Lipoatrophy among HIV-infected patients is associated with higher levels of depression than lipohypertrophy.

OBJECTIVES: We sought to determine the association between body morphology abnormalities and depression, examining lipoatrophy and lipohypertrophy separately. METHODS: An observational cross-sectional study of 250 patients from the University of Washington HIV Cohort was carried out. Patients completed an assessment including measures of depression and body morphology. We used linear regression analysis to examine the association between lipoatrophy or lipohypertrophy and depression. Analysis of variance was used to examine the relationship between mean depression scores and lipoatrophy and lipohypertrophy in 10 body regions. RESULTS: Of 250 patients, 76 had lipoatrophy and 128 had lipohypertrophy. Mean depression scores were highest among patients with moderate-to-severe lipoatrophy (16.4), intermediate among those with moderate-to-severe lipohypertrophy (11.7), mild lipohypertrophy (9.9) and mild lipoatrophy (8.5), and lowest among those without body morphology abnormalities (7.7) (P=0.002). After adjustment, mean depression scores for subjects reporting moderate-to-severe lipoatrophy were 9.2 points higher (P<0.001), scores for subjects with moderate-to-severe lipohypertrophy were 4.8 points higher (P=0.02), and scores for subjects with mild lipohypertrophy were 2.8 points higher (P=0.03) than those for patients without body morphology abnormalities. Facial lipoatrophy was the body region associated with the most severe depression scores (15.5 vs. 8.9 for controls; P=0.03). CONCLUSIONS: In addition to long-term cardiovascular implications, body morphology has a more immediate effect on depression severity.

Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: a review of the literature.

Adherence to antiretroviral medications is central to reducing morbidity and mortality among people living with HIV/AIDS. Relatively few studies published to date address HIV adherence among special populations. The purpose of this article is to review the existing literature on HIV antiretroviral adherence, with an emphasis on studies among the triply diagnosed population of people living with HIV/AIDS, mental illness, and chemical dependency. In order to reflect the most current information available, data from conference proceedings, federally funded studies in progress, and the academic literature are presented for consideration.

Rearrest: does HIV serostatus make a difference?

Correctional facilities have become collection and containment centres for HIV-seropositive individuals. This is due to factors that affect incarceration in general: past criminal behaviour, age and crime type. In addition, the sex trade industry, intravenous drug use and community instability are likely factors affecting this particular population. The objective of this study was to determine whether HIV-positive offenders have higher rates of rearrest than HIV-negative offenders. A sample of HIV-positive offenders (n = 57) were seen for mental health evaluation at the King County Correctional Facility (KCCF) in Seattle Washington. They were compared to a historical sample (n = 254) of HIV-negative individuals also from the KCCF. After three months, 50% of both samples had been rearrested. Using the log rank test in Kaplan-Meier survival analysis, statistical difference in the relative risk of rearrest occurred for the HIV-positive group (logrank = 0.03). Statistical adjustment for mental illness, age, race, ethnicity, substance abuse history and past criminal history did not affect rearrest significantly. Nonetheless, HIV-positive individuals who presented with mental health needs appeared to be significantly more vulnerable to rearrest after the first three months of release into the community.

Do characteristics of HIV/AIDS education and training affect perceived training quality? Lessons from the evaluation of seven projects.

Initial and continuing HIV/AIDS education and training has been a critical way to bring the nation's health providers up to date on emerging developments and approaches. This study reports cross-cutting findings from seven HIV/AIDS education and training projects. Trainers described over 600 training sessions from these projects in terms of their structural characteristics and design elements, while trainees described these sessions on several dimensions related to training quality. Training characteristics were compared to trainee assessments of training quality. Using a decision-tree analytic approach for major training attributes, considerable support emerged for links between training characteristics and perceived quality of the HIV/AIDS training experience. More favorable quality ratings were associated with certain projects, the training setting, the types of trainees served by the training, the intended training impact, discussion of special populations, and training methods involving interactive learning. With increased knowledge regarding how these educational experiences relate to the ways they are perceived and processed, more targeted approaches to training design on HIV/AIDS can be developed.

Trainee characteristics and perceptions of HIV/AIDS training quality.

