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Article Excerpt
ALCOHOLISM AND HIV INFECTION each have negative effects on objectively measured health status and self-assessed health-related quality of life (HRQOL; Donovan et al., 2005; Douaihy and Singh, 2001). Each disease also has independent deleterious effects on the brain and associated cognitive and motor behavior (Pfefferbaum et al., 2002). Further, the use of alcohol not only increases risk behaviors associated with acquisition of HIV infection (Stein et al., 2005), but may lead to progression of HIV infection by contributing to immune suppression (Wang and Watson, 1995), reducing medication adherence (Kresina et al., 2002; Samet et al., 2004a), and blocking effectiveness of therapeutic regimens (Miguez et al., 2003). Analysis of a national probability sample (Galvan et al., 2002) found that 8% of patients with HIV infection reported heavy alcohol consumption. Studies based on HIV clinic attendees (Cook et al., 2001; Lefevre et al., 1995; Miguez et al., 2003; Page-Shafer et al., 1996; Samet et al., 2004b) report significant alcohol use in up to 63% of HIV patients. Whether excessive alcohol use most commonly precedes or follows HIV infection is usually not explicitly investigated; however, attention increasingly is being paid to the deleterious effects of their coexistence in individuals (Cook et al., 2001; Petry, 1999; Samet et al., 2003, 2004a,b) as well as their impact on medication compliance (e.g., Braithwaite et al., 2005). Other disorders, especially depression (Bing et al., 2001), hepatitis C virus (HCV) infection (Hilsabeck et al., 2005), and nonalcohol substance abuse (Bing et al., 2001), are also highly prevalent in HIV-infected populations. The chronic nature of alcoholism and HIV infection means that people affected by both disorders must cope with these illnesses and their associated morbidities for decades. Thus, it is important to consider how combinations of conditions exacerbate health-related quality of life and what factors, if any, may mitigate their impact.
HRQOL is a multidimensional concept. It reflects the patient's own experience of the effect of their state of health on their daily activities and sense of well-being. A number of HRQOL instruments have been developed, some generic to any illness (Coons et al., 2000) and others specifically focused on HIV-related disease (Davis and Pathak, 2001). Such instruments have been widely used to assess self-perceptions of health and functioning in patients with HIV/ AIDS (for review, see Douaihy and Singh, 2001) and alcoholism (for review, see Donovan et al., 2005), and have established reliability and validity (Coons et al., 2000). The focus on self-assessment differentiates these instruments from either clinician ratings (e.g., the Global Assessment of Functioning [GAF; Endicott et al., 1976], an overall rating made as part of the Structured Clinical Interview for DSM-IV [SCID-IV; First et al., 1998] that is based on psychiatric symptoms as well as occupational and social functioning) or objective markers of disease severity (e.g., viral load, CD4 T-cell count, Centers for Disease Control and Prevention [CDC] stage for HIV patients, or quantity and recency of excessive alcohol consumption for alcohol-dependent patients).
Among patients with HIV infection, comorbidity of psychiatric conditions, particularly depression (Douaihy et al., 2003; Orlando et al., 2005; Sherbourne et al., 2000; Tate et al., 2003; Trepanier et al., 2005; Vitiello et al., 2003) and substance abuse (Bing et al., 2001; Dausey and Desai, 2003), are usually associated with lower HRQOL. The contribution of alcohol consumption to HRQOL in HIV-infected individuals has been less well studied. One study reported that "heavy drinking" (>3 drinks at least half of the days in the last 4 weeks) did not affect HRQOL (Sherbourne et al., 2000), whereas another study found lower HRQOL in the subgroup of HIV-infected patients who reported hazardous drinking (>14 drinks/week or >4 drinks/occasion) at study entry (Jia et al., 2005).
