Symptoms can predict increases in viral load for patients taking HIV treatment

Physical and psychological symptoms can predict increases in viral load in patients taking antiretroviral therapy who have an undetectable viral load, researchers from London report in the August 15^th edition of the Journal of Acquired Immune Deficiency Syndromes.

Individual symptoms especially associated with a rebound in viral load included worry, feeling sad and diarrhoea.

“The most likely mechanism linking symptoms to virologic rebound  is cART [combination antiretroviral therapy] nonadherence, including treatment interruption or discontinuation”, comment the investigators. They add, “it is possible that symptom measures capture additional information about nonadherence that is not captured by direct inquiry on missed cART doses.”

Earlier research has shown that depression may predict disease progression in patients with HIV, but researchers at the Royal Free Hospital in London wanted to see is physical and psychological symptoms could predict increases in viral load in patients taking antiretroviral therapy.

They therefore designed a study involving 188 patients, all of whom were being treated with anti-HIV drugs and had an undetectable viral load.

In 2005, these patients completed a questionnaire which asked if they had experienced any of 32 physical and mental health symptoms in the previous week. They were then followed to see if these symptoms were associated with changes in viral load.

Symptoms were grouped into six areas:

• Physical distress. This included symptoms such as pain, lack of energy, nausea, and weight loss.

• Psychological distress. This measure included symptoms such as worry, anxiety, and difficulty sleeping or concentrating.

• Global distress. An assessment of ten symptoms, including pain, lack of appetite, tiredness, dry mouth, sadness, nervousness and irritability.

• Total number of symptoms. Other symptoms such as diarrhoea were added to this assessment.

• Anxiety and depression.

• Suicidal thoughts.

Symptoms in the first three categories were scored according to how much distress they caused (0.8, “not at all”) to 4 (“very much”). A score of zero was awarded if the symptom was not present.

Overall, moderate distress was caused by symptoms. The median physical distress score was 0.7, the psychological distress score was 1.2, and the global distress score was 1.0.

Nevertheless, there was a high prevalence of symptoms. The most commonly reported symptoms were tiredness (25%), worry (25%), sleeping problems (22%), lack of energy (21%), and irritability (20%).

Almost half (48%) of patients reported depression, and a fifth said that they had thought of suicide in the past week.

During a median of 2.2 years of follow-up, 22 patients experienced an increase in their viral load to above 200 copies/ml, with 46 patients having a rebound in their viral load to above 50 copies/ml. In each case, seven patients had taken a break from HIV therapy.

A higher physical symptom score (1 or above) was associated with an increased risk of a rebound in viral load to above 200 copies/ml (p = 0.05) and 50 copies/ml (p = 0.20). However, after adjusting for reported poor adherence, the association with an increase above 200 copies/ml was of only borderline significance (p = 0.072).

Similarly, compared to patients with the lowest scores for psychological distress, those with higher scores were significantly more likely to experience rebounds in their viral load (200 copies/ml p = 0.034; 50 copies/ml p = 0.023). But after adjusting for adherence, these associations were reduced to borderline significance.

A similar pattern was observed when global distress was measured.

The investigators also explored the association between the number of reported symptoms and increase in viral load. Even after adjusting for adherence, the greater the number of symptoms a patient experienced, the more likely their viral load was to increase to above 200 copies/ml (p = 0.042) and 50 copies/ml (p = 0.019).

Anxiety and depression was significantly associated with viral load rebound after taking into account adherence (200 copies/ml, p = 0.011; 50 copies/ml, p = 0.043). After controlling for adherence, the investigators found that there was also a significant relationship between anxiety and depression and two consecutive viral load measures above 50 copies/ml (p = 0.04).

“Among…HIV patients on successful ART, physical and psychological symptoms were common and were among the strongest predictors of virologic rebound”, write the investigators.

They note that this is the first study to show an association between physical symptoms and increases in viral load. They suggest that “physical symptoms may result in anxiety and depression, or be manifestations of psychological distress.”

The researchers believe that their findings could have implications for the type of care offered patients taking treatment. They suggest that an assessment “of virologic failure risk that is based solely on laboratory results, treatment history and adherence may be missing an important dimension – information from the patient’s perspective”.

A simple assessment of symptoms would identify patients at risk of treatment failure, they suggest, and “provide an opportunity not only for addressing adherence but also for appropriate medical or psychological interventions to address physical symptoms and psychological distress.”

Lampe FC et al. Physical and psychological symptoms and risk of virologic rebound among patients with virologic suppression on antiretroviral therapy. J Acuir Immune Defic Syndr 54: 500-505, 2010.