were evaluated using the Diagnostic Interview Schedule Version IIIR (DIS-IIIR).

RESULTS

Elevated current and lifetime rates of major depression were detected in both HIV negative and HIV positive homosexual/bisexual men. Lifetime rates of alcohol abuse/dependence were significantly elevated in HIV positive men (CDC group IV) when compared with HIV negative men. Among the HIV positive group the majority of psychiatric disorders detected were preceded by a pre-HIV diagnosis of psychiatric disorder. Major depression represented the disorder most likely to have first onset after HIV infection diagnosis.

CONCLUSIONS

Lifetime rates of major depression were elevated in this sample of HIV-negative and HIV-positive men. In the HIV-positive men, psychiatric disorder was significantly associated with the presence of lifetime psychiatric disorder prior to HIV infection diagnosis. The findings indicate the importance of evaluation of psychiatric history prior to HIV infection and the clinical significance of depressive syndromes in this population.

Disease severity, physical limitations and depression in HIV-infected men

Previous research has failed to identify a consistent relationship between HIV disease severity and depression. However, HIV/AIDS can lead to substantial physical limitations in those with advanced disease, which may influence mood. This study examined the extent to which HIV disease severity and physical limitations were associated with depressive symptoms in 49 HIV-infected men at the final stages of a 5-year prospective study. No differences were found in depression or quality of life among men who were asymptomatic, symptomatic, or diagnosed with AIDS. Forty-three percent of subjects reported substantial physical limitations, which were associated with higher depression scores and poorer quality of life. Degree of physical limitation predicted depression concurrently as well as depression 6 months later, after controlling for disease stage, physical symptoms, and CD4 cell counts. Findings suggest that physical limitations are more important than laboratory markers of disease progression in understanding psychological adjustment to illness in HIV-infected men.

Neurophysiological changes associated with psychiatric symptoms in HIV-infected individuals without AIDS

HIV-1 infection may be complicated by a number of psychopathological conditions. While organic mental disorders, such as HIV-related psychosis and dementia, are late manifestations, mood disorders may occur during both asymptomatic and symptomatic stages of infection. The possible impact of brain involvement due to neurotropism of HIV-1 has not been investigated systematically in these latter conditions. The psychiatric caseness of HIV-seropositive individuals without AIDS and seronegative controls was assessed using a standardized clinical interview (Present State Examination). A comparison was made between individuals with and without psychiatric caseness using clinical, neuropsychological, and neurophysiological assessments. An increased prevalence of current psychiatric illness was found in subjects with early symptomatic HIV infection compared to those with asymptomatic infection and controls. This could not be attributed to psychiatric history, as well as to clinical and immunological markers of HIV infection, however, psychiatric caseness in early symptomatic infection was associated with marked neurophysiological changes, detectable by quantitative electroencephalography. Altogether, this study provided preliminary evidence that psychiatric symptoms in symptomatic but not asymptomatic HIV infection may be associated with subtle brain involvement preceding the immunological and neurocognitive impairment characteristic for AIDS.

Women and HIV infection: investigation of its psychosocial consequences

HIV infection is associated with substantial psychological and social morbidity, although there is a dearth of studies of women with the infection. In recent years, developed countries have reported an increase in the prevalence of HIV infection in women, a fact that makes it all the more important to address the study of their psychological and social status. The study is a controlled investigation of HIV seropositive (n = 49) and seronegative women (n = 43), including study of psychological status and history, social functioning and perceived supports, coping style, life events, and sexual difficulties. The results show that about a third of women were psychiatric cases, regardless of HIV status, although more than half of symptomatic women were psychiatric cases. Seropositive women were less likely to use instrumental social supports and more likely to use mental disengagement as ways of coping. Regarding perceived social supports, positive women had lower scores on social integration and guidance. Positive women were more likely to experience sexual difficulties and not to be in a relationship. Negative women reported more adverse life events in the last 6 months. Psychiatric morbidity was associated with poorer social adjustment and more adverse life events, but not with serostatus. HIV positive women and those at risk of HIV infection have substantial levels of psychological and social morbidity that require recognition by those involved in their care and provision of adequate mental health intervention.

Psychological interventions in infection with the human immunodeficiency virus

BACKGROUND

Infection with the human immunodeficiency virus (HIV) is associated with substantial psychiatric morbidity. This paper summarises the main forms of psychological intervention currently used, and reviews research evidence for their efficacy.

