National estimates of HIV-related symptom prevalence from the HIV Cost and Services Utilization Study

Factors Associated with Bothersome Symptoms in Individuals With and Without HIV Who Report Alcohol Use

Bothersome symptoms potentially related to drinking are commonly reported by people with and without HIV (PWH/PWoH). However, the relationship between bothersome symptoms and level of alcohol use is often not appreciated by patients or providers. Therefore, among persons reporting prior-year alcohol use, we assessed whether alcohol use level (AUDIT-C score), HIV status, and demographic covariates influenced the likelihood of the patient reporting a bothersome symptom. We used the Veterans Aging Cohort Study (VACS) surveys (2002-2018), including a validated symptoms index. Among 3679 PWH and 3830 PWoH currently drinking alcohol, the most commonly reported symptoms were muscle/joint pain (52%), sleep disturbance (51%), and fatigue (50%). Level of alcohol use was independently associated with 18 of 20 bothersome symptoms, including seven symptoms more common among PWH. Results can help inform PWH/PWoH who drink alcohol about the strong relationship between level of alcohol use and bothersome symptoms, potentially motivating reduced use.

HIV-Specific Reported Outcome Measures: Systematic Review of Psychometric Properties

BACKGROUND

The management of people living with HIV and AIDS is multidimensional and complex. Using patient-reported outcome measures (PROMs) has been increasingly recognized to be the key factor for providing patient-centered health care to meet the lifelong needs of people living with HIV and AIDS from diagnosis to death. However, there is currently no consensus on a PROM recommended for health care providers and researchers to assess health outcomes in people living with HIV and AIDS.

OBJECTIVE

The purpose of this systematic review was to summarize and categorize the available validated HIV-specific PROMs in adults living with HIV and AIDS and to assess these PROMs using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology.

METHODS

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of 3 recommended databases (PubMed, Embase, and PsychINFO) was conducted on January 15, 2021. Studies were included if they assessed any psychometric property of HIV-specific PROMs in adults living with HIV and AIDS and met the eligibility criteria. The PROMs were assessed for 9 psychometric properties, evaluated in each included study following the COSMIN methodology by assessing the following: the methodological quality assessed using the COSMIN risk of bias checklist; overall rating of results; level of evidence assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation approach; and level of recommendation.

RESULTS

A total of 88 PROMs classified into 8 categories, assessing the psychometric properties of PROMs for adults living with HIV and AIDS, were identified in 152 studies including 79,213 people living with HIV and AIDS. The psychometric properties of most included PROMs were rated with insufficient evidence. The PROMs that received class A recommendation were the Poz Quality of Life, HIV Symptom Index or Symptoms Distress Module of the Adult AIDS Clinical Trial Group, and People Living with HIV Resilience Scale. In addition, because of a lack of evidence, recommendations regarding use could not be made for most of the remaining assessed PROMs (received class B recommendation).

CONCLUSIONS

This systematic review recommends 3 PROMs to assess health outcomes in adults living with HIV and AIDS. However, all these PROMs have some shortcomings. In addition, most of the included PROMs do not have sufficient evidence for assessing their psychometric properties and require a more comprehensive validation of the psychometric properties in the future to provide more scientific evidence. Thus, our findings may provide a reference for the selection of high-quality HIV-specific PROMs by health care providers and researchers for clinical practice and research.

Barriers and facilitators to recruitment and enrollment of HIV-infected individuals with opioid use disorder in a clinical trial

BACKGROUND

The CTN-0067 CHOICES trial tests implementation of extended-release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for opioid use disorders (OUD) in HIV clinics to improve HIV viral suppression. The study team investigated recruitment strategies to elucidate the barriers and facilitators to recruitment and enrollment in the study.

MAIN TEXT

Methods: Semi-structured, in-depth, digitally recorded interviews were completed with study recruitment-related staff and medical providers (n = 26) from six participating HIV clinics in the fall of 2018. Interviews probed 1) factors that might prevent prospective participants from engaging in study recruitment and enrollment procedures and 2) strategies used by study staff that encourage eligible patient participation. Interviews were transcribed and thematically analyzed using a content analysis approach.

RESULTS

All respondents reported that barriers to recruitment and enrollment included challenging patient social and structural factors (e.g., homelessness or living environments with high substance use, criminal justice involvement), difficulty locating patients with unsuppressed HIV viral load and OUD within the HIV clinic, time-consuming study enrollment processes, and stigma around HIV and OUD which inhibited treatment seeking. Some respondents observed that distrust of research and researchers impeded recruitment activities in the community. A specific medication-related barrier was patient fear of opioid abstinence required prior to XR-NTX induction. Facilitators of recruitment included use of trusted peer outreach/recruitment workers in the community, hospitalizations that offered windows of opportunities for screening and XR-NTX induction, providing participant transportation, and partnerships with harm reduction organizations for referrals.

CONCLUSIONS

Though study personnel encountered barriers to recruitment in the CHOICES study, persons with untreated HIV and OUD can be enrolled in multisite clinical trials by using enhanced recruitment strategies that extend outside of the HIV clinic. Employing peer outreach workers and collaborating with syringe service programs may be especially helpful in facilitating recruitment and merit inclusion in similar study protocols.

In people living with HIV (PLWH), menopause (natural or surgical) contributes to the greater symptom burden in women: results from an online US survey

OBJECTIVE

The majority of people living with HIV in the United States are now over the age of 50, but symptom burden research has seldom included older women or the potential role of menopause. The aim of the study was to examine the influence of menopause as part of sex differences in HIV symptom burden.

METHODS

A cross-sectional study was conducted that included both a sex-based analysis of previously reported HIV symptom characteristics of 1,342 respondents to an online survey (males, n = 957; female, n = 385) and a follow-up online survey of menstrual bleeding patterns (inferred menopause) in eligible females (n = 242) from the respondent pool. Using linear mixed models, we identified predictors of symptom burden scores in female respondents.

RESULTS

For the most troublesome symptoms assessed in the sex-based analysis, depression scores were similar (P > 0.05), but higher (worse) burden scores for fatigue (P = 0.013) and muscle aches/pains (P = 0.004) were exclusively observed in females after adjusting for covariates. Respondents to the female survey (n = 222) were predominantly Black, heterosexual, nonsmokers, and obese, with an HIV diagnosis of approximately 16 years and at least one comorbid condition. Burden scores were higher in women reporting amenorrhea due to natural menopause or hysterectomy (n = 104) versus the menstruating group (n = 118) for muscle aches/pains (P = 0.05), fatigue (P = 0.03), and difficulty falling asleep (P = 0.04), independent of age, HIV duration, and number of HIV-associated non-AIDS conditions.

