Physicians' recognition of the symptoms experienced by HIV patients: how reliable?

Supportive and palliative care in hemato-oncology: how best to achieve seamless integration and subspecialty development?

While recent medical advances have led to cure, remission, or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses, and frequently are associated with significant symptom and quality of life burden for patients and families. Patients with hematological cancer are referred to palliative care (PC) services less often than those with solid tumors, despite higher inpatient mortality and shorter interval between first consultation and death. The complexity of individual prognostication, ongoing therapeutic goals of cure, the technical nature and complications of treatment, the intensity of medical care even when approaching end of life, and the speed of change to a terminal event all pose difficulties and hinder referral. A modified palliative care model is an unmet need in hemato-oncology, where PC is introduced early from the diagnosis of hematological malignancy, provided alongside care of curative or life-prolonging intent, and subsequently leads to death and bereavement care or cure and survivorship care depending on disease course. From current evidence, the historical prioritization of cancer care at the center of palliative medicine did not guarantee that those diagnosed with a hematological malignancy were assured of referral, timely or otherwise. Hopefully, this article can be a catalyst for debate that will foster a new direction in integration of clinical service and research, and subspecialty development at the interface of hemato-oncology and palliative care.

Phase II mixed methods' feasibility cluster randomised controlled trial of a novel community-based enhanced care intervention to improve person-centred outcomes for people living with HIV in Ghana

Person-centred care (PCC) for people living with HIV (PLWH) is a global goal for WHO and the UNAIDS strategy. We aimed to develop a novel person-centred intervention for community providers, test the feasibility of participant recruitment and retention, intervention delivery and to establish acceptability. Findings from qualitative interviews with PLWH and healthcare professionals were mapped onto a PCC theory in an expert intervention development workshop. A parallel feasibility cluster randomised controlled trial (cRCT) was conducted. We randomly assigned clusters (1:1) either to intervention or to standard care. The primary outcome was trial recruitment and retention. We screened 83 PLWH, enrolled 60 with 30 allocated to each arm. Recruitment and retention rates were 87% and 97%, respectively. Potential effect size achieved at final timepoint: a measure of person-centred outcomes [0.7 (95% CI 0.17-1.23) p < 0.001]; MOSHIV [0.7 (95% CI 0.17-1.23) p < 0.001]; Patient Experience Questionnaire [0.8 (95% CI 0.27-1.31) p < 0.001]; CARE Measure [1.0 (95% CI 0.45-1.55) p < 0.001], POSITIVE OUTCOMES [0.7 (95% CI 0.17-1.23) p < 0.001]. Post-trial interviews revealed general acceptability of the intervention. The results confirm the feasibility and justify a definitive cRCT of the enhanced care intervention to improve person-centred outcomes for PLWH.Trial registration number ISRCTN13630241.

How can we achieve person-centred care for people living with HIV/AIDS? A qualitative interview study with healthcare professionals and patients in Ghana

Although person-centred care (PCC) has been identified as a means to achieve the 90-90-90 targets, limited research has considered PCC in low- or middle-income settings. We aimed to explore what constitutes PCC from the perspectives of PLWHA and healthcare professionals (HCP) in Ghana. We conducted 39 semi-structured qualitative interviews with PLWHA and HCP in two community clinics in Ghana, West Africa. Interviews were analysed deductively using thematic analysis, and sampling continued until thematic saturation was achieved. Twenty-four PLWHA (median age 42.5, 50% female) and 15 HCP (median age 34, 53% female) were interviewed. Three interconnected themes emerged across PLWHA and HCP: (1) care structures not built around the person, (2) priority outcomes and components of PCC and (3) re-engineering HIV care to be more person-centred. A conceptual model showing the overlap between PLWHA and HCP's perspectives of PCC and a framework to inform PCC delivery have been developed from these findings. Our data revealed that PLWHA want PCC to improve care outcomes, well-being and quality of life. Further testing of this model is required to inform PCC delivery for PLWHA in low- and middle-income countries.

Depressive symptoms, physical symptoms, and health-related quality of life among older adults with HIV

PURPOSE

In the United States, approximately 45% of persons living with HIV (PLHIV) are ≥ 50 years of age. Many older PLHIV have multi-morbidities that complicate HIV infection and/or interfere with, or are exacerbated by, antiretroviral treatment. Physical health symptoms and psychiatric disorders, particularly depression, can worsen life quality in older PLHIV.

METHODS

This study assessed associations among physical symptoms, indicators of HIV-related health status (i.e., time since diagnosis; ever diagnosed with AIDS; having attained viral suppression), depressive symptoms, and health-related quality of life (HRQoL) in older PLHIV. Regression analyses examined data from 296 PLHIV ≥ 50 years of age living in Cincinnati, OH, Columbus, OH, and New York City.

RESULTS

Depressive symptoms and physical symptoms, particularly those related to appearance and sexual functioning, most strongly predicted HRQoL. Indicators of HIV health status did not significantly predict HRQoL. Depressive symptoms were a particularly robust predictor of HRQoL, even when accounting for physical health symptoms.

CONCLUSION

Findings suggest that symptom management is critical to HRQoL in older PLHIV, and symptoms related to physical appearance and sexual functioning should not be overlooked in this growing population.

Perceived HIV-related physical fatigue, sociodemographic characteristics and physical activity: A cross-sectional study

AIMS AND OBJECTIVES

To get a deeper understanding of correlates of perceived HIV-related fatigue by exploring its associations with sociodemographic characteristics and physical activity level of HIV-infected people.

BACKGROUND

Previous studies on HIV-related fatigue have mainly focused on physiological and psychological characteristics, but few have considered its associations with sociodemographic variables. In addition, while physical activity has been found to reduce acute fatigue among HIV-infected people, its links with chronic HIV-related fatigue remain to be explored.

DESIGN

The study employed an observational and cross-sectional survey design. The manuscript was organised according to STROBE guidelines.

METHOD

A total of 560 people living with HIV in France completed a measure of perceived physical fatigue using the Fatigue Intensity Scale. The predictors targeted sociodemographic characteristics and two measures of individuals' reported level of physical activity. Data were analysed by a stepwise multiple regression model.

RESULTS

The results showed that lower age, higher physical activity level and socio-economic status were significantly associated with reduced perceived physical fatigue, explaining 25% of the variance.

CONCLUSIONS

The results highlighted the importance of considering sociodemographic and lifestyle characteristics to better characterise HIV-related fatigue, in particular in an era where HIV as a chronic illness challenges questions of quality of life throughout increasingly longer lifespans.

RELEVANCE TO CLINICAL PRACTICE

The results of this study have implications for HIV care professionals in terms of improving strategies for managing chronic fatigue or promoting physical activity according to more specific profiles of HIV-infected people.