METHOD

Publications on the mental health aspects of HIV infection and psychological interventions were identified through the main HIV journals and general psychiatric and psychological periodicals, with the assistance of AIDS Abstracts.

RESULTS

Publications concerned psychological interventions at the time of HIV testing, interventions for infected people at different stages of disease, and risk-reduction interventions. While many publications were identified describing uncontrolled investigations, only a few studies had involved systematic evaluative research.

CONCLUSIONS

There is a need for systematic evaluation of psychological interventions for HIV infection, in terms of both efficacy and cost.

A longitudinal study of the neuropsychiatric consequences of HIV-1 infection in gay men. II. Psychological and health status at baseline and at 12-month follow-up

The aim of this study was to determine whether HIV infection is associated with increased psychosocial distress in the asymptomatic and early symptomatic stages of disease and to determine the factors associated with reporting health symptoms. Subjects included 61 gay men (41 HIV--, 20 HIV+) who were assessed at the time of requesting their first HIV test and again 12 months later. Measures included a detailed standardized psychiatric interview (Present State Examination, PSE), a range of psychosocial self-report measures and a physical symptom checklist. There were no differences between the HIV+ and HIV-- groups in terms of self-reported symptoms. Multiple regression analysis showed that the symptom reporting was not associated with clinical or immunological markers of disease progression but was associated with measures of psychosocial distress. Although both groups showed elevated levels of psychosocial distress at the time of HIV testing, there were no differences between serostatus groups at follow-up. Multiple regression analysis indicated that the best predictors of PSE scores at follow-up were baseline PSE score and a history of psychiatric illness. Early HIV disease is not associated with increased psychosocial distress and symptom reporting is more closely related to psychological measures than to clinical or immunological markers of disease.

Psychosexual problems in people with HIV infection: controlled study of gay men and men with haemophilia

HIV infection can be associated with major psychological and social disturbance. Psychosexual problems would be expected to arise in the context of the infection, in view of the contribution that sexual behaviour can make to the acquisition and spread of HIV infection. Here the results of a study of the psychosexual consequences of HIV infection in gay men and men with haemophilia are presented, with the inclusion of data from control groups. Sixteen HIV-positive and 23 HIV-negative gay men, and 20 HIV-positive and 24 HIV-negative men with haemophilia with sexual partners were studied. HIV infection was found to be associated with the greater risk of development of sexual dysfunction in seropositives, in particular in relation to ejaculatory difficulties, both delayed ejaculation in the case of gay men and men with haemophilia, and premature ejaculation in the case of men with haemophilia. Possible aetiological mechanisms are considered, including the possibility of organic disease. The findings are of relevance to those involved in the care of people with HIV infection.

Heterosexuals and HIV disease: a controlled investigation into the psychosocial factors associated with psychiatric morbidity

The aim of the study was to evaluate the prevalence of current and past psychiatric morbidity among HIV seropositive and HIV seronegative heterosexual men and women and to identify the psychosocial factors associated with psychiatric morbidity. Twenty-four asymptomatic HIV seropositive and twenty-six HIV seronegative heterosexuals were included in the study. Outcome measures included socio-demographic data, psychiatric history, current psychological status (Zung Self-Report Anxiety Scale, Zung Self-Report Depression Scale, Symptom Check List 90-R), Social Supports and Locus of Control Scales, and information on changes in work, social, and sexual life after HIV testing. There were no significant differences between HIV seropositive heterosexuals and HIV seronegative controls on any of the outcome measures. Levels of psychiatric morbidity were generally low and similar to those expected in a general out-patient medical population. Multiple regression analyses showed that degree of social support was the only significant factor associated with psychiatric morbidity. The implications of the findings are discussed.

Hopelessness in i.v. drug users not in treatment and seeking HIV testing and counselling

The Beck Hopelessness Scale (BHS) was administered to 2379 intravenous drug users who were not in treatment, unaware of their human-immunodeficiency-virus (HIV) status and seeking HIV testing and counselling. Three BHS principal components were identified reflecting resignation to the futility of changing the future, rejection of the possibility of a hopeful future, and acceptance of the inevitability of a hopeless future. The principal component scores representing these three dimensions were positively related to self-reported depression and suicidal ideation; the rejection scores were positively correlated with confirmed HIV seropositivity.

