Symptom Management in HIV-Infected Patients

Knowledge, practice and correlates of sleep hygiene among people living with HIV/AIDS attending anti-retroviral therapy at Zewditu Memorial Hospital, Addis Ababa, Ethiopia: a cross-sectional study

Background

Sleep hygiene is a series of behavioral practices that can be performed by individuals with sleep complaints to prevent or reverse sleep difficulties. The feasibility, cost-effectiveness, absence of side effects and immediate responses to sleep problems make sleep hygiene practices more applicable than other treatment options for people living with HIV/AIDS. However, there is no evidence regarding sleep hygiene awareness and its practice in people with HIV/AIDS in Ethiopia.

Objectives

This study aimed to assess the knowledge, practice and correlates of sleep hygiene among adults attending outpatient anti-retroviral treatment at Zewditu Memorial Hospital.

Methods

This was an institutional based cross-sectional study conducted from 1st of May to 16th of June 2018 amongst people attending anti-retroviral therapy follow-up at Zewditu Memorial Hospital. Systematic random sampling technique was used to recruit a total of 396 study participants. Data were collected using interviewer-administered questionnaire. The Sleep Hygiene Index was used to measure the level of sleep hygiene of study participants. Binary logistic regression analysis was conducted to identify factors associated with sleep hygiene practice. In the multi-variable analysis, variables with P-values of less than 0.05 were considered as significant correlates of sleep hygiene practice with 95% confidence interval.

Results

The findings of this study showed that there are limitations regarding the knowledge and practice of sleep hygiene of people with HIV/AIDS in Ethiopia. None of the participants attended training regarding sleep hygiene. More than half (51.3%) had poor sleep hygiene practice. Female sex [AOR = 5.80:95% CI (3.12, 10.7)], being single [AOR =2.29:95% CI (0.13, 9.51)], depression [AOR = 2.93: 95% CI (1.73, 4.96)] and current khat use [AOR = 3.30; 95% CI (1.67, 6.50)] were identified as statistically significant correlates of poor sleep hygiene practice.

Conclusions

Knowledge regarding sleep hygiene is poor, and its practices are incorrect amongst people living with HIV/AIDS in Ethiopia. These findings demonstrate a need for professionals to play a major role in addressing this problem by integrating sleep hygiene as an added treatment modality to the HIV/AIDS care service. Designing training programs and awareness creation strategies for people with HIV/AIDS to improve their sleep hygiene practice is also highly recommended.

Information sources of self-care strategies for persons living with HIV

OBJECTIVES

A number of studies have been conducted to identify the self-care strategies that are used by persons living with chronic illnesses to manage their symptoms, but little work has been done to identify the primary information source for these self-care strategies.

METHODS

We conducted an anonymous online survey with 1373 persons living with HIV to identify the self-care strategies they use to manage 28 commonly experienced symptoms. Following their report of their symptoms and self-care strategies, we asked an open-ended question to identify where the participant obtained the information. We applied iterative content analysis of the narrative data and multi-nominal regression to identify which demographic factors were significantly related to each information source category.

RESULTS

Respondents reported a total of 8539 information sources for their self-care strategies categorized as follows: Common sense/Self-experience, Healthcare professional, Internet, Literature, Multiple Sources, Social Support, and TV ads.

CONCLUSIONS

We found that respondents with no college education were significantly more likely to report the use of the Internet as the information source for their self-care strategies. On the other hand, males as compared to females were significantly less likely to use the Internet and significantly more likely to use TV ads.

An Educational Intervention to Reduce Pain and Improve Pain Management for Malawian People Living With HIV/AIDS and Their Family Carers: A Randomized Controlled Trial

CONTEXT

Advances being made in improving access to HIV drugs in resource-poor countries mean HIV patients are living longer, and, therefore, experiencing pain over a longer period of time. There is a need to provide effective interventions for alleviating and managing pain.

OBJECTIVES

To assess whether a pain educational intervention compared with usual care reduces pain severity and improves pain management in patients with HIV/AIDS and their family carers.

METHODS

This was a randomized, parallel group, superiority trial conducted at HIV and palliative care clinics of two public hospitals in Malawi. A total of 182 adults with HIV/AIDS (Stage III or IV) and their family carers participated; carer participants were those individuals most involved in the patient's unpaid care. The educational intervention comprised a 30 minute face-to-face meeting, a leaflet, and a follow-up telephone call at two weeks. The content of the educational intervention covered definition, causes, and characteristics of pain in HIV/AIDS; beliefs and myths about pain and pain medication; assessment of pain; and pharmacological and nonpharmacological management. The primary outcome was average pain severity measured by the Brief Pain Inventory-Pain Severity subscale. Assessments were recorded at baseline before randomization and at eight weeks after randomization.