Palliative care in patients with haematological neoplasms: An integrative systematic review

BACKGROUND

Palliative care was originally intended for patients with non-haematological neoplasms and relatively few studies have assessed palliative care in patients with haematological malignancies.

AIM

To assess palliative care interventions in managing haematological malignancies patients treated by onco-haematology departments.

DESIGN

Integrative systematic review with data extraction and narrative synthesis (PROSPERO #: CRD42016036240).

DATA SOURCES

PubMed, CINAHL, Cochrane, Scopus and Web-of-Science were searched for articles published through 30 June 2015. Study inclusion criteria were as follows: (1) published in English or Spanish and (2) containing data on palliative care interventions in adults with haematological malignancies.

RESULTS

The search yielded 418 articles; 99 met the inclusion criteria. Six themes were identified: (1) end-of-life care, (2) the relationship between onco-haematology and palliative care departments and referral characteristics, (3) clinical characteristics, (4) experience of patients/families, (5) home care and (6) other themes grouped together as 'miscellany'. Our findings indicate that palliative care is often limited to the end-of-life phase, with late referral to palliative care. The symptom burden in haematological malignancies patients is more than the burden in non-haematological neoplasms patients. Patients and families are generally satisfied with palliative care. Home care is seldom used. Tools to predict survival in this patient population are lacking.

CONCLUSION

Despite a growing interest in palliative care for haematological malignancies patients, the evidence base needs to be strengthened to expand our knowledge about palliative care in this patient group. The results of this review support the need to develop closer cooperation and communication between the palliative care and onco-haematology departments to improve patient care.

Randomized, Double-Blind, Crossover Trial of Amitriptyline for Analgesia in Painful HIV-Associated Sensory Neuropathy

We conducted a randomized, double-blind, placebo-controlled, crossover study at a single center in South Africa, to ascertain whether amitriptyline is an effective analgesic for painful HIV-associated sensory neuropathy of moderate to severe intensity in: i) antiretroviral drug naive individuals, and ii) antiretroviral drug users. 124 HIV-infected participants (antiretroviral drug naive = 62, antiretroviral drug users = 62) who met the study criteria for painful HIV-associated sensory neuropathy were randomized to once-daily oral amitriptyline (titrated to a median: interquartile range of 50: 25-50 mg) or placebo for six weeks, followed by a three-week washout period and subsequent treatment crossover. The primary outcome measure was change from baseline in worst pain intensity of the feet (measured by participant self-report using an 11-point numerical pain rating scale) after six weeks of treatment. 122 of 124 participants completed all study visits and were included in the analysis of the primary outcome. In the antiretroviral drug-naive group (n = 61) there was no significant difference in the mean change in pain score from baseline after six weeks of treatment with placebo or amitriptyline [amitriptyline: 2.8 (SD 3.3) vs. placebo: 2.8 (3.4)]. Similarly, there was no significant difference in the change in pain score after six weeks of treatment with placebo or amitriptyline in the antiretroviral drug-user group (n = 61) [amitriptyline: 2.7 (3.3) vs. placebo: 2.1 (2.8)]. Controlling for period effects and treatment order effects did not alter the outcome of the analyses. Nor did analyzing the intention-to-treat cohort (missing data interpolated using baseline observation carried forward) alter the outcome of the analyses. In summary, amitriptyline, at the doses used here, was no more effective than an inactive placebo at reducing pain intensity in individuals with painful HIV-associated sensory neuropathy of moderate to severe intensity, irrespective of whether they were on antiretroviral therapy or not.

Integrating early palliative care for patients with HIV: provider and patient perceptions of symptoms and need for services

Increasingly clinicians are using palliative care to address the symptomatic and psychosocial effects of disease often missed by routine clinical care, termed "early" palliative care. Within an inner-city medical center, we began a program to integrate early palliative care into HIV inpatient care. Patient symptom burden and desired services were assessed and compared to provider perceptions of patient's needs. From 2010-2012, 10 patients, with a median CD4+ T-cell count of 32.5 cells/μL, and 34 providers completed the survey. Providers ranked their patients' fatigue, sadness, anxiety, sexual dysfunction, and body image significantly higher than patients it for themselves. Patients ranked medical care, pharmacy, social work, physical therapy, and housing as significantly more important to them than providers estimated them to be. These differences may reflect the fact that physicians often overlook patients' unmet basic needs. Early palliative care may narrow this gap between providers' and patients' perceptions of needs through good communication and targeting barriers, such as housing instability, which are vital to overcome for consistent long-term follow up.

Antiretroviral treatment and quality of life in Africans living with HIV: 12-month follow-up in Burkina Faso

Introduction

The scale-up of highly active antiretroviral therapy (HAART) has led to a significant improvement in survival of the HIV-positive patient but its effects on health-related quality of life (HRQOL) are less known and context-dependent. Our aim was to assess the temporal changes and factors associated with HRQOL among HIV-positive adults initiating HAART in Burkina Faso.

Methods

HIV-positive people initiating HAART were prospectively included and followed over a one-year period in three HIV clinics of Ouagadougou. HRQOL was assessed at baseline and at each follow-up visit using physical (PHS) and mental (MHS) summary scores derived from the Medical Outcome Study 36-Item short-form health survey (MOS SF-36) questionnaire. Toxicity related to HAART modification and self-reported symptoms were recorded during follow-up visits. Determinants associated with baseline and changes in both scores over a one-year period were assessed using a mixed linear model.

Results

A total of 344 patients were included. Their median age at baseline was 37 years [interquartile range (IQR) 30–44] and their median CD4 count was 181 cells/mm³ (IQR 97–269). The mean [standard deviation (SD)] PHS score increased from 45.4 (11.1) at baseline to 60.0 (3.1) at 12 months (p<10⁻⁴) and the mean (SD) MHS score from 42.2 (8.7) to 43.9 (3.4) (p<10⁻²). After one year of treatment, patients that experienced on average two symptoms during follow-up presented with significantly lower PHS (63.9) and MHS (43.8) scores compared to patients that presented no symptoms with PHS and MHS of 68.2 (p<10⁻⁴) and 45.3 (p<10⁻³), respectively.

Discussion

The use of HAART was associated with a significant increase in both physical and mental aspects of the HRQOL over a 12-month period in this urban African population. Perceived symptoms experienced during follow-up visits were associated with a significant impairment in HRQOL. The appropriate and timely management of reported symptoms during the follow-up of HAART-treated patients is a key component to restore HRQOL.

Agreement between self-report and medical records on signs and symptoms of respiratory illness

BACKGROUND

Information on patient symptoms can be obtained by patient self-report or medical records review. Both methods have limitations.

AIMS

To assess the agreement between self-report and documentation in the medical records of signs/symptoms of respiratory illness (fever, cough, runny nose, sore throat, headache, sinus problems, muscle aches, fatigue, earache, and chills).