Neuropsychiatric aspects of HIV-1 infection in gay men: controlled investigation of psychiatric, neuropsychological and neurological status

The aim of this study was to determine whether HIV infection is associated with psychiatric morbidity or neuropsychological impairment in asymptomatic and early symptomatic stages of disease in gay men. The subjects were 100 gay men (68 HIV-ve, 32 HIV+ve, 6 being CDC IV). All subjects were recruited at the time of requesting their first HIV test and the assessment was double-blind to HIV serostatus. There were no differences in psychiatric status or neuropsychological performance between the HIV-ve and HIV+ve groups. Multiple regression analysis and logistic regression were used to identify factors associated with psychiatric morbidity, neuropsychological impairment and subjective reporting of memory problems and physical symptoms for all 100 subjects. Previous psychiatric history and current illegal (non-dependent) drug use were associated with psychiatric morbidity, poor education was associated with neuropsychological impairment and psychiatric status (score on HAD and PSE) was associated with subjective reporting of memory problems and physical symptoms.

The psychosocial impact of HIV infection in gay men, drug users and heterosexuals. Controlled investigation

The aim of this study was to establish the prevalence of current and past psychiatric morbidity in HIV seropositive asymptomatic subjects belonging to three transmission categories (gay men, intravenous drug users, and heterosexuals) compared with that found in HIV seronegative controls from the same groups. A cross-sectional, controlled study including 279 seropositive subjects belonging to groups II and III defined by the Center for Disease Control (94 gay men, 157 intravenous drug users, and 28 heterosexuals) and 159 seronegative subjects (38 gay men, 91 intravenous drug users, and 30 heterosexuals) is reported. Outcome measures included standardised, self-report questionnaires and a semistructured interview to assess current psychopathological status and past psychiatric history. In addition, a psychiatric diagnosis according to DSM-III-R criteria Axis I and II was made in the seropositive subjects. Results showed that these subjects differed very little from the controls and that overall levels of psychiatric disturbances in both groups were low and similar to those found in other life-threatening illnesses. Furthermore, intravenous drug users, regardless of HIV serological status, had the highest levels of psychological morbidity. Psychosocial distress was associated with previous and current lifestyle, independently of HIV status.

The psychosocial impact of HIV infection in women

The aim of the investigation was to study the prevalence of current and past psychiatric morbidity and psychosocial problems in HIV seropositive (HIV +ve) asymptomatic women. A cross-sectional controlled study including 57 HIV +ve women belonging to CDC group II and III (43 intravenous drug users and 14 non-IVDUs heterosexuals) and 23 HIV -ve women (15 intravenous drug users and 8 non-IVDUs heterosexuals) is reported. Outcome measures included, past psychiatric history, current psychological status (Zung Anxiety and Depression scales, Symptom Check List 90-Revised), Social Supports and Locus of Control Scales, and information on changes in work, social and sexual life after HIV testing. Results showed that HIV +ve women differed very little from HIV -ve controls regarding outcome measures and indeed for some variables HIV infected women had lower levels of psychological morbidity. Multiple regression analyses showed that alcohol misuse and a predominantly external locus of control accounted for the 29% of the variance of psychiatric distress (F = 9.23, p < 0.0006). The implications of the findings are discussed.

The psychosocial impact of HIV infection in gay men. A controlled investigation and factors associated with psychiatric morbidity

This study aimed to establish the prevalence of psychosocial problems in gay men with HIV infection, and to identify factors associated with psychological morbidity. The study was a cross-sectional controlled investigation, which included 24 HIV seropositive and 25 seronegative gay men. Outcome measures included current psychological status and psychiatric history; coping and health beliefs; and social and sexual functioning. Seropositive subjects had worse scores on the PSE total score, and greater sexual difficulties. There were also differences in health beliefs and coping. Psychological morbidity was associated with hopelessness, previous psychiatric illness, symptomatic HIV disease, and low self-esteem.

Partners of men with HIV infection and haemophilia: controlled investigation of factors associated with psychological morbidity

The study was concerned with determining the prevalence of psychosocial problems in partners of men with haemophilia and HIV infection, and with identifying factors associated with psychological morbidity. Partners of 17 HIV positive and partners of 19 HIV negative men with haemophilia were assessed in a cross-sectional controlled investigation. Outcome measures included current psychological status and psychiatric history; coping and health beliefs; and social and sexual functioning. Partners of HIV positive men with haemophilia, the majority of whom were asymptomatic, were not found to suffer more psychological difficulties than the partners of HIV negative men with haemophilia. However, partners of haemophiliacs regardless of HIV status suffer from higher levels of psychological distress than comparable women in the community, and those with past psychiatric history and current social difficulties are particularly at risk. The sexual relationships of couples with HIV positive men were more adversely affected than those of HIV negative couples.