RESULTS

Of the 182 patient/carer dyads randomly allocated, 157 patient/carer dyads completed the trial. Patients in the intervention group experienced a greater decrease in pain severity (mean difference = 21.09 points, 95% confidence interval = 16.56-25.63; P < 0.001).

CONCLUSION

A short pain education intervention is effective in reducing pain and improving pain management for Malawian people living with HIV/AIDS and their family carers.

HIV-1 Nef expression in microglia disrupts dopaminergic and immune functions with associated mania-like behaviors

BACKGROUND

Neuropsychiatric disorders during HIV/AIDS are common although the contribution of HIV-1 infection within the brain, and in particular individual HIV-1 proteins, to the development of these brain disorders is unknown. Herein, an in vivo transgenic mouse model was generated in which the HIV-1 Nef protein was expressed in microglia cells, permitting investigation of neurobehavioral phenotypes and associated cellular and molecular properties.

METHODS

Transgenic (Tg) mice that expressed full length HIV-1 nef under the control of the c-fms promoter and wildtype (Wt) littermates were investigated using different measures of neurobehavioral performance including locomotory, forced swim (FST), elevated plus maze (EPM) and T-maze tests. Host gene and transgene expression were assessed by RT-PCR, immunoblotting, enzymatic activity and immunohistochemistry. Biogenic amine levels were measured by HPLC with electrochemical detection.

RESULTS

Tg animals exhibited Nef expression in brain microglia and cultured macrophages. Tg males displayed hyperactive behaviors including augmented locomotor activity, decreased immobility in the FST and increased open-arm EPM exploration compared to Wt littermates (p<0.05). Tg animals showed increased CCL2 expression with concurrent IFN-α suppression in striatum compared with Wt littermates (p<0.05). Dopamine levels, MAO activity and the dopamine transporter (DAT) expression were reduced in the striatum of Tg animals (p<0.05).

CONCLUSIONS

HIV-1 Nef expression in microglia induced CCL2 expression together with disrupting striatal dopaminergic transmission, resulting in hyperactive behaviors which are observed in mania and other psychiatric comorbidities among HIV-infected persons. These findings emphasize the selective effects of individual viral proteins in the brain and their participation in neuropathogenesis.

Sources and types of information on self-care symptom management strategies for HIV and AIDS

BACKGROUND

It has been reported that South Africa has the highest number of people living with HIV worldwide, with more women being infected than men. Women living with HIV have been documented as experiencing various symptoms related to HIV and use various strategies to manage these symptoms.

OBJECTIVE

The objective of this study was to explore the sources and types of information regarding self-care symptom management strategies received by women living with HIV.

METHOD

The study was conducted at an HIV clinic in an urban area of KwaZulu-Natal. Individual in-depth interviews were completed with 11 women who were living with HIV,exploring the sources of information received on how they manage the HIV- (and/or AIDS-) related symptoms they experienced as well as the types of information received. The collecteddata were analysed using qualitative content analysis.

RESULTS

The participants identified various sources, which mainly included groups of people who provided them with information on how to manage their HIV-related symptoms, namely healthcare providers, their personal networks and the community. The different sources offered different types of information, including the use of medication, complementary treatments and self-comforting activities.

CONCLUSION

The study highlights that participants used multiple sources to get information about how to manage the experienced symptoms related to HIV, namely, healthcare providers, family and friends as well as themselves. It is to be noted that each source provided a preferred type of information.

Feasibility testing of a web-based symptom self-management system for persons living with HIV

The purpose of this study was to explore the feasibility of using a Web-based tool to provide tailored symptom management strategies for persons living with HIV (PLWH) and to estimate the effect size of the tool for future studies. Testing the components of the Web-based system was done by incorporating a repeated-measures design measuring the outcomes of symptom frequency and intensity, use of symptom management strategies, and engagement with health care providers. We recruited 42 PLWH; participants were enrolled in the study for 12 weeks and were asked to use the system and complete the questionnaires every 2 weeks. Our results showed that participants who used the strategies were more likely to have a decrease in symptom frequency and intensity. Findings from this feasibility study provide preliminary evidence for the use of a Web-based HIV symptom management tool with self-management strategies for individuals living with HIV infection.