METHODS

Respondents were 176 research participants in the Hutterite Influenza Prevention Study during the 2008-2009 influenza season with information about the presence or absence of signs/symptoms from both self-report and primary care medical records.

RESULTS

Compared with medical records, lower proportions of self-reported fever, sore throat, earache, cough, and sinus problems were found. Total agreements between self-report and medical report of symptoms ranged from 61% (for sore throat) to 88% (for muscle aches and earache), with kappa estimates varying from 0.05 (for chills) to 0.41 (for cough) and 0.51 (for earache). Negative agreement was considerably higher (from 68% for sore throat to 93% for muscle aches and earache) than positive agreement (from 13% for chills to 58% for earache) for each symptom except cough where positive agreement (77%) was higher than negative agreement (64%). Agreements varied by age group. We found better agreement for earache (kappa = 0.62) and lower agreements for headache, sinus problems, muscle aches, fatigue, and chills in older children (aged >5 years) and adults.

CONCLUSIONS

Agreements were variable depending on the specific symptom. Contrary to research in other patient populations which suggests that clinicians report fewer symptoms than patients, we found that the medical record captured more symptoms than selfreport. Symptom agreement and disagreement may be affected by the perspectives of the person experiencing them, the observer, the symptoms themselves, measurement error, the setting in which the symptoms were observed and recorded, and the broader community and cultural context of patients.

Integration of palliative care throughout HIV disease

People with HIV have a high burden of pain and physical, psychological, and social difficulties that can be managed effectively with palliative care. However, most individuals do not have access to this type of care. Palliative care is holistic patient-centred management of life-limiting progressive disorders and is recognised by WHO as an essential element of HIV care, from diagnosis to end of life. Historically, palliative care and HIV care were linked closely, but misconceptions divide the two disciplines today. Palliative care can augment patients' outcomes and boost adherence to antiretroviral treatments and life expectancy. In much of the world, services providing palliative care are isolated, and most individuals in need have no access to this care. The commitment to provide palliative care for all people with HIV can be fulfilled if clinical workers are trained in this therapeutic approach and if care is delivered at community level, with support for family caregivers.

Pain and physical and psychological symptoms in ambulatory HIV patients in the current treatment era

CONTEXT

HIV infection has become a manageable chronic disease. There are few studies of pain and symptoms in the current treatment era.

OBJECTIVES

Our primary objective was to determine the prevalence of and risk factors for pain and physical and psychological symptoms in a population of ambulatory HIV patients.

METHODS

We performed a cross-sectional study using the Brief Pain Inventory and the Memorial Symptom Assessment Scale-Short Form (MSAS).

RESULTS

We evaluated 156 individuals with a median age of 47.5 years (range 21-71), median time since HIV diagnosis of 11 years (range <1 to 25), and median CD4+ cell count of 502 cells/mm(3) (interquartile range [IQR] 308-683). Most (125, 80.6%) of the patients had an undetectable viral load. Seventy-six (48.7%) patients reported pain, of whom 39 (51.3%) had moderate to severe pain, and 43 (57.3%) had pain that caused moderate to severe interference with their lives. The median number of symptoms was eight (IQR 5-14.5) of 32 queried. In multivariable analyses, patients with psychiatric illness were 39.8% more likely to have pain (P<0.001). Psychiatric illness was associated with 0.7 and 1.2 point higher MSAS subscale scores, and IV drug use was associated with 0.4 and 0.5 higher subscale scores (out of four).

CONCLUSION

Pain and other physical and psychological symptoms were common among ambulatory HIV patients. Pain and symptoms were strongly associated with psychiatric illness and IV drug use. Future investigation should evaluate interventions that include psychiatric and substance abuse components for HIV patients with pain.

Physiological and psychosocial factors that predict HIV-related fatigue

Fatigue is one of the most common and debilitating symptoms experienced by HIV-infected people. We report the results of our longitudinal analysis of physiological and psychosocial factors that were thought to predict changes in HIV-related fatigue in 128 participants over a 1-year period, in an effort to sort out the complex interplay among a comprehensive set of physiological and psychosocial variables. Physiological measures included hepatic function (aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transpeptidase, alkaline phosphatase, total bilirubin, hepatitis C status), thyroid function (thyroid stimulating hormone, thyroxine), HIV viral load, immunologic function (CD4, CD8, CD4/CD8 ratio, CD16, CD8CD38), gonadal function (testosterone, dehydroepiandrosterone), hematologic function (hemoglobin, hematocrit, serum erythropoietin), and cellular injury (lactic acid). Psychosocial measures included childhood and adult trauma, anxiety, depression, social support, stressful life events, and post-traumatic stress disorder (PTSD). Unemployment, not being on antiretroviral therapy, having fewer years since HIV diagnosis, more childhood trauma, more stressful life events, less social support, and more psychological distress (e.g., PTSD, anxiety and depression) put HIV-infected persons at risk for greater fatigue intensity and fatigue-related impairment in functioning during 1-year follow-up. Physiological variables did not predict greater fatigue. Stressful life events had both direct and indirect effects on fatigue.

Opinions toward pain management and palliative care: Comparison between HIV specialists and oncologists

Despite the introduction of HAART, pain is still a common symptom in people living with HIV/AIDS. For these persons, pain management supplied by palliative care teams may support standard HIV care. This study compares opinions toward palliative care of 83 HIV specialists and 217 oncologists (French national survey: Palliative Care 2002). Data were collected by phone questionnaire. A cluster analysis was carried out in order to identify contrasted profiles of opinions toward palliative care. A logistic regression was performed to test the relationships between identified clusters and physicians' characteristics. With a two-cluster partition, we observed a profile corresponding to a restrictive conception of palliative care. Within this profile, physicians were more prone to consider that palliative care should be used only for terminally-ill patients, and only after all curative treatments have failed, with a restrained prescriptive power for physicians providing palliative care. This conception was associated with reluctance toward morphine analgesia. Once controlled for other physicians' characteristics, HIV specialists were more likely than oncologists to endorse this restrictive conception (OR=1.9, CI 95% [1.1; 3.3]). Thus French HIV specialists should be more informed about the utility of providing palliative care, even for patients who are not in terminal stage.

Integrating palliative care into HIV outpatient clinical settings: preliminary findings from an intervention study in Vietnam

Symptom assessment and treatment for people living with HIV (PLHIV) cannot only lead to improvements in quality of life but contribute to combination antiretroviral adherence and early detection of virologic rebound. The majority of PLHIV in Vietnam receive their care in HIV outpatient settings, whereas very few clinics provide palliative care. The Ministry of Health has called for palliative care to be incorporated into existing HIV and cancer services, but there is limited guidance regarding how to operationalize integration. An HIV outpatient clinic palliative care intervention was tested in northern Vietnam to explore the accessibility, acceptability, and feasibility of integrated services. Primary outcome measures included changes in identification and treatment of pain and other symptoms, the prevalence of depression and anxiety, and perceived social support. The palliative care intervention included introduction of tools and mentoring to assess and treat pain and other symptoms as well as mental health and social support screening, counseling, and treatment services. The intervention resulted in significant changes in provider practice and service delivery. Providers and patients reported overall satisfaction with the intervention and resulting improvements in quality of care.