CONCLUSIONS

Two of the most common symptoms in people living with HIV-fatigue and muscle aches/joint pains-invoke additional burden in women. Independent of aging, symptom burden may be exacerbated after menopause, supporting a shifting paradigm for HIV care management.

Racial and socioeconomic disparities in the symptom reporting of persons living with HIV

Persons living with HIV (PLWH) today can survive decades with the disease, making the symptom experience much more relevant to their lifestyle and health outcomes. The goal of the research reported here was to assess the symptom reporting of PLWH in the Unites States (US) in the combined antiretroviral therapy (cART) age of the epidemic. We conducted an anonymous online survey of symptomatic PLWH in the US and asked participants to report the frequency and intensity of 28 frequently occurring symptoms in the past 30 days. The relationship between symptom reporting and demographic factors was investigated using the adaptive least absolute shrinkage and selection operator (LASSO) method. Fatigue was the most frequently reported symptom in our study population. Those with the lowest income were more likely to report more burdensome symptoms. In comparison to other racial and ethnic groups, Black non-Hispanic participants were significantly more likely to report a lower symptom burden score for fatigue, depression, muscle aches, anxiety, difficulties with memory and concentration. There were no racial/ ethnic differences in the burden of the symptoms related to sleep or neuropathy. Findings from this study present new evidence on the symptom reporting of PLWH in the US. Neuropathy continues to be a pervasive neurological symptom with no difference noted between racial/ ethnic groups.

A Review of HIV-Specific Patient-Reported Outcome Measures

The use of patient-reported outcome (PRO) measures to provide added feedback to health providers is receiving interest as a means of improving clinical care and patient outcomes, and contributing to more patient-centered care. In human immunodeficiency virus (HIV), while PROs are used in research, their application in clinical practice has been limited despite their potential utility. PRO selection is an important consideration when contemplating their use. As past reviews of PROs in HIV have focused on particular areas (e.g. disability, satisfaction with care), a more comprehensive review could better inform on the available instruments and their scope. This article reviews HIV-specific PROs to produce an inventory and to identify the central concepts targeted over time. Seven databases were searched (HAPI, MEDLINE, PsychINFO, PubMed, EMBASE, CINAHL, Google Scholar), generating 14,794 records for evaluation. From these records, 117 HIV-specific PROs were identified and categorized based on a content analysis of their targeted concept: Health-Related Quality of Life (23; 20 %), ART and Adherence-Related Views and Experiences (19; 16 %), Healthcare-Related Views and Experiences (15; 13 %), Psychological Challenges (12; 10 %), Symptoms (12; 10 %), Psychological Resources (10; 9 %), HIV Self-Management and Self-Care (8; 7 %), HIV-Related Stigma (8; 7 %), Body and Facial Appearance (4; 3 %), Social Support (3; 3 %), Sexual and Reproductive Health (2; 2 %), and Disability (1; 1 %). This review highlights the variety and evolution of HIV-specific PROs, with the arrival of seven categories of PROs only after the advent of highly-active antiretroviral therapy. Our inventory also offers a useful resource. However, the interest of further HIV-specific PRO development should be explored in sexual health, which received little independent attention.

Pain in amaXhosa women living with HIV/AIDS: a cross-sectional study of ambulant outpatients

Background

Pain is one of the most commonly reported symptoms in people living with HIV/AIDS, whether or not they are receiving anti-retroviral therapy. A recent systematic review identified a paucity of studies exploring pain in women in low and middle income countries. The prevalence and characteristics of pain in women living with HIV/AIDS may differ from that of men as many chronic pain conditions are more prevalent in women. The aims of this study were to establish pain prevalence, characteristics and management in amaXhosa women living with HIV/AIDS. In addition, we aimed to identify whether there were associations between pain in this population and the psychosocial factors of employment, education, self-efficacy, depression, post-traumatic stress disorder, health related quality of life and childhood trauma.

Methods

A cross-sectional study of 229 women who had undergone HIV testing and were registered patients at a community health centre was conducted. Data were collected by interview with a demographic questionnaire, the Brief Pain Inventory-Xhosa, Childhood Trauma Questionnaire–Xhosa, Harvard Trauma Questionnaire–Xhosa for PTSD, Self-Efficacy for Managing Chronic Disease 6-Item Scale-Xhosa; the EQ-5D health related quality of life instrument, and the Beck Depression Inventory.

Results

170 of the women had pain, a prevalence rate of 74.24% (95%CI 68.2 – 79.47%). The women reported significant pain with pain severity of 5.06 ± 1.57 and pain interference of 6.39 ± 1.96 out of 10. Only two women were receiving adequate pain management according to the pain management index. Participants reported a mean of 2.42 ± 1.21 different anatomical sites of pain. There were more unemployed participants in the group with pain and they had significantly fewer years of schooling. Those with pain had lower self-efficacy; health related quality of life and increased depression and PTSD symptom severity.

Conclusion

This study highlights that pain is a common problem for amaXhosa women living with HIV/AIDS. These data emphasise the need to prioritise pain assessment and management in amaXhosa women living with HIV/AIDS. Routinely assessing for the presence of pain in women with HIV/AIDS has the potential to improve pain management and minimise the impact of pain on function.

A Structural Equation Model of HIV-related Symptoms, Depressive Symptoms, and Medication Adherence

Adherence to combined antiretroviral therapy (cART) remains critical in management of HIV infection. This study evaluated depression as a potential mechanism by which HIV-related symptoms affect medication adherence and explored if particular clusters of HIV symptoms are susceptible to this mechanism. Baseline data from a multi-visit intervention study were analyzed among 124 persons living with HIV (PLWH). A bifactor model showed two clusters of HIV-related symptom distress: general HIV-related symptoms and gastrointestinal (GI) symptoms. Structural equation modeling showed that both general HIV-related symptoms and GI symptoms were related to higher levels of depressive symptoms, and higher levels of depressive symptoms were related to lower levels of medication adherence. Although general HIV-related symptoms and GI symptoms were not directly related to adherence, they were indirectly associated with adherence via depression. The findings highlight the importance of early recognition and evaluation of symptoms of depression, as well as the underlying physical symptoms that might cause depression, to improve medication adherence.