An educational intervention to reduce pain and improve pain management for Malawian people living with HIV/AIDS and their family carers: study protocol for a randomised controlled trial

Background

Many HIV/AIDS patients experience pain often due to advanced HIV/AIDS infection and side effects of treatment. In sub-Saharan Africa, pain management for people with HIV/AIDS is suboptimal. With survival extended as a direct consequence of improved access to antiretroviral therapy, the prevalence of HIV/AIDS related pain is increasing. As most care is provided at home, the management of pain requires patient and family involvement. Pain education is an important aspect in the management of pain in HIV/AIDS patients. Studies of the effectiveness of pain education interventions for people with HIV/AIDS have been conducted almost exclusively in western countries.

Methods/design

A randomised controlled trial is being conducted at the HIV and palliative care clinics of two public hospitals in Malawi. To be eligible, patient participants must have a diagnosis of HIV/AIDS (stage III or IV). Carer participants must be the individual most involved in the patient’s unpaid care. Eligible participants are randomised to either: (1) a 30-minute face-to-face educational intervention covering pain assessment and management, augmented by a leaflet and follow-up telephone call at two weeks; or (2) usual care. Those allocated to the usual care group receive the educational intervention after follow-up assessments have been conducted (wait-list control group). The primary outcome is pain severity measured by the Brief Pain Inventory. Secondary outcomes are pain interference, patient knowledge of pain management, patient quality of life, carer knowledge of pain management, caregiver motivation and carer quality of life. Follow-up assessments are conducted eight weeks after randomisation by palliative care nurses blind to allocation.

Discussion

This randomised controlled trial conducted in sub-Saharan Africa among people living with HIV/AIDS and their carers will assess whether a pain education intervention is effective in reducing pain and improving pain management, quality of life and carer motivation.

Trial registration

Current Controlled Trials ISRCTN72861423.

Pain among ambulatory HIV/AIDS patients: multicenter study of prevalence, intensity, associated factors, and effect

This study aimed to determine the prevalence, intensity, associated factors, and effect of pain among ambulatory HIV/AIDS patients. Three-hundred two adult ambulatory HIV/AIDS patients were consecutively recruited from HIV/AIDS outpatient clinics at 2 teaching hospitals in Uganda. The presence and intensity of pain were self-reported using the Brief Pain Inventory (BPI); symptom data were collected using the Memorial Symptom Assessment Scale (MSAS-SF); and quality of life (QOL) was assessed using the Medical Outcome Scale-HIV. Forty-seven percent reported pain in the 7 days prior to the survey and pain was a symptom at the time of diagnosis for 68%. On the 0 to 10 numeric scale, 53% reported mild pain (1-4 rating), 20% reported moderate pain (5-6 rating) while 27% reported severe pain (7-10 rating). Gender was not associated with pain intensity, but reduced functional performance, increasing number of symptoms, advanced HIV disease , physical symptom distress (MSAS-SF), and number of health comorbidities were significantly associated with pain intensity (P < .04). Increasing pain intensity was associated with greater functional ability impairment (BPI functional interference index) and poorer QOL. Pain is a common symptom among ambulatory HIV/AIDS patients and has a debilitating effect on QOL. There is a significant unmet need for pain relief in the population.

PERSPECTIVE

This article discusses the characteristics and effect of pain on function and QOL in East African patients. It also contributes information on characteristics of HIV/AIDS adult patients in the East Africa demonstrating the aspects in which pain is similar across different cultures.

Symptom Status Predicts Patient Outcomes in Persons with HIV and Comorbid Liver Disease

Persons living with human immunodeficiency virus (HIV) are living longer; therefore, they are more likely to suffer significant morbidity due to potentially treatable liver diseases. Clinical evidence suggests that the growing number of individuals living with HIV and liver disease may have a poorer health-related quality of life (HRQOL) than persons living with HIV who do not have comorbid liver disease. Thus, this study examined the multiple components of HRQOL by testing Wilson and Cleary's model in a sample of 532 individuals (305 persons with HIV and 227 persons living with HIV and liver disease) using structural equation modeling. The model components include biological/physiological factors (HIV viral load, CD4 counts), symptom status (Beck Depression Inventory II and the Medical Outcomes Study HIV Health Survey (MOS-HIV) mental function), functional status (missed appointments and MOS-HIV physical function), general health perceptions (perceived burden visual analogue scale and MOS-HIV health transition), and overall quality of life (QOL) (Satisfaction with Life Scale and MOS-HIV overall QOL). The Wilson and Cleary model was found to be useful in linking clinical indicators to patient-related outcomes. The findings provide the foundation for development and future testing of targeted biobehavioral nursing interventions to improve HRQOL in persons living with HIV and liver disease.