Access to pain treatment as a human right

BACKGROUND

Almost five decades ago, governments around the world adopted the 1961 Single Convention on Narcotic Drugs which, in addition to addressing the control of illicit narcotics, obligated countries to work towards universal access to the narcotic drugs necessary to alleviate pain and suffering. Yet, despite the existence of inexpensive and effective pain relief medicines, tens of millions of people around the world continue to suffer from moderate to severe pain each year without treatment.

DISCUSSION

Significant barriers to effective pain treatment include: the failure of many governments to put in place functioning drug supply systems; the failure to enact policies on pain treatment and palliative care; poor training of healthcare workers; the existence of unnecessarily restrictive drug control regulations and practices; fear among healthcare workers of legal sanctions for legitimate medical practice; and the inflated cost of pain treatment. These barriers can be understood not only as a failure to provide essential medicines and relieve suffering but also as human rights abuses.

SUMMARY

According to international human rights law, countries have to provide pain treatment medications as part of their core obligations under the right to health; failure to take reasonable steps to ensure that people who suffer pain have access to adequate pain treatment may result in the violation of the obligation to protect against cruel, inhuman and degrading treatment.

Development of an electronic medical record-based clinical decision support tool to improve HIV symptom management

Common symptoms associated with HIV disease and its management are often underrecognized and undertreated. A clinical decision support tool for symptom management was developed within the Veterans Health Administration electronic medical record (EMR), aiming at increasing provider awareness of and response to common HIV symptoms. Its feasibility was studied in March to May 2007 by implementing it within a weekly HIV clinic, comparing a 4-week intervention period with a 4-week control period. Fifty-six patients and their providers participated in the study. Patients' perceptions of providers' awareness of their symptoms, proportion of progress notes mentioning any symptom(s) and proportion of care plans mentioning any symptom(s) were measured. The clinical decision support tool used portable electronic "tablets" to elicit symptom information at the time of check-in, filtered, and organized that information into a concise and clinically relevant EMR note available at the point of care, and facilitated clinical responses to that information. It appeared to be well accepted by patients and providers and did not substantially impact workflow. Although this pilot study was not powered to detect effectiveness, 25 (93%) patients in the intervention group reported that their providers were very aware of their symptoms versus 27 (75%) control patients (p = 0.07). The proportion of providers' notes listing symptoms was similar in both periods; however, there was a trend toward including a greater number of symptoms in intervention period progress notes. The symptom support tool seemed to be useful in clinical HIV care. The Veterans Health Administration EMR may be an effective "laboratory" for developing and testing decision supports.

Chronicity and remission of fatigue in patients with established HIV infection

Fatigue is one of the most common and debilitating complaints of HIV-positive individuals, potentially leading to important functional limitations. We recruited 128 HIV-positive individuals (fatigued and nonfatigued) between March 2005 and May 2006; 66% were male, 66% were African American, 45% had greater than a high school education, 67% were unemployed, and ages ranged from 26-66 (median, 44). Every 3 months for 15 months, participants completed a 56-item self-report fatigue scale developed and validated by the authors. Participants were classified as fatigued or not fatigued at each assessment and received scores for fatigue intensity and impact of fatigue on functioning. We used linear mixed-effects models to assess longitudinal variation in fatigue scores and generalized estimating equations for binary outcomes to model predictors of fatigue remission among those fatigued at baseline. At baseline, 88% of the sample was fatigued. Fatigue measures were highly correlated across time points (rho 0.63-0.85 [intensity], 0.63-0.80 [functioning]) and showed no evidence of overall improvement, deterioration, or convergence over time. Predictors of lower fatigue scores included higher income, employment, longer time since HIV diagnosis, and antiretroviral therapy use. Those employed at baseline were likely to show improvements in fatigue while those unemployed were not. Of those fatigued at baseline, 11% experienced remission during follow-up; remission was associated with Caucasian race and employment. In summary, fatigue intensity and related functional limitations were persistent, stable, and unlikely to remit over 15 months of follow-up in this sample of patients with established HIV infection.

Trauma, stressful life events and depression predict HIV-related fatigue

Despite the fact that fatigue is a common and debilitating symptom among HIV-infected persons, we know little about the predictors of fatigue in this population. The goal of this cross-sectional study was to examine the effects of early childhood trauma, recent stressful life events and depression on intensity and impairment of fatigue in HIV, over and above demographic factors and clinical characteristics. We studied 128 HIV-infected men and women from one southern state. The median number of childhood traumatic events was two and participants tended to have at least one moderate recent stressful event. Multiple regression findings showed that patients with less income, more childhood trauma, more recent stressful events and more depressive symptoms had greater fatigue intensity and fatigue-related impairment in daily functioning. Recent stresses were a more powerful predictor of fatigue than childhood trauma. None of the disease-related measures (e.g. CD4, viral load, antiretroviral medication) predicted fatigue. Although stress and trauma have been related to fatigue in other populations, this is the first study to examine the effects of traumatic and recent stressful life events on fatigue in an HIV-infected sample.

Demographic and illness-related variables associated with HIV-related fatigue

Fatigue is one of the most debilitating symptoms suffered by those with HIV infection, yet little is known about its correlates. The primary aims of this study were to describe the degree to which fatigue affects daily functioning and the demographic and illness-related predictors of fatigue. The sample (n = 128) was composed of primarily poor, unemployed people of color. Fatigue most often interfered with the ability to think quickly, perform household chores, exercise, work, engage in recreational activities, walk, plan activities, and think clearly. The consequences of fatigue were highest for lowered motivation, difficulty concentrating, increased drowsiness, losing patience, and interference with work, family, and social life. Multiple linear regression analyses showed statistically significant associations of employment status, monthly income, current antidepressant use, and number of years living with HIV infection as predictors of fatigue. These must be better understood to develop interventions to successfully ameliorate HIV-related fatigue.

The gastro-oesophageal reflux disease impact scale: a patient management tool for primary care

BACKGROUND

Symptoms of gastro-oesophageal reflux disease have a substantial impact on patients' everyday lives.

AIM

To develop and test a short questionnaire to aid patient-doctor communication.

METHODS

The Gastro-oesophageal Reflux Disease Impact Scale was developed from a systematic literature review, focus groups of patients and primary care physicians, and patient cognitive interviews. A psychometric validation study was conducted based on two consultations in new (n = 100) or chronic (n = 105) gastro-oesophageal reflux disease patients.