HIV/AIDS education and training have played a vital role in keeping health providers up to date on emerging developments and approaches. This study reports findings from seven HIV/AIDS education and training projects. Participants in more than 600 training sessions described themselves, their professional background, and their general reasons for taking the training. Immediately following the training, they also rated the quality of their educational experience along several dimensions. Trainee characteristics were related to assessments of training quality, using a regression decision-tree analytic approach. Although effect sizes were generally small, quality ratings of the HIV/AIDS training experiences were associated with certain projects, basic trainee demographic characteristics, professional background, and experience in the HIV field. Greater understanding about participant characteristics can provide clues about how these training experiences are perceived and processed and may inform decision making about instructional HIV/AIDS curricula.

Effects of HIV/AIDS education and training on patient care and provider practices: a cross-cutting evaluation.

Initial and continuing training in HIV/AIDS service provision is a critical way to enable the nation's health providers to use state-of-the-art developments and perspectives. Typically, the efficacy of HIV/AIDS training programs is evaluated using assessments administered to trainees immediately following the training. This study reports cross-cutting findings from telephone interviews conducted with 218 trainees an average of 8 months after training. Long-term training effects are examined in three domains: (a) general perspectives on HIV/AIDS; (b) health care provider service provision; and (c) changes in procedures and operations at the health care system level. The findings show the different ways that the training experience had long-term positive and observable effects in these three domains. In some cases, background characteristics and job positions predicted the specific type of reported training effects. The pattern of results suggests ways in which training methods can be targeted to specific audiences.

Association between delirium and death in AIDS patients.

The purpose of this study was to examine the relationship between delirium and death in AIDS patients. Forty-one patients admitted to a combination skilled nursing and assisted-living facility in 1994 were included in the retrospective chart review. Patients were grouped according to the presence versus absence of delirium during the first week of admission. Demographic characteristics and medical morbidity of the two groups were compared using the Chi-square statistic. Kaplan-Meier survival analysis was used to estimate survival functions during the study period for the delirious and nondelirious groups. Nine patients (22%) were found to have an episode of delirium in the first week of admission. There were no significant differences in demographic characteristics or medical morbidity between the delirious and nondelirious groups. Median days from admission to death for those with delirium (10 days) versus those without delirium (135 days) was significantly different (log rank = 19.03; p < 0.0001). Authors concluded that delirium is a marker for decreased survival in this sample of AIDS patients. Future research needs to demonstrate whether improved care of AIDS patients can prevent delirium or limit adverse outcomes associated with it.

Outcomes associated with delirium in acutely hospitalized acquired immune deficiency syndrome patients.

The study demonstrates that delirium in acquired immune deficiency syndrome (AIDS) patients is associated with mortality, the need for long-term care, and an increased length of hospitalization. Data were collected prospectively on human immunodeficiency virus (HIV)/AIDS patients admitted to a teaching hospital from January 1996 through December 1996. The data included demographic characteristics of the participants, medical diagnoses, CD4 cell count, Karnofsky functional assessment, mortality during admission, length of stay, and discharge placement. Participants were evaluated throughout their hospital stay for evidence of delirium. The presence of delirium was determined using DSM-IV diagnostic criteria. There were no significant differences between delirious and nondelirious patients with respect to demographic characteristics or markers of medical morbidity. Patients with delirium were more likely to die during admission (chi-square [chi2] = 39.1, df = 1, P<.0010), to stay longer in hospital (t = 3.50, df = 12.9, P<.0041), or to need long-term care if discharged alive (chi2 = 12.8, df = 2, P<.0021). Delirium is associated with adverse outcomes in hospitalized AIDS patients. More research is needed to characterize the nature of this association.

Validity of two scales in identifying HIV-associated dementia.

OBJECTIVES: To examine and compare the validity of the HIV Dementia Scale (HDS) and Executive Interview (EXIT) in detecting HIV/AIDS dementia. METHODS: The sample included hospitalized or skilled nursing/assisted-living facility (SNF) HIV/AIDS patients (N = 103). Participants completed the HDS, EXIT, and the Structured Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). A chart review also was performed. RESULTS: Sample was predominantly male (93%) and white (79%), with a mean age of 38 years (standard deviation [SD] = 8 years). Twelve patients had a clinical diagnosis of HIV dementia. Cutoff scores of 10 or less for the HDS and 11 or more for the EXIT optimized sensitivity and specificity. Education level was related to performance for both tests. Using separate logistic regression analyses, the HDS and the EXIT were significant individual predictors of dementia. When entered together, the EXIT was the only significant predictor of dementia. Selected items of the HDS and EXIT also performed well in identifying patients with dementia. CONCLUSIONS: The HDS and the EXIT show promise as brief, well-tolerated screening tools for HIV dementia in ill patients. The HDS was more sensitive, but the EXIT added additional predictive power over the HDS in identifying dementia.