Health Benefits of Exercise for People Living With HIV: A Review of the Literature

With life expectancy increasing and the symptomatology of HIV being altered since the advent of antiretroviral therapy (ART), we now have begun to see metabolic changes with negative implications among people living with HIV/AIDS (PLWHA). Some of these changes include increased blood lipids, central fat accumulation, lipodystrophy, and decreased aerobic capacity. All of which are known risk factors for cardiovascular disease, cancer, and all-cause mortality. A common practice among healthy and other clinical populations to help modify these risk factors is some form of aerobic exercise, resistance exercise, or a combination of both. It has been demonstrated that PLWHA could respond in a similar manner, which in turn may enhance life expectancy and/or quality of life. The purpose of this literature review was to examine the evidence of health benefits of routine exercise training among PLWHA since the advent of ART. Although limited in strength because of small sample sizes and limited intervention durations, there is overall consistency in the general findings. An overview of the findings would indicate that physical activity and exercise are both safe and effective in improving cardiorespiratory fitness, metabolic profile, and quality of life among PLWHA.

Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine

BACKGROUND

People who inject drugs (PWID) experience poor outcomes and fuel HIV epidemics in middle-income countries in Eastern Europe and Central Asia. We assess integrated/co-located (ICL) healthcare for HIV-infected PWID, which despite international recommendations, is neither widely available nor empirically examined.

METHODS

A 2010 cross-sectional study randomly sampled 296 HIV-infected opioid-dependent PWID from two representative HIV-endemic regions in Ukraine where ICL, non-co-located (NCL) and harm reduction/outreach (HRO) settings are available. ICL settings provide onsite HIV, addiction, and tuberculosis services, NCLs only treat addiction, and HROs provide counseling, needles/syringes, and referrals, but no opioid substitution therapy (OST). The primary outcome was receipt of quality healthcare, measured using a quality healthcare indicator (QHI) composite score representing percentage of eight guidelines-based recommended indicators met for HIV, addiction and tuberculosis treatment. The secondary outcomes were individual QHIs and health-related quality-of-life (HRQoL).

RESULTS

On average, ICL-participants had significantly higher QHI composite scores compared to NCL- and HRO-participants (71.9% versus 54.8% versus 37.0%, p<0.001) even after controlling for potential confounders. Compared to NCL-participants, ICL-participants were significantly more likely to receive antiretroviral therapy (49.5% versus 19.2%, p<0.001), especially if CD4 ≤ 200 (93.8% versus 62.5% p<0.05); guideline-recommended OST dosage (57.3% versus 41.4%, p<0.05); and isoniazid preventive therapy (42.3% versus 11.2%, p<0.001). Subjects receiving OST had significantly higher HRQoL than those not receiving it (p<0.001); however, HRQoL did not differ significantly between ICL- and NCL-participants.

CONCLUSIONS

These findings suggest that OST alone improves quality-of-life, while receiving care in integrated settings collectively and individually improves healthcare quality indicators for PWID.

'My dreams are shuttered down and it hurts lots'-a qualitative study of palliative care needs and their management by HIV outpatient services in Kenya and Uganda

BACKGROUND

Despite the huge burden of HIV in sub-Saharan Africa, there is little evidence of the multidimensional needs of patients with HIV infection to inform the person-centred care across physical, psychological, social and spiritual domains stipulated in policy guidance. We aimed to describe the problems experienced by people with HIV in Kenya and Uganda and the management of these problems by HIV outpatient services.

METHODS

Local researchers conducted in depth qualitative interviews with HIV patients, caregivers and service staff at 12 HIV outpatient facilities (6 in Kenya, 6 in Uganda). Interview data were analysed thematically.

RESULTS

189 people were interviewed (83 patients, 47 caregivers, 59 staff). The impact of pain and symptoms and their causes (HIV, comorbidities, treatment side-effects) were described. Staff reported that effective pain relief was not always available, particularly in Kenya. Psychosocial distress (isolation, loneliness, worry) was exacerbated by stigma and poverty, and detrimentally affected adherence. Illness led to despair and hopelessness. Provision of counselling was reported, but spiritual support appeared to be less common. Neither pain nor psychosocial problems were routinely reported to service staff. Collaboration with local hospices and income-generation activities for patients were highlighted as useful.

CONCLUSIONS

The findings demonstrate the multiple and interrelated problems associated with living with HIV and how psychosocial and spiritual distress can contribute to 'total pain' in this population. In line with the palliative care approach, HIV care requires holistic care and assessment that take into account psychological, socioeconomic and spiritual distress alongside improved access to pain-relieving drugs, including opioids.

Perceived discrimination and physical health among HIV-positive Black and Latino men who have sex with men

We conducted the first study to examine health correlates of discrimination due to race/ethnicity, HIV-status, and sexual orientation among 348 HIV-positive Black (n = 181) and Latino (n = 167) men who have sex with men. Participants completed audio computer-assisted self-interviews. In multivariate analyses, Black participants who experienced greater racial discrimination were less likely to have a high CD4 cell count [OR = 0.7, 95 % CI = (0.5, 0.9), p = 0.02], and an undetectable viral load [OR = 0.8, 95 % CI = (0.6, 1.0), p = 0.03], and were more likely to visit the emergency department [OR = 1.3, 95 % CI = (1.0, 1.7), p = 0.04]; the combined three types of discrimination predicted greater AIDS symptoms [F (3,176) = 3.8, p < 0.01]. Among Latinos, the combined three types of discrimination predicted greater medication side effect severity [F (3,163) = 4.6, p < 0.01] and AIDS symptoms [F (3,163) = 3.1, p < 0.05]. Findings suggest that the stress of multiple types of discrimination plays a role in health outcomes.

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.