RESULTS

The Gastro-oesophageal Reflux Disease Impact Scale demonstrated internal consistency (Cronbach's alpha ranged from 0.68 to 0.82), reproducibility (intraclass correlation coefficient in stable patients ranged from 0.61 to 0.72) and construct validity (Spearman correlations with Quality of Life in Reflux and Dyspepsia instrument and Reflux Disease Questionnaire: 0.5-0.8 in both patient groups). Effect sizes in new and chronic gastro-oesophageal reflux disease patients ranged from 0.9 to 1.5 and 0.32 to 0.42, respectively. Doctors reported altering their treatment decision based on information provided by the Gastro-oesophageal Reflux Disease Impact Scale in 35% of patients, and 77% of doctors found it to be useful.

CONCLUSIONS

The Gastro-oesophageal Reflux Disease Impact Scale demonstrated good psychometric properties in newly diagnosed gastro-oesophageal reflux disease patients and those already receiving treatment. This simple communication tool is a useful aid for managing primary care patients with gastro-oesophageal reflux disease.

Fatigue among HIV-infected patients in the era of highly active antiretroviral therapy

OBJECTIVE

To describe the prevalence of operationally defined fatigue in an ethnically diverse HIV-infected population in south London, and to examine the association of fatigue with demographic characteristics, stage of disease, antiretroviral therapy and psychological factors.

METHODS

A descriptive comparative cross-sectional study of HIV-infected patients attending a London HIV clinic over a 5-month period in 2002 was performed. Demographic and clinical data were obtained from the local database. Participants completed four self-administered questionnaires-the Chalder Fatigue Scale (CFS), a measure of physical and mental fatigue; the General Health Questionnaire (GHQ-12) to detect anxiety and depression; the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to measure functional status, and the Illness Perception Questionnaire (IPQ). Fatigue 'cases' were defined as those scoring at least 4 on the CFS. Multivariate logistic regression was used to identify factors associated with the presence of fatigue.

RESULTS

Two hundred and five patients were approached and 148 (72%) agreed to participate. Overall, 65% of patients were defined as fatigued. Significant psychological distress on the GHQ-12, functional impairment on the SF-36 and a higher CD4 count were all independently associated with the presence of fatigue. There was no association with use of antiretroviral therapy or demographic characteristics.

CONCLUSIONS

The presence of fatigue in HIV-infected patients is most strongly associated with psychological factors and not with more advanced HIV disease or the use of highly active antiretroviral therapy. This highlights the importance of investigation and management of underlying depression and anxiety in patients presenting with fatigue.

“Nobody Understands”: On a Cardinal Phenomenon of Palliative Care

In the clinical practice of palliative medicine, recommended communication models fail to approximate the truth of suffering associated with an impending death. I provide evidence from patients' stories and empiric research alike to support this observation. Rather than attributing this deficiency to inadequate training or communication skills, I examine the epistemological premises of the biomedical language governing the patient-physician communication. I demonstrate that the contemporary biomedicine faces a fundamental aporetic occlusion in attempting to examine death. This review asserts that the occlusion defines, rather than simply complicating, palliative care. Given the defining place of aporia in the care for the dying, I suggest that this finding shape the clinicians' responses to the needs of patients in clinical care and in designing palliative research. Lastly, I briefly signal that a genuinely apophatic voice construing the occlusion as a mystery rather than an aporia may be superior to the present communication and empathy models.

Patient reports of symptoms and their treatment at three palliative care projects servicing individuals with HIV/AIDS

Self-reports of 32 symptoms and their treatments were obtained from patients of three palliative care programs that provide services to seriously ill HIV patients (>or=95% AIDS) in Alabama (n=47), Baltimore (n=91), and New York City (n=117). On average, patients reported 10.9 (SD=7.6) to 12.7 (SD=6.2) symptoms. Pain, lack of energy, and worrying were reported by a majority of patients at all sites, often with a high level of associated distress. For only four symptoms (pain, nausea, difficulty swallowing, and mouth sores) did half or more of patients at all sites experiencing the symptom also report treatment. Less than a third of patients experiencing 12 symptoms (five of six comprising a psychological subscale) reported treatment. Results show that despite the availability of more efficacious treatments, many HIV/AIDS patients continue to experience significant physical and psychological symptomatology. Many of those experiencing symptoms, however, do not perceive their symptoms as being treated.

The relationship between lipodystrophy-associated body changes and measures of quality of life and mental health for HIV-positive adults

OBJECTIVES

To investigate the relationship between lipodystrophy-specific symptom severity and wellbeing.

METHODS

HIV-positive adult patients with body fat redistribution (lipodystrophy syndrome) associated with antiretroviral therapy reported their total non-lipodystrophy symptoms and side effects and completed measures assessing body fat changes (yielding Atrophy, Hypertrophy and Total Lipodystrophy scores), mental health and quality of life. Effects of total symptom complex and lipodystrophy severity on quality of life and mental health were analyzed using Spearman's rho correlations. Logistic regression analyses were utilized to determine the relative-odds of depression produced by overall symptom count and lipodystrophy score increments.

RESULTS

Mean ratings for Hypertrophy and Atrophy corresponded to 'very mild' and 'mild' degrees of severity, respectively. The total symptom complex was associated with ratings for most of the mental health and quality of life measures. Patient-perceived body image scores were the sole study variable responsive to lipodystrophy severity ratings. In comparison to reference norms, a pronounced degree of body image impairment was evident.

CONCLUSION

Although responsive to the total symptom profile, psychosocial measures typically utilized for evaluating quality of life and mental health status in HIV disease lacked sensitivity and specificity for measuring the consequences of lipodystrophy-associated fat distribution changes alone. Lipodystrophy severity did impact negatively on body image.

Access and equity in HIV/AIDS palliative care: a review of the evidence and responses

The high prevalence of pain and other symptoms throughout the HIV disease trajectory, the need for management of side effects related to antiretroviral therapy, the continuing incidence of cancers and new emerging co-morbidities as a result of extended life expectancy under new therapeutic regimes, and the ongoing need for terminal care all prove the curative versus palliative dichotomy to be inappropriate. Although there is evidence for both need and effectiveness of palliative care in HIV patient care, access is often poor and care less than optimal. This review aimed to identify evidence of barriers and inequalities in HIV palliative care in order to inform policy and service development. Biomedical databases were searched using a specific strategy, and evidence extracted into the barrier and inequity categories of patient, clinician, service and disease factors. A model of the barriers and inequalities is presented from the evidence. Recommendations are made from the evidence for promoting access and outcomes through integrated palliative care from diagnosis to end-of-life, alongside antiretroviral therapy when initiated. Service responses that have attempted to increase access to palliative care are presented.