Antidepressant efficacy in HIV-seropositive outpatients with major depressive disorder: an open trial of nefazodone.

BACKGROUND: Treatment studies of major depression in patients who are seropositive for the human immunodeficiency virus (HIV) have shown comparable efficacy for both tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Nefazodone appears to be more tolerable than TCAs and similar to SSRIs. This study examined the efficacy and tolerability of nefazodone in an open 12-week trial of HIV-seropositive outpatients with major depressive disorder. METHOD: Fifteen HIV-seropositive patients with DSM-IV major depressive disorder and a 21-item Hamilton Rating Scale for Depression (HAM-D) score of > or =18 were treated with open-label nefazodone for 12 weeks. Hamilton Rating Scale for Anxiety, HAM-D, Clinical Global Impressions scale, and Systematic Assessment for Treatment Emergent Events general inquiry (for safety and tolerability) scores were obtained at weeks 2, 4, 6, 8, and 12. RESULTS: Of 15 patients receiving nefazodone, 4 discontinued treatment (1 for adverse effects). Of 11 patients who completed the trial, 8 (73%) were classified as full responders with a 50% reduction in HAM-D scores and final CGI score of 1 or 2, and 10 (91%) were classified as partial responders (only 50% reduction in HAM-D scores). Nefazodone-treated subjects experienced few total adverse effects (mean = 1.5), no sexual side effects, and low rates of adverse-effect-related dropout (1 subject, 7%). CONCLUSION: Depressed HIV-seropositive outpatients respond to nefazodone comparably to other outpatient populations and have few adverse effects, suggesting that nefazodone may have a role in the treatment of depression in HIV-seropositive patients. Potential drug interactions with protease inhibitors indicate that it is essential to evaluate for appropriate dosing to avoid adverse effects and increase overall antidepressant efficacy.

Systems change resulting from HIV/AIDS education and training. A cross-cutting evaluation of nine innovative projects.

An evaluation of nine diverse HIV/AIDS training programs assessed the degree to which the programs produced changes in the ways that health care systems deliver HIV/AIDS care. Participants were interviewed an average of 8 months following completion of training and asked for specific examples of a resulting change in their health care system. More than half of the trainees gave at least one example of a systems change. The examples included the way patient referrals are made, the manner in which agency collaborations are organized, and the way care is delivered.

Use of hospital services by AIDS patients with psychiatric illness.

The purpose of this study was to assess the effect of psychiatric illness on length of stay and patterns of admission among AIDS patients hospitalized for medical illnesses. Medical records were abstracted for AIDS patients admitted to hospitals in Washington State from 1990 through 1992. Psychiatric comorbidity was defined by the presence of an International Classification of Disease-9 code reflecting psychiatric illness. Medical morbidity was addressed using CD4 count and AIDS-defining illnesses as markers of disease severity. Of 2834 admissions, 15% included one or more psychiatric diagnoses. Psychiatric illness (F 39.1; df 1,2830; p < 0.001) and discharge disposition (F 81.2; df 2,2830; p < 0.001) contributed significantly to the model, explaining increased length of stay (F 67.2; df 3,2830; p < 0.001). Future research needs to address the possible etiology of psychiatric comorbidity's contribution to length of stay and the effect on quality and cost of care.

Randomized, placebo-controlled trial of paroxetine versus imipramine in depressed HIV-positive outpatients.

OBJECTIVE: This study examined whether a selective serotonin reuptake inhibitor (paroxetine) had comparable efficacy but greater tolerability than a tricyclic antidepressant (imipramine) in depressed patients with HIV infection. METHOD: Seventy-five HIV-positive patients (45% of whom had AIDS) were blindly and randomly assigned to receive paroxetine (N = 25), imipramine (N = 25), or placebo (N = 25) in a 12-week trial. The Hamilton Anxiety Rating Scale, the Hamilton Depression Rating Scale, the Clinical Global Impression scale, and the SAFETEE general inquiry (for safety and tolerability) were administered at weeks 2, 4, 6, 8, and 12. RESULTS: Fifty-six (75%) of the 75 patients completed 6 weeks and 34 (45%) completed 12 weeks of the trial. The mean daily doses of both paroxetine (33.9 mg) and imipramine (162.5 mg) were significantly more effective than placebo; they were comparably effective at weeks 6, 8, and 12 according to the intent-to-treat analysis and at week 8 according to the analysis for the subjects who completed the trial (for them, only imipramine was superior to placebo at week 12). There were significantly more dropouts due to side effects from imipramine (48%) than from both paroxetine (20%) and placebo (24%). CONCLUSIONS: Depressed patients with HIV infection responded to imipramine or paroxetine at a higher rate than to placebo irrespective of severity of immunosuppression. Because paroxetine was much better tolerated than imipramine, its overall effectiveness may be greater. However, because of the small study group and the high attrition rate, these findings cannot be generalized and may need replication in a larger study group.