Symptoms experienced by HIV-infected Individuals on antiretroviral therapy in KwaZulu-Natal, South Africa

Symptom management in HIV/AIDS is a critical issue that influences the quality of life of those living with the disease. Although the goals of treating the numbers living with HIV/AIDS have not yet been achieved, availability of antiretroviral therapies (ARVs) has been expanded to many clinical settings in KwaZulu-Natal, the epicenter of HIV infection in South Africa. The South African Department of Health (2007) estimates indicate that 5.54 million South Africans are living with HIV/AIDS, whereas UNAIDS (2007) estimates suggest that 18.8% of the population in South Africa is affected. Because the symptom experience may influence adherence to ARVs and quality of life, this study focused on the prevalence of symptoms reported by patients (N = 149) diagnosed with HIV/AIDS and adherence to medications and appointments. Self-report data were obtained from this community-based sample of HIV-infected patients who received care in outpatient clinics in Durban, KwaZulu-Natal, South Africa. With an average of three side effects, the most frequently reported by the study participants were fatigue/tiredness (41%), rashes (40%), headaches (32%), insomnia (31%), sadness (24%), disturbing dreams (23%), numbness (22%), pain (22%), and self-appearance (20%). On a scale of 1 to 10 (10 being worst possible), those with symptoms reported an average intensity of 4.2 (SD = 2.0), and the degree to which symptoms affected activity levels was 3.2 (SD = 2.2). Although intensity of symptoms and effects on activity levels were strongly correlated (r = .78, p < .001), there were no significant relationships between adherence and the intensity of symptoms or the relationship of symptoms with activity levels. Logistic regression analyses indicate that the presence of a greater number of symptoms was not associated with greater adherence (odds ratio = 2.27, 95% confidence interval = 0.60-8.70, ns). However, those who reported higher adherence were 1.5 times more likely to report greater physical health than low adherers (p = .04). High adherers were also 1.6 times more likely to report greater psychological health than low adherers (p = .03). This suggests that further study is needed to investigate adherence motivations for those living with HIV/AIDS in South Africa because adherence seems not to be linked to the frequency of symptoms or limitations on activity related to symptoms.

Does "asymptomatic" mean without symptoms for those living with HIV infection?

Throughout the history of the HIV epidemic, HIV-positive patients with relatively high CD4 counts and no clinical features of opportunistic infections have been classified as "asymptomatic" by definition and treatment guidelines. This classification, however, does not take into consideration the array of symptoms that an HIV-positive person can experience long before progressing to AIDS. This short report describes two international multi-site studies conducted in 2003-2005 and 2005-2007. The results from the studies show that HIV-positive people may experience symptoms throughout the trajectory of their disease, regardless of CD4 count or classification. Providers should discuss symptoms and symptom management with their clients at all stages of the disease.

The symptom experience of people living with HIV and AIDS in the Eastern Cape, South Africa

Background

Symptom management for persons living with HIV (PLHIV) or AIDS is an important part of care management. Limited information about symptom prevalence exists about HIV infected persons in South Africa, in particular in the context of antiretroviral treatment (ART). The aim of this study was to assess HIV symptoms and demographic, social and disease variables of people living with HIV in South Africa.

Methods

In 2007 607 PLHIV, sampled by all districts in the Eastern Cape Province and recruited through convenience sampling, were interviewed by PLHIV at health facilities, key informants in the community and support groups.

Results

Two-thirds of the PLHIV (66%) classified themselves with being given an AIDS (advanced stage of HIV) diagnosis, 48% were currently on ART, 35% were currently on a disability grant for HIV/AIDS and for 13% the disability grant had been stopped. Participants reported that on the day of the interview, they were experiencing an average of 26.1 symptoms out of a possible 64. In a regression model with demographic and social variables, higher HIV symptom levels were associated with lower educational levels, higher age, urban residence and not on a disability grant, lack of enough food and having a health insurance, and in a regression model with demographic, social and disease variables only being on ART, lack of enough food and having a health insurance were associated with HIV symptoms.