Associations between lower HRQOL and HIV markers of greater disease severity (e.g., viral load, CD4 count, or CDC stage) have been reported cross-sectionally (Burgess et al., 1993), longitudinally (Weinfurt et al., 2000), and predictively (Jia et al., 2005) in some studies, but not in others (Burgoyne and Saunders, 2001). HIV-infected people improve or maintain HRQOL levels with HIV treatment (Cohen et al., 2001; Richardson et al., 2002; Suarez et al., 2001), and alcoholics show HRQOL improvement with abstinence (Foster et al., 1999, 2000b).
Several studies have demonstrated that among people with HIV infection, those of higher cognitive status report better HRQOL (Kaplan et al., 1997; Pandya et al., 2005; Tozzi et al., 2003; Trepanier et al., 2005). Cognitive reserve, reflected in educational background and premorbid cognitive performance, has also been shown to enhance survival in patients with persistent viremia despite treatment (Tozzi et al., 2005), mediate 12-month decline in neuropsychological functioning in patients with stable HIV status (Basso and Bornstein, 2000), and mitigate the early emergence of HIV-related cognitive deficits (Pereda et al., 2000; Satz et al., 1993; Stern et al., 1996).
Drawing on the above observations, we sought to test the hypothesis that patients with combined HIV infection and alcohol dependence would manifest poorer HRQOL than patients equivalently ill with either condition alone. We also hypothesized that current depressed mood would reduce HRQOL but that cognitive reserve would enhance HRQOL. Toward this end, we assessed HRQOL using an instrument based on the Medical Outcomes Study Short Form-36 (Bozzette et al., 1995), which assesses recent health limitations on functioning in different domains. Our sample comprised groups of men and women with alcohol dependence or abuse (alcohol), HIV infection (HIV), and both conditions combined (alcohol + HIV) as well as a comparison group of healthy individuals unaffected by any disease (control). Illness severity, presence of other psychiatric conditions, and current mood state were also assessed in each group.
Method
Participant recruitment and screening
Patients were recruited by referral from several San Francisco Bay Area outpatient HIV/AIDS and alcohol and substance abuse treatment centers and by means of presentations and outreach. Control subjects were recruited by referral from patient participants, Internet posting, newspaper advertisements, flyers, and word of mouth. Initial phone screenings excluded subjects who reported symptoms consistent with schizophrenia, bipolar disorder, neurological disease not related to alcohol use or HIV, nonalcohol drug abuse or dependence in past 3 months, or inability to undergo magnetic resonance imaging (MRI) scanning. A nurse then obtained informed consent, took a brief medical history, and obtained a blood sample to confirm HIV status and T cell count. HIV patients with T cell count < 100 or Karnofsky score (Karnofsky, 1949) < 70 (can care for self but unable to carry out normal activity) were excluded from the study.
Participants were further screened using the SCID-IV (First et al., 1998) administered by clinical psychologists (S.A.S. and A.O.) to (1) identify patients who met criteria for alcohol dependence or abuse; (2) exclude subjects who met lifetime criteria for schizophrenia or bipolar disorder, or for nonalcohol substance dependence or abuse within the prior 3 months; (3) identify any patients who met criteria for a depressive or anxiety disorder; and (4) confirm that prospective controls did not meet DSM-IV criteria for any Axis-I disorder (American Psychiatric Association, 1994). A history of alcohol consumption (Pfefferbaum et al., 1992; Skinner, 1982; Skinner and Sheu, 1982) that elicited quantity and frequency of drinking during subject-defined drinking epochs was also obtained. This yielded measures of total lifetime consumption of alcohol and time since last drink. Participants were assigned to one of four groups on the basis of this assessment: (1) HIV-infected patients who had never met criteria for alcohol dependence or abuse and had never consumed an average of more than six drinks per day for men, or four per day for women, over any 30-day period (HIV), (2) HIV-infected patients who also met criteria for alcohol dependence or abuse within the past 3 years (alcohol + HIV), (3) patients who met lifetime criteria for alcohol dependence within the past 3 years but were not HIV-infected (alcohol), and (4) a control group who were neither HIV infected nor met criteria for alcohol dependence/abuse or other Axis-I diagnoses.
Subject descriptions
Once admitted to the study, all HIV patients underwent a series of structured interviews designed to characterize...
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