Cognitive functions and complaints in HIV-1 individuals treated for depression.

Progressive neuropsychological dysfunction and complaints of cognitive difficulty frequently accompany HIV-1 infection. Providing appropriate treatment to HIV-1 patients requires determination of the extent to which the presentation of cognitive complaints reflects HIV-1-associated neuropsychological abnormalities or represents expression of depressive symptomatology. We prospectively treated 75 HIV-1 patients who were not demented but met criteria for major mood disorder with antidepressants for 12 weeks and compared pretreatment and posttreatment measures of depression, cognitive complaints, and neuropsychological performance. Complaints of difficulty with memory and attention were found to be independent of neuropsychological impairment, whereas memory complaints were highly correlated with severity of depression. Cognitive complaints declined significantly across the course of treatment for those patients who responded to antidepressant treatment. All patients, regardless of antidepressant treatment response, exhibited parallel improvement on 12-week follow- up neuropsychological examination. These findings suggest that treatment of depression affects cognitive complaints in HIV-1 individuals and that cognitive complaints of patients in asymptomatic or early symptomatic stages of HIV-1 infection may signal the need for evaluation of depression. In patients with more advanced HIV-1 infection, investigation into the basis of cognitive complaints may require a dual assessment of mood disturbance and neuropsychological status.

Delirium in AIDS patients: recognition and medication factors.

The purpose of this study is to determine the frequency of delirium in AIDS patients residing at a skilled nursing facility and to identify factors and outcomes associated with delirium episodes. Medical records were reviewed for 137 patients discharged from or dying at the facility in 1994. Presence or absence of delirium was determined using the Confusion Assessment Method. Patients with delirium were compared to those without delirium regarding demographics, medical conditions, and medication exposure using Mann-Whitney U, chi-square, and two-tailed t-tests. A model for delirium based on medication exposure was determined using multiple logistic regression. Forty-six percent of patients (n = 63) were determined to have at least one delirium episode; only one episode was diagnosed at the time of occurrence. Associated medical conditions included medication changes (44%), fever (38%), and infection (26%). Narcotics, benzodiazepines, anticholinergic/antihistaminic, and steroid medications each contributed significantly to the model for delirium (chi 2 = 60.19; df = 4; p = 0.0000). The authors concluded that delirium is a common yet underidentified condition in AIDS patients, and that patterns of medication use contribute to a large number of delirium episodes.

Psychiatric comorbidity and length of stay in hospitalized AIDS patients.

OBJECTIVE: The purpose of this study was to assess the effect of psychiatric comorbidity on specific measures of hospital utilization, including length of stay, among hospitalized AIDS patients. METHOD: Data collection involved medical record abstraction for AIDS patients admitted to any one of 19 hospitals in Washington State during 1990. Psychiatric comorbidity was defined by the presence of an ICD-9 code reflecting psychiatric illness. Medical/surgical admissions of AIDS patients with psychiatric diagnoses were compared to those of AIDS patients without psychiatric diagnoses on measures of mean length of stay for the first admission in 1990, total number of hospitalizations in 1990, and total number of hospital days in 1990. Medical morbidity was addressed using CD4+ cell count and current and previous AIDS-defining illnesses as markers of disease severity. RESULTS: Of 357 patients hospitalized with AIDS, 49 (14%) had at least one psychiatric diagnosis. Patients with psychiatric illness were hospitalized an average of 6.6 days longer than AIDS patients without such illnesses. Differences in medical morbidity did not account for the longer length of stay. CONCLUSIONS: Psychiatric comorbidity increased the average length of stay among hospitalized AIDS patients. Future research needs to address the possible effects of this phenomenon on quality and cost of care received by AIDS patients.