Perceived adverse effects of antiretroviral therapy

Adverse effects from antiretroviral therapy (ARV) for HIV are associated with medication nonadherence. The purposes of this study were to explore group differences in the reporting of adverse effects, identify individual adverse effects that are linked to nonadherence, and to explore the role of coping in the relationship between adverse effects and adherence. Cross-sectional interviews of 2,765 HIV-positive adults on ARV therapies in four U.S. cities were performed using a computerized assessment of self-reported adverse effects, coping self-efficacy, and adherence. There were no gender differences in the rate or severity of adverse effects reported. Latino respondents reported more adverse effects than either White or African Americans. Those taking a protease inhibitor (PI) reported a higher rate and greater severity of adverse effects. Older participants reported fewer adverse effects despite being more likely to be on a regimen containing a PI. Respondents with less than 90% adherence reported greater numbers and severity of adverse effects overall. In multivariate analyses, nausea, skin problems, vomiting, and memory adverse effects were independently related to less than 90% adherence over the prior three days. Coping moderated the relationship between nausea and adherence such that individuals who reported lower coping self-efficacy and experienced nausea were at increased risk for nonadherence, regardless of the length of time on the current ARV regimen. Women and men are similar in their overall reports of adverse effects, and Latinos report more adverse effects to ARVs than White or African American patients. Specific adverse effects (skin problems, memory problems, vomiting, and nausea) are more likely than others to be associated with missing ARV medications. Increasing adaptive coping self-efficacy among patients experiencing nausea may be a particularly effective strategy in increasing medication adherence.

Assessing symptoms in gastroesophageal reflux disease: how well do clinicians' assessments agree with those of their patients?

OBJECTIVES

This study aimed to determine the extent of agreement between clinicians and patients regarding assessments of reflux symptom severity in patients with gastroesophageal reflux disease.

METHODS

Data were analyzed from four randomized clinical trials involving 2,674 patients treated with esomeprazole, omeprazole, ranitidine, or placebo. The extent of agreement was determined for symptom severity before and after 4-8 wk of treatment, and for the absence of symptoms after treatment. Agreement was further analyzed by determining weighted kappa values, which were interpreted according to the criteria of Landis and Koch.

RESULTS

Before treatment, clinician-patient agreement regarding symptom severity in the four studies was slight to moderate (kappa: 0.17-0.53); 48-52% of assessments agreed for heartburn, 24-35% for epigastric pain, 36-43% for regurgitation, and 63% agreed for dysphagia. Poor agreement reflected clinician underestimation of symptom severity relative to patient ratings in three studies and clinician overestimation in one study. Agreement regarding symptom severity improved following treatment, and was fair to substantial (kappa: 0.31-0.73); 58-78% of assessments agreed for heartburn, 42-60% for epigastric pain, 66-76% for regurgitation, and 86% agreed for dysphagia. After treatment, agreement was greatest for patients reporting absence of symptoms and decreased with increasing severity of symptoms.

CONCLUSIONS

The agreement between clinicians and patients in their assessments of the severity of reflux symptoms is poor, particularly before treatment and for more severe symptoms. Improvements in clinician-patient communication may help to bridge this gap, and greater reliance on patient assessments may be appropriate.

Patient-reported and physician-estimated adherence to HAART: social and clinic center-related factors are associated with discordance

OBJECTIVES

To evaluate the rate of discordance between patients and physicians on adherence to highly active antiretroviral therapy (HAART) and identify factors related to discordance in these two assessments.

DESIGN

Prospective, multicenter, cohort study (AdICONA) nested within the Italian Cohort Naive Antiretrovirals (ICONA) study.

SETTING

Tertiary clinical centers.

PARTICIPANTS

The patients filled out a 16-item self-administered questionnaire on adherence to HAART. At the same time, physicians estimated the current HAART adherence of their patient.

MAIN OUTCOME MEASURE

Discordance between patient and physician on adherence to antiretroviral therapy.

RESULTS

From May 1999 to March 2000, 320 paired patient-physician assessments were obtained. Patients had a mean plasma HIV RNA of 315 copies/ml (64% had undetectable HIV RNA) and a mean CD4+ cell count of 577 cells x 10(6)/L. Nonadherence was reported by 30.9% of patients and estimated by physicians in 45.0% cases. In 111 cases (34.7%), patients and physicians were discordant on adherence to HAART. Kappa statistics was 0.27. Using patient-assessed adherence as reference, sensitivity, specificity, positive predictive value, and negative predictive value of physician-estimated adherence were 64.7%, 66.6%, 81.2%, and 45.8%, respectively. On multivariable analysis, low education level, unemployment, absence of a social worker in the clinical center, and unavailability of afternoon visits were significantly correlated with patient-physician discordance on adherence to antiretrovirals.

CONCLUSIONS

Physicians did not correctly estimate patient-reported adherence to HAART in more than one third of patients. Both social variables and factors related to the clinical center were important predictors of discordance between patients and physicians. Interventions to enhance adherence should include strategies addressed to improve patient-physician relationship.

The benefits of exercise training for quality of life in HIV/AIDS in the post-HAART era

The use of highly active antiretroviral therapy (HAART) has served to significantly reduce the mortality of HIV-infected persons. However, this treatment is associated with a host of adverse effects: fatigue, nausea, pain, anxiety and depression. Rather than utilise traditional pharmacological treatments for these effects, many HIV/AIDS patients are utilising adjunct therapies to maintain their quality of life while they undergo treatment. Exercise has consistently been listed as one of the most popular self-care therapies and a small number of studies have been conducted to examine the impact of exercise on the most common self-reported symptoms of HIV and AIDS and the adverse effects of treatment. Although the results are generally positive, there are clear limitations to this work. The existing studies have utilised small samples and experienced high rates of attrition. In addition, the majority of the studies were conducted prior to the widespread use of HAART, which limits the ability to generalise these data. As a result, data from other chronic disease and healthy samples are used to suggest that exercise has the potential to be a beneficial treatment across the range of symptoms and adverse effects experienced by HIV-infected individuals. However, additional research is required with this population to demonstrate these effects.

Causal attributions for fatigue among late middle-aged and older adults with HIV infection

Fatigue, a symptom with many possible causes, is highly prevalent among persons with HIV/AIDS. The causal attributions HIV+ individuals make for their fatigue are important because they largely guide the coping responses they use to manage it. In a study to better understand the symptom appraisal process among 100 HIV+ older adults (50+), 49 participants discussed in depth their experience with fatigue. Many participants felt confused, at least initially, about the source of their fatigue, although most offered their HIV disease as a possible cause. However, many who did so also believed it was caused in part by other, generally less threatening causes, such as age, overexertion, or excess weight. HIV medications and other symptoms or comorbidities were also frequently cited as causes of fatigue. Health care professionals and HIV+ peers often helped to shape or reinforce participants' attributions for their fatigue.