Can palliative care integrated within HIV outpatient settings improve pain and symptom control in a low-income country? A prospective, longitudinal, controlled intervention evaluation

A high burden of pain, symptoms and other multidimensional problems persist alongside HIV treatment. WHO policy indicates palliative care as essential throughout the disease course. This study aimed to determine whether palliative care delivered from within an existing HIV outpatient setting improves control of pain and symptoms compared to standard care. A prospective, longitudinal controlled design compared patient outcomes at an outpatient facility that introduced palliative care training to clinicians and stocked essential palliative care drugs, to outcomes of a cohort of patients at a similar HIV care facility with no palliative care, in Tanzania. Inclusion criteria were clinically significant pain or symptoms. Patients were followed from baseline fortnightly until week 10 using validated self-report outcome measures. For the primary pain outcome, the required sample size of 120 patients was recruited. Odds of reporting pain reduced significantly more at intervention site (OR=0.60, 95% CI 0.50-0.72) than at control (OR=0.85, 95% CI 0.80-0.90), p=0.001. For secondary outcomes, longitudinal analysis revealed significant difference in slope between intervention and control, respectively: Medical Outcomes Study-HIV (MOS-HIV) physical score 1.46 vs. 0.54, p=0.002; MOS-HIV mental health 1.13 vs. 0.26, p=0.006; and POS total score 0.84 vs. 0.18, p=0.001. Neither baseline CD4 nor antiretroviral therapy (ART) use was associated with outcome scores. These data are the first to report outcomes evaluating integrated HIV outpatient palliative care in the presence of ART. The data offer substantive evidence to underpin the existing WHO clinical guidance that states an essential role for palliative care alongside HIV treatment, regardless of prognosis.

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.

Mindfulness-based stress reduction for HIV treatment side effects: a randomized, wait-list controlled trial

CONTEXT

Advances in antiretroviral therapy (ART) for HIV offer life-extending benefit; however, the side effects associated with ART use negatively impact quality of life and medication adherence among people living with HIV.

OBJECTIVES

This study tested the efficacy of Mindfulness-Based Stress Reduction (MBSR) for reducing ART symptoms and bother/distress related to ART side effects. Secondary aims were to test the impact of MBSR on medication adherence and psychological functioning.

METHODS

Seventy-six people living with HIV who were actively taking ART and reported distress from ART-related side effects were randomly assigned to an MBSR program or a wait-list control (WLC) standard care condition. We measured side effects, ART adherence, perceived stress, depression, positive and negative affect, and mindfulness at three time points: baseline, three-month follow-up, and six-month follow-up. Side effects and related distress were assessed separately from other symptoms.

RESULTS

Compared with a WLC, participants in the MBSR condition experienced a reduction in the frequency of symptoms attributable to ARTs at three months post-intervention (mean difference=0.33; 95% confidence interval [CI]=0.01, 0.66; t(132)=2.04, P=0.044) and six months post-intervention (mean difference=0.38; 95% CI=0.05, 0.71; t(132)=2.27, P=0.025). MBSR participants also experienced a reduction in distress associated with those symptoms at three months post-intervention (mean difference=0.47; 95% CI=0.003, 0.94; t(132)=1.99, P=0.048) compared with the WLC condition.

CONCLUSION

MBSR is a promising approach for reducing HIV treatment-related side effects.

Epidemiology of HIV-related neuropathy: a systematic literature review

We sought to identify and summarize the incidence and prevalence of neuropathy among HIV patients and subgroups. A systematic search of the literature was performed using MEDLINE and EMBASE. The relevant literature was identified based on predefined criteria. Prevalence data were collected from cross-sectional and cohort studies. Incidence data were collected from cohort and case-control studies. Thirty-seven studies were included of which there were 23 cohort studies, 13 cross-sectional studies, and one case-control study. The prevalence of neuropathy among HIV patients derived from 25 studies varied from 1.2% to 69.4%. Regarding the development of neuropathy among HIV-positive patients, standardized by study duration, the rates per 100 person-years ranged from 0.7 to 39.7. Among older patients there is a greater risk of neuropathy. The same seems to be the case for patients with more severe disease. Currently available studies providing information on the incidence and prevalence of neuropathy among HIV patients suggest a significant burden, but there is a great variation in results across studies. There is no definitive explanation for the variation. However, it underscores the fact that complexity of the disease, along with absence of standardized diagnostic criteria, has considerably influenced the methodologies and outcomes of the studies.

Pain in ambulatory HIV-positive South Africans

We investigated the prevalence and intensity of pain, factors associated with having pain, and analgesic medications employed in a population consisting predominantly of Black African and female human immunodeficiency virus (HIV)-positive individuals attending outpatient clinics in a rural (n = 125; 79% female; 100% Black African) and a metropolitan (n = 396; 75% female; 94% Black African) area of South Africa. Pain intensity, interference and treatment were assessed using the Wisconsin Brief Pain Questionnaire. Seventy-two percent of rural participants and 56% of metropolitan participants had pain at the time of the interview, and this pain was moderate to severe in intensity in 60% of rural participants and 59% of metropolitan participants. Forty-six percent of rural participants and 61% of metropolitan participants had multiple pain sites. The most common pain sites in rural participants were the abdomen (30%), chest (26%), head (19%) and genitals (15%), while in the metropolitan cohort the head (39%), feet (33%), chest (30%) and abdomen (20%) were the most common sites. In the rural cohort, antiretroviral therapy was independently associated with reduced risk of pain, while in the metropolitan cohort increasing age was weakly, but independently associated with having pain. Pharmacological management of pain was poor, with 29% of rural participants and 55% of metropolitan participants with pain not receiving any treatment. Of those receiving treatment, no participants were receiving strong opioids, and only 3% of metropolitan participants were receiving a weak opioid. Thus, HIV-related pain is common and is poorly treated in both the rural and metropolitan setting in South Africa.

Impact of childhood trauma on functionality and quality of life in HIV-infected women

BACKGROUND

While there are many published studies on HIV and functional limitations, there are few in the context of early abuse and its impact on functionality and Quality of Life (QoL) in HIV.

METHODS

The present study focused on HIV in the context of childhood trauma and its impact on functionality and Quality of Life (QoL) by evaluating 85 HIV-positive (48 with childhood trauma and 37 without) and 52 HIV-negative (21 with childhood trauma and 31 without) South African women infected with Clade C HIV. QoL was assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), the Patient's Assessment of Own Functioning Inventory (PAOFI), the Activities of Daily Living (ADL) scale and the Sheehan Disability Scale (SDS). Furthermore, participants were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) and the Childhood Trauma Questionnaire (CTQ).

RESULTS

Subjects had a mean age of 30.1 years. After controlling for age, level of education and CES-D scores, analysis of covariance (ANCOVA) demonstrated significant individual effects of HIV status and childhood trauma on self-reported QoL. No significant interactional effects were evident. Functional limitation was, however, negatively correlated with CD4 lymphocyte count.

CONCLUSIONS

In assessing QoL in HIV-infected women, we were able to demonstrate the impact of childhood trauma on functional limitations in HIV.

