Stressful life events have profound impact on ART
Study outlines public health problem
It's no surprise to clinicians that many or most of their HIV patients are negatively impacted by major life stresses. But new research shows that HIV medication adherence among people with the most stressful lives is abysmally low.
Investigators found that 87% of HIV-infected people with six or more stressful life events were not adherent to their antiretroviral therapy (ART) within the previous two weeks, says Jane Leserman, PhD, a professor at the University of North Carolina at Chapel Hill.1
"When we look at people who have either zero or one of the stressful life events we measured, about 22% of those people were not adherent in the past two weeks," Leserman says.
"So you see a huge difference," Leserman says. "My interpretation is that people who have a lot of stressful life events tend to have much more traumatic lives with all kinds of chaotic events that go on in their lives, and this interrupts their ability to be adherent to their medication."
When HIV patients are worried about where they'll sleep, or when they have huge fights with their families, then these are the pressing concerns of their day — not taking their HIV drugs, she adds.
Since HIV clinicians need their patients to achieve a 95% adherence rate to prevent the development of drug resistant strains, which can be transmitted to others, then this reaction to stressful life events is a very serious problem, Leserman says.
"We have medications to help this population, but the problem is getting people to take those meds in a regular way," Leserman adds.
The study of 105 HIV-infected men and women found that 44.8% had missed a medication dose in the previous two weeks, and 22.1 % had missed a dose the previous weekend.
Adherence was measured from a questionnaire that included questions about when was the last time they missed any medications.
"If you have to have 95% adherence to prevent the development of drug resistance, and in a two-week period almost 45% of people said they missed one of their doses — that's bad," Leserman says. "This tells us we need to develop interventions for adherence that really address these issues of stress."
Researchers measured stressful life events through a modified version of the Life Events Survey. It looked at only moderate to severely stressful events based on previous research, and these included change in relationships, death or serious illness among family or close friends, work/financial problems, accidents or safety issues, crime or legal problems, and other life changes.1
Leserman has long studied the effects of stressful events and trauma on disease progression in HIV. In a study published last fall, she showed that women and men in the rural Southeast had more traumatic life events with a faster progression in terms of all causes of AIDS.2
"We found stress was an important predictor of progression to AIDS over a nine-year period," Leserman notes.
"The other areas where I've shown stress to have an impact include functioning," she adds. "We found that stressful life events and trauma were very highly related to core functioning, such as the degree to which stress impacts your ability to carry out your daily chores, to function physically and emotionally."
Future research will focus on the impact of stress on HIV fatigue, Leserman says.
"This population has a lot of stressful and traumatic events in their lives," Leserman says. "In terms of depression, 21% met the criteria for depression in this study."
The study also found that 41% had chronic financial stress, 24% had a serious argument or separation from their partner, 24% had estrangement from their family, and 19% had a major illness that was not related to HIV infection.1
"So you get the idea that these are fairly serious kinds of stresses the subjects in our study have experienced," Leserman says.
The HIV-infected people who participated in the study also exhibited poor health habits, including 51 % who smoked cigarettes, 34.3% who used illicit drugs in the past month, and 37.6% who drank alcoholic beverages in the past month.1
For clinicians, it's important to monitor their HIV patients' mental health as consistently as they monitor CD4 cell counts, Leserman says.
"It's important to ask about stressful events, depression, post-traumatic stress disorder," she explains. "Obviously, physicians can't treat everything and may not be trained to treat the mental health, but they can refer patients to other types of services that would provide interventions in adherence."
Adherence counseling and psychological services should be an integral part of HIV care because of the high percentage of HIV patients who have mental health issues, past traumas, and stressful life events, Leserman says.
Investigators are exploring an intervention in which HIV patients write about their trauma and stress in their lives and write about their daily life events to see if the act of writing about these will have a positive affect, she adds.
"We need to address mental health issues and stressful life events, as well as patients' CD4 cell count and viral load," Leserman says.
References
- Leserman J, Ironson G, O'Cleirigh C, et al. Stressful life events and adherence in HIV. AIDS Patient Care STDS. 2008;22(5):1-9.
- Pence BW, Reif S, Whetten K, et al. Minorities, the poor, and survivors of abuse: HIV-infected patients in the US deep South. South Med J. 2007;100(11):1114-1122.
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