Palliative care for AIDS: challenges and opportunities in the era of highly active anti-retroviral therapy

In contrast to the first decade of the AIDS epidemic, the past decade has seen an increasing separation between AIDS care and palliative care services. While this may be due in part to the perception that AIDS is no longer a uniformly fatal illness, AIDS in fact remains an important cause of morbidity and mortality for young adult populations in the United States, particularly among certain racial-ethnic minorities. Death rates have remained steady since the dramatic decreases noted in the mid-1990s, and causes of death now increasingly include co-morbidities such as hepatitis B, C, end-organ failure, and various malignancies. Moreover, as AIDS has been transformed into a more manageable, chronic disease in the era of 'highly active antiretroviral therapy' (HAART), the opportunities for palliative care interventions have only increased. Patients with AIDS continue to experience a high burden of pain and other chronic symptoms, over a longer period of time, with a disease course marked by more cumulative exacerbations and remissions than when AIDS was a stereotypic, rapidly fatal illness. Advance care planning and discussions of goals of care are more complex and involve more uncertainty than was the case when prognosis was clear-cut and treatment options were more limited. For all of these reasons, it is important for the distance which has developed between HIV and palliative care providers to be bridged. Contrary to popular perceptions, palliative medicine continues to have much to offer in the HAART era for the care of patients and families with HIV/AIDS, for whom treatment outcomes will only benefit from greater integration of disease-specific and palliative interventions. The challenge for care providers is now to implement successful strategies for integrating AIDS and palliative care services in all relevant clinical environments.

Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes

BACKGROUND

Despite major advances in therapy, acquired immune deficiency syndrome (AIDS) remains an important cause of morbidity and mortality in young adult populations. As AIDS has been converted into a chronic disease, it has resulted for some patients in a more protracted course of symptomatic illness. Comprehensive care for late-stage human immunodeficiency virus (HIV) disease now involves an increasingly complex mixture of disease-specific and palliative therapies, requiring coordination and collaboration between AIDS and palliative care services. We describe the experience of developing a palliative care consultation service for patients with AIDS at a large urban teaching hospital, funded by the Health Resources and Services Administration as one of six national demonstration projects for the integration of HIV and palliative care.

SETTING

An 1100-bed medical center in the Bronx, New York. The multidisciplinary consultation team included a physician, nurse practitioner, social worker, chaplain, outreach worker, psychiatrist, and ethicist. Patients were referred from inpatient AIDS services and outpatient care sites.

METHODS

Patients underwent standardized assessment with clinical case review, Memorial Symptom Assessment Scale (MSAS), Mini-Mental Status Examination (MMSE), Karnofsky score, and Rapid Disability Rating Scale (RDRS). Interventions and follow-up outcomes were recorded and categorized. All deaths were analyzed and predictors of mortality were determined by bivariate and logistic regression analysis.

RESULTS

Program referrals have been steady, with 132 patients followed by the consultation service from July 2000 through October 2001; 73% were referred from inpatient services (representing 12% of all AIDS inpatients admitted to the hospital during the study period); 57% of patients were male, 36% African American, 55% Hispanic; 44% had a history of injection drug use. Median baseline values included: CD4+ T-lymphocyte count = 35/mm3, HIV viral load = 53,813 copies per milliliter, Karnofsky = 40, MMSE = 0 (with a median score of 24 for those able to complete the examination); number of severe symptoms reported by MSAS = 4; 71% had one or more serious impairments in activities of daily living (ADL) by RDRS. In addition to AIDS, 20% of patients had malignancies and 13% had end-stage liver disease. Presenting problems and priority issues identified at consultation included: care decisions/goals of care (68%), pain (40%), psychosocial issues (31%), depression (23%), anxiety (19%), nausea/vomiting (14%), insomnia (13%), and patient/family/team conflict (13%); these problems were fully or partially resolved in 68-91% of cases. 63 patients died (median days enrolled = 35); leading causes of death included AIDS (38%), sepsis (19%), cancer (19%), and liver failure/cirrhosis (17%). Death was predicted only by baseline functional status (Karnofsky, MMSE, ADL impairment), and not by CD4+ count, viral load, or any AIDS-specific variables.

CONCLUSION

Results suggest an important and ongoing need for palliative care services for patients with advanced HIV/AIDS, whose needs are likely to increase as AIDS evolves into more of a chronic disease. Patients were readily referred from predominantly inpatient settings, with very advanced disease; problems included a mix of medical and psychosocial issues, and were readily resolved by the consultation team in most cases. Death was predicted only by baseline functional status, not by traditional HIV disease markers. Mortality reflected both AIDS-related and non-AIDS-specific causes. Further studies are needed to identify more specific prognostic variables and to continue to improve palliative care treatment outcomes in late-stage patients with AIDS.

Self-care management of anxiety and fear in HIV disease

The purpose of this study is to describe the frequency and correlates of self-reported anxiety and fear and the self-care behaviors used to manage these symptoms. Data were collected in a convenience sample (N = 422) of HIV-positive subjects. Demographic and disease-related variables were compared for those who did and did not report anxiety and fear. Anxiety and fear were the most frequently reported symptoms (17.3%, n = 73). There were significant differences on gender, level of education, and the use of antiretroviral medications. Self-care behaviors (n = 212) for anxiety and fear were grouped into seven categories: using activities for distraction = 25%, talking to others = 21%, using alternative/complementary therapies = 18%, taking prescribed medications = 10%, using self-talk = 9%, using substances = 9%, and using avoidance behaviors = 7%. Anxiety and fear are commonly experienced by people with HIV/AIDS. Self-care strategies are imperative in the management of these clinical manifestations.

Physiological and psychological markers associated with HIV-related fatigue

Fatigue is among the most common and debilitating complaints of HIV-positive individuals. These data are part of a larger exploratory study investigating the relationships of selected psychological and physiological factors among 40 participants with HIV-related fatigue. Fatigue severity was measured using the HIV-Related Fatigue Scale. Fatigue was correlated with depression (r = .40, p < .01), state anxiety (r = .40, p <.01), and trait anxiety (r = .46, p <.01). Of the physiological factors, there were three statistically significant correlations: thyroid-stimulating hormone was negatively correlated with fatigue severity (r = -.36, p = .02), and platelets (r = .35, p = .03) and alkaline phosphatase (r = .27, p = .09) were positively correlated with fatigue severity. There were no correlations between fatigue severity and CD4 count (r = -.16, p = .31) or fatigue severity and HIV viral load levels (r = .031, p = .84). Even among the group with excellent viral suppression, fatigue scores were still very high for many participants.

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.

Predicting fatigue and depression in HIV-positive gay men

HIV-related fatigue is a prevalent and troubling symptom for HIV-positive people. The purpose of the study was to develop a model for predicting fatigue and depression among HIV-positive gay men as a function of history of fatigue and depression in the previous year and to determine whether psychological and psychosocial variables or physiologic variables better predict fatigue. Data from 96 HIV-positive gay men followed longitudinally for up to 7.5 years were used to develop logistic regression models for predicting fatigue and depression. Fatigue was predicted by both physiologic and psychological risk factors, whereas depression was predicted by only psychological risk factors.