Acupuncture and the relaxation response for treating gastrointestinal symptoms in HIV patients on highly active antiretroviral therapy

OBJECTIVES

To examine the effect of acupuncture and the relaxation response (RR) for treating gastrointestinal (GI) symptoms in HIV patients who are using highly active antiretroviral therapy (HAART).

METHODS

The authors conducted a 4-arm 2×2 double-blind randomised controlled trial in an acupuncture clinic in the USA. Sham acupuncture and health education were used as the control conditions of real acupuncture and RR elicitation, respectively. Enrolled patients were randomised to real acupuncture+RR (AR), sham acupuncture+RR (SR), real acupuncture+health education (AE) or sham acupuncture+health education (SE) study arm. Participants listened to CDs with RR-eliciting instructions or health education while receiving acupuncture intervention. Interventions were provided twice weekly for 4 weeks and once weekly for another 4 weeks. Participants used daily diaries to record GI symptom severity ratings (0-10). The authors estimated the intervention effect as the changes in symptom rating per intervention session increase using a mixed-effects regression model.

RESULTS

A total of 130 people with HIV/AIDS who were on HAART and had persistent GI symptoms were enrolled and 115 started the study intervention. The AR group had greater intervention effects for loose stools symptoms than the other three groups (β=-0.149, -0.151 and -0.144, p value=0.013, 0.013 and 0.018 comparing AR to AE, SR and SE, respectively). The AR group also had significant intervention effects on reducing nausea symptoms when the intervention was given twice per week (β=-0.218, p=0.001).

CONCLUSIONS

Our trial provided preliminary data demonstrating the potential synergistic effects of acupuncture and RR for treating GI symptoms in HIV patients on HAART.

Nausea and vomiting in HIV/AIDS

HIV infection has become a chronic illness with the availability of potent antiretroviral agents. Many of the agents used to manage HIV, however, have been associated with distressing symptoms such as nausea and vomiting posing challenges to maintain adherence to therapy and quality of life. This article highlights the mechanism, evaluation, and management of HIV-associated nausea and vomiting. Supportive symptom management information is also presented.

Patient and provider-reported symptoms in the post-cART era

Prior research has consistently demonstrated that providers often under recognize symptoms. However, this research was limited by the different ways in which patients and providers were asked about the symptoms patients experience. We sought to (1) describe the prevalence of patient-reported symptoms in the post-cART era; (2) identify those patient-reported symptoms which are most strongly associated with health-related quality of life (HRQoL), hospitalization and mortality; and (3) determine whether primary providers recognize symptoms associated with HRQoL, hospitalization and mortality. We conducted a secondary analysis using baseline survey data from the Veterans Aging Cohort Study and determined which patient-reported symptoms correlated with clinical outcomes using regression analyses. Kappa scores were then calculated. HIV-infected patients suffer from a high burden of symptoms in the post-cART era. Nine out of 20 symptoms correlated with clinical outcomes. Providers universally under recognized symptoms and demonstrated poor agreement beyond chance when patient-report was used as the gold standard.

Substance use and the quality of patient-provider communication in HIV clinics

The objective of this study was to estimate the influence of substance use on the quality of patient-provider communication during HIV clinic encounters. Patients were surveyed about unhealthy alcohol and illicit drug use and rated provider communication quality. Audio-recorded encounters were coded for specific communication behaviors. Patients with vs. without unhealthy alcohol use rated the quality of their provider's communication lower; illicit drug user ratings were comparable to non-users. Visit length was shorter, with fewer activating/engaging and psychosocial counseling statements for those with vs. without unhealthy alcohol use. Providers and patients exhibited favorable communication behaviors in encounters with illicit drug users vs. non-users, demonstrating greater evidence of patient-provider engagement. The quality of patient-provider communication was worse for HIV-infected patients with unhealthy alcohol use but similar or better for illicit drug users compared with non-users. Interventions should be developed that encourage providers to actively engage patients with unhealthy alcohol use.

Improving adherence to HIV quality of care indicators in persons with opioid dependence: the role of buprenorphine

BACKGROUND

Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients.

METHODS

We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible × 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants.

RESULTS

One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (β 8.55; 95% confidence interval, 2.06-15.0).

CONCLUSIONS

In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes.

Self-reported side effects in buprenorphine and methadone patients receiving antiretroviral therapy: results from the MANIF 2000 cohort study

AIMS

The aim of the study was to investigate the relationship between methadone and buprenorphine treatment and self-reported symptoms in HIV-infected opioid dependent individuals receiving antiretroviral therapy (ART).

DESIGN

Longitudinal study.

SETTING

The French MANIF2000 cohort was used to compare self-reported symptoms in buprenorphine and methadone patients also receiving ART.

PARTICIPANTS

We selected individuals receiving ART and OAT (342 visits among 106 patients).

MEASUREMENTS

Symptoms were self-reported using a list of 14 symptoms (e.g. nausea, fatigue, fever) perceived during the previous 4 weeks, including three painful symptoms (abdominal or muscular pain, headaches). A two-step Heckman approach enabled us to account for the non-random assignment of OAT: a probit model identified predictors of starting either buprenorphine or methadone. A Poisson regression based on generalized estimating equations (GEE) was then used to identify predictors of the number of symptoms while adjusting for the non-random assignment of OAT.

FINDINGS

The median (interquartile range) number of symptoms was 4 (1-6) and 2 (1-6) among buprenorphine and methadone patients, respectively. After adjustment for non-random assignment of OAT type, depressive and opioid withdrawal symptoms, anxiolytics consumption and daily cannabis use, methadone patients were more likely to report a lower number of symptoms than those receiving buprenorphine.

CONCLUSIONS

Methadone patients on ART report fewer symptoms than buprenorphine patients on ART under current treatment conditions in France. Further experimental research is still needed to identify an OAT-ART strategy which would minimize the burden of self-reported symptoms and potential interactions, while assuring sustainability and response to both treatments.

Provision of pain- and symptom-relieving drugs for HIV/AIDS in sub-Saharan Africa

CONTEXT

Although pain and burdensome symptoms among HIV-infected persons can be effectively managed, the availability of opioids and other symptom-controlling drugs is a particular challenge in sub-Saharan Africa.

OBJECTIVES

This study aimed to identify current drug availability and prescribing practices in 12 sub-Saharan African countries and to examine the barriers and potential facilitators for use of opioids and other key HIV/AIDS symptom-controlling drugs.