Conclusion

Symptom assessment provides information that may be valuable in evaluating AIDS treatment regimens and defining strategies to improve quality of life. Because of the high levels of symptoms reported, the results imply an urgent need for effective health care, home- and community-based as well as self-care symptom management to help patients and their families manage and control AIDS symptoms.

A randomized controlled trial testing the efficacy of an HIV/AIDS symptom management manual

This study investigates whether using an HIV/AIDS symptom management manual with self-care strategies for 21 common symptoms, compared to a basic nutrition manual, had an effect on reducing symptom frequency and intensity. A 775-person, repeated measures, randomized controlled trial was conducted over three months in 12 sites from the United States, Puerto Rico, and Africa to assess the relationship between symptom intensity with predictors for differences in initial symptom status and change over time. A mixed model growth analysis showed a significantly greater decline in symptom frequency and intensity for the group using the symptom management manual (intervention) compared to those using the nutrition manual (control) (t=2.36, P=0.018). The models identified three significant predictors for increased initial symptom intensities and in intensity change over time: (1) protease inhibitor-based therapy (increased mean intensity by 28%); (2) having comorbid illness (nearly twice the mean intensity); and (3) being Hispanic receiving care in the United States (increased the mean intensity by 2.5 times). In addition, the symptom manual showed a significantly higher helpfulness rating and was used more often compared to the nutrition manual. The reduction in symptom intensity scores provides evidence of the need for palliation of symptoms in individuals with HIV/AIDS, as well as symptoms and treatment side effects associated with other illnesses. The information from this study may help health care providers become more aware of self-management strategies that are useful to persons with HIV/AIDS and help them to assist patients in making informed choices.

Perceptions of health and self-care learning needs of outpatients with HIV/AIDS

Health promotion increases healthy behaviors, enhances health status, and decreases health care costs of chronically ill persons. As HIV has become a chronic illness, many HIV-positive persons may have health learning needs that affect their behaviors, health status, and health care costs. Health learning needs may be general or HIV specific. Social stigma may affect learning resource usage. We used Pender's Health Promotion Model and community-based health promotion principles as theoretical underpinnings for an exploratory study of perceived health and self-care learning needs, barriers, and preferred learning modalities of outpatients with HIV/AIDS. A nonrandom sample of 151 adults completed a researcher-designed self-report survey. Most (97%) expressed interest in health and self-care. Many identified multiple topics, learning barriers, and preferred learning modalities. A statistically significant difference (p=.027) was noted in communication needs of participants diagnosed with HIV versus AIDS. Findings have led to practice changes, health promotion activities, and further research.

Antidepressant therapy can improve adherence to antiretroviral regimens among HIV-infected and depressed patients

Several strategies have been introduced to manage nonadherence to highly active antiretroviral therapy (HAART). Treatment with antidepressants may improve self-reported adherence. In this brief report, a small sample of HIV-depressed patients (n = 9) were treated for a 6-month period with antidepressants improving self-reported adherence based on the HAART scale (poor, good, satisfactory, and optimal). Before the antidepressant treatment, adherence was reported as "good" by 3 patients and "satisfactory" by 6 patients. After antidepressant therapy, adherence to antiretroviral regimes was statistically higher in HIV-depressed on treatment than in HIV-depressed patients not treated with antidepressants (P < 0.0001). We used chi2 test with a significance level at P < 0.05. Treating depression in HIV-infected patients may serve to improve adherence to HAART.

Knowing How to Play the Game: Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief

This study explored hospitalized substance abusers' perspectives about getting their pain adequately addressed in the hospital setting and their interactions with nurses about pain-management issues. The aim of the study was to generate theory that can contribute to a greater understanding of the problem of pain management with this population. A grounded theory approach was used to interview participants with a substance abuse problem who were hospitalized with a medical/surgical problem. Interviews were conducted using an interview guide; interviews were audiotaped and transcribed. In addition, a focus group of nurses who worked with this population met twice, once midway through the study, and before the final participant interview. The nurses commented on the fit of the developing model according to their experiences of working with the population described. Eighteen participants were interviewed for a total of 20 interviews (two participants were interviewed twice). All participants were polysubstance abusers and had a painful medical/surgical problem for which they were hospitalized. The Model of "Knowing How to Play the Game" was developed on the basis of participants' descriptions of their experiences and consisted of two core action categories "Feeling Respected/Not Respected" and " Strategizing to Get Pain Relief." Participants had many suggestions about nursing actions that were helpful or not helpful in assisting them to obtain pain relief. Nursing practice, education, research, and policy implications were discussed.