Pain and other symptoms in ambulatory HIV patients in the age of highly active antiretroviral therapy

To determine whether and how highly active antiretroviral therapy (HAART) has influenced the prevalence of pain and other symptoms experienced in persons with HIV disease, HIV+ patients at an urban outpatient clinic were asked to complete a symptom checklist before seeing a clinician. Among those who completed the checklists (N = 484), 68% reported at least one symptom and 96% of those reported more than one symptom. Almost half of this cohort reported symptoms with an intensity of 5 or greater, indicating symptoms of at least moderate to severe intensity. The most frequently experienced symptoms were fatigue, trouble sleeping, anxiety, and pain. Despite methodological limitations, the results of this survey project indicate that pain and other symptoms--though less frequent than during the pre-HAART era--continue to be a problem.

Self-care for fatigue in patients With HIV

PURPOSE/OBJECTIVES

To identify when fatigue is reported as a problem by people who are HIV positive, what the perception of fatigue is, and which self-care behaviors are used and with what efficacy.

DESIGN

Multisite descriptive study.

SETTING

University-based AIDS clinics, community-based organizations, and homecare agencies located in cities across the United States, in Norway, and through a university Web site.

SAMPLE

Convenience sample of 422 self-identified people who are HIV positive.

MAIN RESEARCH VARIABLES

Symptom description, symptom relief, symptom help, and self-care strategies.

FINDINGS

The sixth most reported symptom in this study, fatigue, was treated with a variety of self-designed strategies. In only three instances was consultation with a healthcare provider (i.e., physician) or an injection (medication not defined) mentioned. The most frequently used interventions were supplements, vitamins, and nutrition followed by sleep and rest; exercise; adjusting activities, approaches, and thoughts; distraction; and complementary and alternative therapies. In addition to self-designed strategies, the media and friends and family were sources of information.

CONCLUSIONS

Fatigue was reported less frequently in this study than in other HIV-, AIDS-, or cancer-related studies. This may be an artifact of the study design. The use of informal networks for assistance, let alone the prevalence of unrelieved fatigue, indicates the need for more attention to this problem among people with AIDS.

IMPLICATIONS FOR NURSING

Careful assessment of the pattern of fatigue and its onset, duration, intervention, and resolution is required if the varied types of fatigue are to be identified and treated successfully.

Symptom management in Taiwanese patients with HIV/AIDS

The purpose of this study was to explore HIV/AIDS patients' symptom experiences and self-care symptom management strategies using a semi-structured questionnaire. Concurrently, the investigators gathered information about patients' symptom management strategies from healthcare providers. A total of 134 HIV-infected persons and 31 healthcare providers voluntarily participated in this study. Nausea, pain, anxiety, vomiting, diarrhea, fear and lack of appetite were described frequently by HIV-infected participants. Nausea, anxiety, diarrhea, fever, fear, pain and vomiting were observed frequently by healthcare providers. The management strategies used by these patients are presented and the differences in findings between Taiwan and Western cultures are discussed. In general, the results indicated that healthcare providers hold limited knowledge about self-care symptom management of HIV/AIDS. Filling this knowledge gap is an essential task for all healthcare providers in Taiwan.

Failure to maintain long-term adherence to highly active antiretroviral therapy: the role of lipodystrophy

In a sample of 277 patients included in the French APROCO cohort study who were initially adherent at follow-up visit 4 months after initiation of a protease inhibitor-containing regimen, 76.4% self-reported at least one lipodystrophy-related symptom and 30.0% failed to maintain adherence behaviour 20 months after enrolment. After multiple adjustment for other related factors, such as younger age, alcohol consumption and poor housing conditions, the number of self-reported lipodystrophy symptoms was independently associated with adherence failure.

Development and validation of a self-completed HIV symptom index

Traditional, open-ended provider questions regarding patient symptoms are insensitive. Better methods are needed to measure symptoms for clinical management, patient-oriented research, and adverse drug-event reporting. Our objective was to develop and initially validate a brief, self-reported HIV symptom index tailored to patients exposed to multidrug antiretroviral therapies and protease inhibitors, and to compare the new index to existing symptom measures. The research design was a multistage design including quantitative review of existing literature, qualitative and quantitative analyses of pilot data, and quantitative analyses of a prospective sample. Statistical analyses include frequencies, chi-square tests for significance, linear and logistic regression. The subjects were from a multisite convenience sample (n = 73) within the AIDS Clinical Trials Group and a prospective sample from the Cleveland Veterans Affairs Medical Center (n = 115). Measures were patient-reported symptoms and health-related quality of life, physician-assessed disease severity, CD4 cell count, and HIV-1 RNA viral quantification. A 20-item, self-completed HIV symptom index was developed based upon prior reports of symptom frequency and bother and expert opinion. When compared with prior measures the index included more frequent and bothersome symptoms, yet was easier to use (self-report rather than provider interview). The index required less than 5 minutes to complete, achieved excellent completion rates, and was thought comprehensive and comprehensible in a convenience sample. It was further tested in a prospective sample of patients and demonstrated strong associations with physical and mental health summary scores and with disease severity. These associations were independent of CD4 cell count and HIV-1 RNA viral quantification. This 20-item HIV symptom index has demonstrated construct validity, and offers a simple and rational approach to measuring HIV symptoms for clinical management, patient-oriented research, and adverse drug reporting.

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.

Self-reported symptoms after initiation of a protease inhibitor in HIV-infected patients and their impact on adherence to HAART

PURPOSE

The purpose of our study was to assess short-term self-reported symptoms in patients who were started on two nucleoside reverse transcriptase inhibitors and one protease inhibitor (PI) in the multicenter APROCO cohort (N = 336) and to assess the influence of these symptoms on adherence.

METHOD

Adherence and patient's reported symptoms were measured at 1 and 4 months (M) after initiation of highly active antiretroviral therapy (HAART) through self-administered questionnaires.

RESULTS

Most patients reported at least one symptom (94.0% at M1; 88.0% at M4); fatigue and diarrhea were the most often reported symptoms. Respectively, 81.3% and 75.0% of patients were strictly adherent to HAART during the 4 days prior to M1 and M4 visits. After adjustment for younger age, history of antiretroviral treatment, unstable housing, poor social support, and alcohol consumption, patients who reported a high number of symptoms at M1 were more likely to be nonadherent at M4 (odds ratio per symptom = 1.13; 95% CI = 1.03-1.24).

CONCLUSION

Patients reporting a high number of symptoms soon after HAART initiation are at higher risk of future nonadherence and could be targeted for interventions to achieve good levels of adherence and to improve treatment outcome.