METHODS

This was a cross-sectional survey, integrating data from palliative care facilities and competent authorities within ministries of health in 12 African countries.

RESULTS

Of 62 responding facilities, problems were reported in accessing named nonopioids, with a small number of facilities unable to dispense them. Less than half the facilities were currently prescribing opioids of any strength. Further problems were identified in terms of the availability and supply continuity of named antiemetics and anxiolytics. The data identified a number of systemic problems, suggesting that opioid supply issues are similar to less controlled drugs, such as antiemetics. Among competent authorities, there was no agreement on whether further opioid expansion was possible. Integration of data from care facilities and competent authorities highlighted a disparity in the understanding of the availability of specific drugs, with competent authorities naming drugs that were not listed by any responding facility in their respective country.

CONCLUSION

This study shows that opioid expansion needs to balance supply and skills: Currently there are insufficient trained clinical personnel to prescribe, and supply is unreliable. Efforts to expand supply should ensure that they do not weaken current systems.

Sources of emotional distress associated with diarrhea among late middle-age and older HIV-infected adults

CONTEXT

Although the experience of physical symptoms can adversely influence emotional well-being, the specific emotional reactions experienced in response to specific symptoms are not well understood.

OBJECTIVES

To examine the emotional impact of diarrhea among HIV+ late middle-age and older adults (i.e., age 50 years and older).

METHODS

In-depth interviews were conducted with 100 participants, of whom 29 had experienced diarrhea and spoke about the emotional impact it had had on them.

RESULTS

Three principal themes emerged: 1) I don't control the diarrhea, the diarrhea controls me; 2) I feel ashamed, dirty, and tainted; and 3) I fear what the diarrhea is doing to me and what it means. Their inability to control when and where their diarrhea would occur was a great source of emotional distress for participants. Almost all feared the possibility of fecal incontinence while out in public and the humiliation it would bring. To avoid this, many greatly restricted their time outside the home or where they would go to ensure access to a restroom. Others felt shame and perpetually "dirty" even when not dealing with a bout of diarrhea. Many also worried about the effect the diarrhea would have on their health and whether it signaled progression to end-stage disease.

CONCLUSION

The data strongly support the need to aggressively manage diarrhea in HIV-infected adults, as the social and emotional consequences can be profound. When it cannot be effectively controlled, physicians and social service agencies should address the isolation by providing home-based opportunities for social support and interaction.

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.

HIV or HIV-therapy? Causal attributions of symptoms and their impact on treatment decisions among women and men with HIV

OBJECTIVES

Among people with HIV, we examined symptom attribution to HIV or HIV-therapy, awareness of potential side effects and discontinuation of treatment, as well as sex/gender differences.

METHODS

HIV-patients (N=168, 46% female) completed a comprehensive symptom checklist (attributing each endorsed symptom to HIV, HIV-therapy, or other causes), reported reasons for treatment discontinuations and potential ART-related laboratory abnormalities.

RESULTS

Main symptom areas were fatigue/sleep/energy, depression/mood, lipodystrophy, and gastrointestinal, dermatological, and neurological problems. Top HIV-attributed symptoms were lack of stamina/energy in both genders, night sweats, depression, mood swings in women; and fatigue, lethargy, difficulties concentrating in men. Women attributed symptoms less frequently to HIV than men, particularly fatigue (p<.01). Top treatment-attributed symptoms were lipodystrophy and gastrointestinal problems in both genders. Symptom attribution to HIV-therapy did not differ between genders. Over the past six months, 22% switched/interrupted ART due to side effects. In women, side effect-related treatment decisions were more complex, involving more side effects and substances. Remarkably, women took predominantly protease inhibitor-sparing regimens (p=.05). Both genders reported only 15% of potential ART-related laboratory abnormalities but more than 50% had laboratory abnormalities. Notably, women had fewer elevated renal parameters (p<.01).

CONCLUSIONS

Men may attribute symptoms more often to HIV and maintain a treatment-regimen despite side effects, whereas women may be more prudent in avoiding treatment side effects. Lacking awareness of laboratory abnormalities in both genders potentially indicates gaps in physician-patient communication. Gender differences in causal attributions of symptoms/side effects may influence treatment decisions.

Influence of coping, social support, and depression on subjective health status among HIV-positive adults with different sexual identities

The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups.

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.

Mild-to-moderate symptoms during the first year of antiretroviral therapy worsen quality of life in HIV-infected individuals

Symptoms and quality of life were assessed among human immunodeficiency virus (HIV)-infected individuals initiating their first course of antiretroviral therapy. Symptoms, which were mostly mild or moderate, were common in the first year and significantly affected the patients' quality of life. Quality of life was inversely related to the number of symptoms and in the change in the number of symptoms from baseline.

Substance abuse treatment in human immunodeficiency virus: the role of patient-provider discussions

Substance abuse treatment is associated with decreases in human immunodeficiency virus (HIV) risk behavior and can improve HIV outcomes. The purpose of this study was to examine factors associated with substance abuse treatment utilization, including patient-provider discussions of substance use issues. We surveyed 951 HIV-infected adults receiving care at 14 HIV Research Network primary care sites regarding drug and alcohol use, substance abuse treatment, and provider discussions of substance use issues. Although 71% reported substance use, only 24% reported receiving substance abuse treatment and less than half reported discussing substance use issues with their HIV providers. In adjusted logistic regression models, receipt of substance abuse treatment was associated with patient-provider discussions. Patient-provider discussions of substance use issues were associated with current drug use, hazardous or binge drinking, and Black race or ethnicity, though substance use was comparable between Blacks and Whites. These data suggest potential opportunities for improving engagement in substance abuse treatment services.

Comprehensive clinical adherence interventions to enable antiretroviral therapy: a case report

Adherence to antiretroviral therapy is key for successful treatment of HIV-infected persons. To enhance adherence, multilevel interventions are necessary. This is often a challenge, as this case of an HIV-infected man with a history of poor adherence and multiple virological failures shows. With a multidisciplinary approach, comprehensive intervention strategies were used to facilitate the patient's adherence to an enfuvirtide-based regimen. The interventions are described in detail and include adherence support with modified daily observed therapy, support regarding symptom management, and social relationships. The patient's clinical progress was monitored using indicators such as clinical surrogate markers, adherence to antiretroviral therapy, and HIV-related symptom and depression scores. The case illustrates how interventions that were individualized, culturally sensitive, and provided by a team of health care providers enabled a patient to optimize his adherence, which led to significant improvement in his clinical surrogate markers and subjective quality of life.

