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Researchers examine factors affecting quality of life for people with HIV

Improved treatments and longer survival times have made functioning and quality of life important treatment goals for people infected with the human immunodeficiency virus (HIV) that causes AIDS. Yet mood disorders and victimization by violence (often related to HIV-seropositive status) threaten the quality of life for many people who have HIV, according to two recent studies supported by the Agency for Healthcare Research and Quality (HS08578). A third AHRQ-supported study (HS07809) shows that certain combination drug therapies that enhance these patients' quality of life also can increase their risk of developing sensory neuropathy.

Sherbourne, C.D., Hays, R.D., Fleishman, J.A., and others (2000, February). "Impact of psychiatric conditions on health-related quality of life in persons with HIV infection." American Journal of Psychiatry 157(2), pp. 248-254.

Nearly 40 percent of people infected with HIV suffer from depression, a rate that is two to three times higher than it is among the general population. Other psychiatric illnesses and substance abuse also are relatively common among patients with HIV. This is the first study to show the burden that mood disorders such as anxiety and depression place on health-related quality of life (HRQOL) for this group of patients. The researchers used data from a nationally representative sample of 2,864 people receiving care for HIV in the United States (the AHRQ-supported HIV Costs and Service Utilization Study [HCSUS]) to examine the extent to which psychiatric conditions (mood disorders, substance use, and heavy drinking) were associated with decrements in their HRQOL.

Of the entire group studied, nearly half had some type of mood disorder, 12 percent were drug abusers, and 6 percent were heavy drinkers (three or more drinks on half the days of the past month). After controlling for the effects of HIV symptoms, CD4 cell count, and stage of disease, patients with any mood disorder had significantly worse functioning and well-being than those without a mood disorder on HRQOL measures of physical and mental health. This was reflected in more days of disability, reduced social functioning, and greater pain, fatigue, and other symptoms. In fact, the degree of poorer physical health for those with mood disorders was equal to the difference between working and being unemployed.

These findings substantiate the considerable additional illness burden associated with mood disorders in HIV-infected people. Probable drug dependence was associated with poorer HRQOL, but most of the impairment disappeared after controlling for the likely presence of a mood disorder, perhaps because depression and anxiety are so intrinsic to the problems of drug dependence. Heavy drinking was not associated with diminished HRQOL, but if heavy drinking had been defined by more drinks, the result might have been different.

Reprints (AHRQ Publication No. 00-R023) are available from the AHRQ Publications Clearinghouse.

Zierler, S., Cunningham, W.E., Andersen, R., and others (2000, February). "Violence victimization after HIV infection in a U.S. probability sample of adult patients in primary care." American Journal of Public Health 90(2), pp. 208-215.

Revealing their HIV-positive status triggered physical assaults on about 45 percent of HIV-infected people who were attacked by someone close to them in this national sample of 2,864 HIV-infected adults receiving medical care and enrolled in the HIV Costs and Service Utilization Study (HCSUS). Overall, 21 percent of women, 12 percent of men who reported having sex with men, and 8 percent of heterosexual men reported physical harm after their HIV diagnosis.

Women who identified themselves as gay, lesbian, or bisexual reported partner or other relationship violence nearly as often as women who self-identified as heterosexual (24 vs. 20 percent). Yet women living with a male versus female sexual partner were almost three times more likely to report violence after their HIV diagnosis (25 vs. 9 percent). Also, women whose CD4 cell counts were at least 500 reported nearly 75 percent more violence than women with lower cell counts, suggesting that revealing HIV status may have triggered the violence. National surveys of U.S. women aged 19 to 29 years in poor families indicate that 6 percent have been assaulted, which is less than one-third the rate reported by the HIV-infected women surveyed by HCSUS.

Men at higher risk of being assaulted were those who reported sex with men, were 40 years of age or younger, were Hispanic, self-identified as gay or bisexual, had no financial assets, had a female partner, were homeless, or reported a history of drug dependence. Men with a high school education or less had nearly three times the odds of being harmed as more educated men.

Moore, R.D., Wong, W-M. E., Keruly, J.C., and McArthur, J.D. (2000). "Incidence of neuropathy in HIV-infected patients on monotherapy versus those on combination therapy with didanosine, stavudine, and hydroxyurea." AIDS 14, pp. 273-278.

Sensory neuropathy (inflammation and degeneration of the peripheral nerves) is a common side-effect of the nucleoside analogue antiretroviral drugs didanosine (ddI) and stavudine (d4T), occurring in 15 to 30 percent of patients taking either of these drugs. The drugs are being used more often in combination to more effectively reduce HIV viral load (number of HIV particles per ml of blood) in HIV-infected patients, and they will continue to play an important role in HIV antiretroviral therapy. Hydroxyurea is used to enhance the antiviral efficacy of these drugs.

Unfortunately, this study found that the combination of ddI and d4T increased the risk of neuropathy over that of either drug alone, and that hydroxyurea further increased this risk. The combined use of these three drugs was associated with a 7.8-fold increase in risk of sensory neuropathy compared with patients on ddI alone and a 5.6-fold increased risk compared with d4T alone, after adjustment for disease severity and other factors. The combined use of both drugs without hydroxyurea was associated with a 3.5-fold increased risk of neuropathy compared with ddI alone and a 2.5-fold increased risk compared with d4T alone.

For ddI or d4T monotherapy, neuropathy is usually reversible with drug cessation, dose reduction, or symptomatic treatment with drugs such as amitriptyline. Further study is needed to determine if neuropathy is reversible when these drugs are used in combination. Clinicians need to be aware that the risk of sensory neuropathy is likely to be higher when these drugs and hydroxyurea are used together, caution the researchers. They calculated the incidence rates of neuropathy for each of five regimens: ddI (with or without hydroxyurea), ddI plus d4T (with or without hydroxyurea), and d4T for 1,116 patients at Johns Hopkins AIDS services.

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