Psychosocial issues affect HIV/AIDS treatment outcomes

June 18, 2008

Psychosocial influences such as stress, depression and trauma have been neglected in biomedical and treatment studies involving people infected with HIV, yet they are now known to have significant health impacts on such individuals and the spread of AIDS, according to a University of North Carolina at Chapel Hill scientist.

Now, a comprehensive update on those influences in the current issue of the journal Psychosomatic Medicine offers a wake-up call and should give infectious disease physicians and other healthcare practitioners working with HIV-infected persons information to improve patient outcomes, said Jane Leserman, Ph.D., sociologist, professor of psychiatry in the UNC School of Medicine and co-editor of the special journal issue subtitled "Psychosocial Influences in HIV/AIDS: Biobehavioral Mechanisms, Interventions and Clinical Implications."

"A huge amount of research has been done in our field around these psychosocial influences, yet we felt not all medical professionals working with HIV-infected persons were aware of this body of knowledge," Leserman said. "Our goal was to publish a comprehensive yet succinct review of the important biobehavior research and its impact on patient care.

"We hope this special issue will serve as a catalyst for healthcare providers to address these problems as part of standard HIV care, and to stimulate collaborations between biomedical and biobehavioral clinicians and researchers working as a team to address the quantity and quality of life for these patients."

Psychosomatic Medicine is the journal of the American Psychosomatic Society. The contents of this special issue will be available as an open-access document, free-of-charge to all interested parties at www.psychosomaticmedicine.org following the journal's publication on June 20.

The special issue contains 13 peer-reviewed articles addressing five overarching themes:

-- Depression, anxiety, and stressful and traumatic life events occur in epidemic proportions in HIV-infected persons.

-- These psychosocial factors (e.g., depression, trauma and coping with stress) have consistent and clinically relevant influences on HIV disease progression.

-- The effects of psychosocial factors may be mediated biologically through changes in the sympathetic nervous system, "stress hormones" and the immune system, as well as behaviorally through changes in such behaviors as non-adherence to medications.

-- Interventions to address depression, stress and coping may help to ameliorate some of the negative health and behavioral effects associated with poor psychological functioning.

-- Asking about past trauma, current stress, depression and coping need to become routine aspects of a multidisciplinary and comprehensive approach to HIV treatment.

Recent large, long-term studies show that HIV and AIDS patients with chronic depression and trauma are about twice as likely to die from AIDS-related causes, Leserman said.

"No one argues about the importance of following the numbers – immune cell counts and levels of the virus in the blood – nor should they," Leserman said. "But there is substantial and consistent evidence that depression, stressful life events and trauma account for some of the variability in HIV disease course. That can't be ignored."

Leserman cited the clinical significance of addressing the psychosocial issues that exist in epidemic proportions in HIV-infected populations. One study of men and women being treated in infectious disease clinics in the southeastern United States found that more than 70 percent of those patients had suffered at least two major lifetime traumas – about half had been sexually and/or physically abused.

"Asking about past trauma and current life issues brings a fuller, truer focus on the patient and should be a routine practice in any multi-disciplinary and comprehensive approach to HIV treatment."

Such inquiries could have a positive impact on patient care if they lead to appropriate referrals for psychological and behavioral treatment, Leserman said.

"In these populations with high psychosocial disturbance, there is also a documented higher proportion of risky behaviors – such as lack of adherence to treatment – that translates into a higher likelihood of developing drug resistance," Leserman said. "Patients developing drug resistance become harder to treat and more likely to pass on a resistant strain of the virus."

Leserman believes more research is needed to investigate the biological and behavioral mediators of the relationship between psychosocial issues and the immune system, and the types of interventions that could lessen the negative health impact of chronic depression and trauma.

"We need ways to integrate what we're learning into the routine practice of medicine," Leserman said. "At one time, psychosocial issues may have seemed irrelevant, but now a wealth of research is indicating that we must pay attention to these factors. Although psychosocial research in HIV is fast becoming a well accepted and traveled road, many questions remain. This field is not yet a super highway."

Source: University of North Carolina at Chapel Hill