Health-related quality of life outcomes in HIV-infected patients starting different combination regimens in a randomized multinational trial: the INITIO-QoL substudy

The health-related quality of life (HRQoL) outcomes in HIV-infected, treatment-naive patients starting different HAART regimens in a 3-year, randomized, multinational trial were compared. HRQoL was measured in a subgroup of patients enrolled in the INITIO study (153/911), using a modified version of the MOS-HIV questionnaire. The regimens compared in the INITIO trial were composed by two NRTIs (didanosine + stavudine) plus either an NNRTI (efavirenz) or a PI (nelfinavir), or both (efavirenz + nelfinavir). Primary HRQoL outcomes were Physical and Mental Health Summary scores (PHS and MHS, respectively). During follow-up, an increase of PHS score was observed in all treatment arms. The MHS score remained substantially unchanged with the four-drug combination and showed with both NNRTI- and PI-based three-drug regimens a marked trend toward improvement, which became statistically significant when a multiple imputation method was used to adjust for missing data. Overall, starting all the combination regimens compared in the INITIO study was associated with a maintained or slightly improved HRQOL status, consistently with the positive immunological and virological changes observed in the main study. The observed differences in the MHS indicate a possible HRQoL benefit associated to the use of three-drug, two-class regimens and no additional benefit for the use of four-drug, three-class regimens, confirming that three-drug, two-class regimens that include two NRTIs plus either an NNRTI or a PI should be preferred as initial treatment of HIV infection.

Clinician gender is more important than gender concordance in quality of HIV care

BACKGROUND

Previous studies have examined the impact of physician gender and gender concordance on preventive care, satisfaction, and communication. Less is known about how physician gender and gender concordance affect care for chronic illnesses, including HIV.

OBJECTIVE

This study sought to determine whether patient-clinician gender concordance (patient and clinician are of the same gender) influences receipt of protease inhibitor (PI) therapy and ratings of care among HIV-infected patients.

METHODS

We reviewed data from 1860 patients and 397 clinicians in the HIV Cost and Services Utilization Study, a nationally representative the association between gender concordance and time to first PI use, and multivariable logistic regression was utilized to examine the association of gender concordance with patients' problems with care and their overall rating of care.

RESULTS

Patients who had a male clinician received PIs earlier than those who had a female clinician (adjusted time ratio = 0.69 for having a male vs having a female clinician; P <or= 0.01). Gender concordance was not a significant predictor of time to PI use. Gender discordance was associated with problems with feeling respected by clinicians. Female patients with a male clinician were most likely, and female patients with female clinicians were least likely, to report a problem with being treated with respect (P <or= 0.01 for the interaction term). Gender discordance was not associated with other problems with care or with overall ratings of care.

CONCLUSIONS

Gender discordance was associated with perceived problems of being treated with respect by clinicians, but not with time to receipt of PIs, overall ratings of care, coordination of care, or obtaining information. The perception of not being respected may represent a significant barrier to care that is particularly worse for women, in that most HIV-infected women receive their care from male clinicians.

Prevalence and impact of diarrhea on health-related quality of life in HIV-infected patients in the era of highly active antiretroviral therapy

OBJECTIVES

Before the introduction of highly active antiretroviral therapy (HAART), the majority of HIV-infected patients experienced diarrhea. The aims of this study were to compare the prevalence of diarrhea among HIV-infected and uninfected patients in the HAART era, and to evaluate the impact of diarrhea on health-related quality of life (HRQOL).

METHODS

Diarrheal symptoms experienced by 163 consecutive HIV-infected patients and 253 HIV-seronegative control subjects were ascertained using a validated questionnaire. The HRQOL of these patients was assessed using the Medical Outcomes Study (MOS) SF-36 and MOS-HIV Health surveys.

RESULTS

Among the 163 HIV-infected patients, the median CD4 cell count was 370 cells/mm and 150 individuals were taking HAART. Significantly, more HIV-infected subjects reported having 3 or more bowel movements daily within the past 7 days than did HIV-seronegative subjects (28.2% vs. 7.1%, P<0.001), even after adjusting for potential confounding variables (odds ratios=6.65; 95% confidence intervals, 3.36-13.17). In addition, diarrhea was significantly more common in HIV-infected patients than in control subjects when assessed by several other criteria. HIV-infected patients reported significantly worse HRQOL across all domains of the MOS SF-36 as compared with control subjects. Among HIV-infected patients, individuals with diarrhea had significantly worse HRQOL in nearly all domains of the MOS-HIV as compared with those without diarrhea.

CONCLUSIONS

Diarrhea remains an important clinical problem in HIV-infected patients and is associated with significant impairments in HRQOL. It is important that healthcare providers specifically evaluate their HIV-infected patients for diarrhea so that these symptoms may be optimally managed.

Pharmacokinetic interaction between darunavir boosted with ritonavir and omeprazole or ranitidine in human immunodeficiency virus-negative healthy volunteers

Darunavir (DRV; TMC114; Prezista) is a human immunodeficiency virus (HIV) protease inhibitor used in combination with low-dose ritonavir (RTV) (DRV/r) as a pharmacokinetic enhancer. Protease inhibitor absorption may be decreased during coadministration of drugs that limit stomach acid secretion and increase gastric pH. This study was conducted to investigate the effect of ranitidine and omeprazole on the plasma pharmacokinetics of DRV and RTV in HIV-negative healthy volunteers. Sixteen volunteers completed the study and received DRV/r, DRV/r plus ranitidine, and DRV/r plus omeprazole, in three separate sessions. Treatment was given for 4 days with an additional morning dose on day 5, and regimens were separated by a washout period of 7 days. Samples were taken over a 12-h period on day 5 for the assessment of DRV and RTV plasma concentrations. Pharmacokinetic parameters assessed included DRV area under the curve, maximum plasma concentration, and trough plasma concentration. The least-squares mean ratios and 90% confidence intervals are reported with treatment of DRV/r alone as a reference. Compared with DRV/r alone, no significant changes in DRV pharmacokinetic parameters were observed during coadministration of DRV/r and either ranitidine or omeprazole. Treatment regimens were generally well tolerated, and no serious adverse events were reported. In conclusion, coadministration of DRV/r and ranitidine or omeprazole was well tolerated by the volunteers. Ranitidine and omeprazole did not have a significant influence on DRV pharmacokinetics. No dose adjustments are required when DRV/r is coadministered with omeprazole or ranitidine.

