A high burden of physical and psychological symptoms is associated with an increased risk of viral load rebounding to detectable levels in patients taking HIV treatment, UK investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.
Researchers from London’s Royal Free Hospital noted, “physical and psychological symptoms were common and were among the strongest predictors of virologic rebound.”
Research into the factors associated with the virologic efficacy of HIV treatment have overwhelmingly focused on treatment factors such as the potency of drugs, or levels of patient adherence.
Little attention has been paid to contribution of patient perceptions of health to treatment outcomes. This is despite the fact that large number of patients taking antiretroviral therapy report symptoms indicating physical or psychological distress.
Therefore, researchers used information obtained from self-completed questionnaires to see if the presence, number and severity of physical and psychological symptoms predicted increases in viral load amongst patients taking HIV treatment who had an undetectable viral load.
The research involved 188 patients, all of whom were on antiretroviral therapy and had an undetectable viral load at the time they completed the questionnaire in 2005.
The questionnaire included questions about the presence and severity of symptoms in six areas:
- Physical distress.
- Psychological distress.
- Global distress.
- Total number of symptoms.
- Anxiety/depression.
- Suicidal thoughts.
Symptoms were scored according to the level of distress they caused, from 0.8 ('not at all'), to 4.0 ('very much').
Overall distress scores were low, and suggest that symptoms only occasionally caused distress. The median number of symptoms reported by patients was eleven.
However, 48% of patients reported depression, and 27% said that they had thought of suicide in the previous week with 4% reporting that such thoughts were constant.
The investigators noted patients who reported physical symptoms were also likely to report psychological symptoms. Approximately 60% of those reporting that physical symptoms “somewhat” caused distress also reported that they “frequently” had psychological symptoms, and 64% of these individuals reported depression.
During a median of 2.2 years of follow-up, viral load rebounded above 200 copies/ml in 22 patients, with a further 46 individuals experiencing a viral load 'blip' above 50 copies/ml.
Patients who reported the symptom-associated distress were five times more likely to experience a rebound in viral load than those with the lowest symptom scores.
The investigators then took into account potentially confounding factors, including adherence to antiretroviral therapy.
These analyses showed that symptoms causing physical distress (p = 0.022), the total number of symptoms (p = 0.19), anxiety and depression (p = 0.043) and suicidal thoughts (p = 0.028) remained significantly associated with a rebound in viral load above 50 copies/ml.
Total number of symptoms (p = 0.042) and anxiety and depression (p = 0.011) were both associated with rebound in viral load above 200 copies/ml.
“In this study, the physical symptom score predicted viral rebound and was highly correlated with psychological measures, suggesting that physical symptoms may result in depression or anxiety, or be manifestations of psychological distress”, write the investigators.
The investigators suggest that symptoms may be predictive of future poor adherence. However the investigators also note “measures of anxiety and depression have been linked to cell-mediated immunity in HIV-infected individuals”.
Asking patients about the presence of symptoms “may be valuable to identify patients at risk of future treatment failure, and provide an opportunity not only for assessing adherence but also for appropriate medical or psychological interventions to address physical symptoms and psychological distress”, conclude the investigators.
Lampe FC et al. Physical and psychological symptoms and risk of virologic rebound among patients with virologic suppression on antiretroviral therapy. J Acquire Immune Defic Syndr (online edition), 2010.