The experience of physical symptoms among women living with HIV

As the number of women living with HIV and AIDS increases, so does survival time for individuals living with this chronic condition. Symptom existence, intensity, and bothersomeness greatly affect quality of life in women living with HIV and AIDS. Symptoms experienced by women living with HIV include symptoms related to HIV infection itself, those related to opportunistic infections, and those related to medications and treatments. Symptoms experienced by women include those common to both genders and those specific to females. The presence and intensity of symptoms varies with progression of the disease and with deteriorating status of HIV disease indicators. While research is limited on this topic, some research on the general symptom experience of women and on symptoms specific to or common among women has been done. Extended life expectancy among women with HIV increases the importance of nursing care focused on symptom assessment and symptom management. This article reviews research on symptoms commonly experienced by women living with HIV and presents implications for the care of women experiencing distressing symptoms.

The Spectrum of Symptoms Among Rural South Africans With HIV Infection

The vast majority of people infected with HIV in South Africa have no access to antiretroviral therapy, making palliative care the only treatment available. An important element of palliative care is symptom management. However, little is known about the range of symptoms and the distress associated with them among rural South Africans living with HIV/AIDS. A cross-sectional study was conducted to describe the spectrum of symptoms experienced by 64 HIV-positive patients who received palliative care from a rural home-based palliative care program. Data were determined using a questionnaire adapted from an HIV symptom list and HIV symptom profile. The physical symptoms of most immediate importance identified by the respondents were localized pain, skin problems, cough, vaginal discharge/infection, and fatigue. The psychological symptoms of the most immediate and overall importance were feelings of anger, loneliness, decreased support from family and friends, and a decreased sense of satisfaction. This study provides insight into the spectrum of HIV-associated symptoms in a rural South African HIV-positive population. Through improved symptom assessment and management, nurses can improve palliative care services to those suffering from the distressful symptoms associated with HIV infection.

Bacterial diarrhea in persons with HIV infection, United States, 1992-2002

BACKGROUND

To describe trends in bacterial diarrhea among human immunodeficiency virus (HIV)-infected persons during 1992-2002, we examined data from a longitudinal record review study of persons with HIV infection who were receiving medical care in >100 medical facilities in 9 major United States cities.

METHODS

An analysis was performed using data from 44,778 persons who were followed up for a mean of 2.6 years. We calculated incidence rates and rate ratios for bacterial diarrhea, by stage of HIV disease, and determined odds ratios (ORs) to compare bacterial diarrhea diagnosis in 2002 versus 1992.

RESULTS

The mean annual incidence of bacterial diarrhea was 7.2 cases per 1000 person-years. The incidence of Clostridium difficile-associated diarrhea, the most common bacterial cause of diarrhea, was 4.1 cases per 1000 person-years. Compared with persons without AIDS, persons with AIDS were more likely to have bacterial diarrhea (incidence rate ratio, 1.3-9.9, varying by clinical versus immunologic AIDS and type of bacterial diarrhea). Between 1992 and 2002, the overall rate of bacterial diarrhea in persons with clinical AIDS decreased (OR, 0.4; 95% confidence interval, 0.2-0.6). During the same period, bacterial diarrhea rates among other persons in the analysis did not significantly change.

CONCLUSIONS

C. difficile is the most common recognized cause of bacterial diarrhea among persons infected with HIV. The risk for bacterial diarrhea increases with increased severity of HIV disease. Health care professionals should be aware that patients with AIDS are at increased risk for bacterial diarrhea, and they should reinforce recommendations for decreasing the chances of acquiring bacterial diarrhea.

Symptom management in HIV/AIDS: advancing the conceptualization

For people living with HIV, symptoms related to the disease, comorbidities, and treatment side effects make symptom management essential. Poorly managed symptoms result in reduced medication adherence, disease progression, and lower quality of life. The Self-regulatory HIV/AIDS Symptom Management Model is a conceptual model that describes how persons living with HIV/AIDS manage their symptoms. The model links symptom experience, symptom management, social support, adherence, and health-related quality of life. It can assist nurses, through a multidimensional approach to illness management, to enhance symptom assessment, better understand factors influencing symptom experience, and to improve symptom management among people living with HIV/AIDS.

Therapeutic Drug Monitoring and Drug–Drug Interactions Involving Antiretroviral Drugs

The consensus of current international guidelines for the treatment of HIV infection is that data on therapeutic drug monitoring (TDM) of non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) provide a framework for the implementation of TDM in certain defined scenarios in clinical practice. However, the utility of TDM is considered to be on an individual basis until more data are obtained from large clinical trials showing the benefit of TDM.

In April 2004, a panel of experts met for the second time in Rome, Italy. This was following the inaugural meeting in Perugia, Italy, in October 2000, which resulted in the manuscript published in AIDS 2002, 16(Suppl 1):S5–S37. The objectives of this second meeting were to review and update the numerous questions surrounding TDM of antiretroviral drugs and discuss the clinical utility, current concerns and future prospects of drug concentration monitoring in the care of HIV-1-infected individuals. A major focus of the meeting was to discuss and critically analyse recent and precedent clinical drug–drug interaction data to provide a clear framework of the pharmacological basis of how one drug may impact the disposition of another.

This report, which has been updated to include material published or presented at international conferences up to the end of December 2004, reviews recent pivotal pharmacokinetic interaction data and provides advice to clinical care providers on how some drug–drug interactions may be prevented, avoided or managed, and, when data are available, on what dose adjustments and interventions should be performed.

The Symptom Experience of People Living With HIV/AIDS in Southern Africa

This study describes the symptom experience of 743 men and women living with HIV/AIDS in Botswana, Lesotho, South Africa, and Swaziland. Data were obtained in 2002 by using a cross-sectional design. A survey of participants included 17 sociodemographic items and the 64-item Revised Sign and Symptom Checklist for Persons with HIV Disease. Results indicate a strong correlation between the frequency of reported symptoms and their intensity (r = .84, p < .00). Participants who reported having enough money for daily expenses also reported significantly fewer symptoms. There were no significant differences in symptom frequency between men and women or by location of residence. The study showed a complex picture of HIV-related symptoms in all four countries. Because of the high levels of symptoms reported, the results imply an urgent need for effective home- and community-based symptom management in countries where antiretroviral therapy is unavailable to help patients and their families manage and control AIDS symptoms and improve quality of life.