Fatigue among HIV-positive patients in the era of highly active antiretroviral therapy

A study published in the September issue of HIV Medicine showed a high level of fatigue in patients attending a specialist HIV clinic in South London in the post-HAART era.

The cross-sectional study covered a five-month period in 2002. Participants completed four self-administered questionnaires measuring fatigue, functional status, anxiety and depression, and illness perception.

Of the 205 patients approached, 148 agreed to participate, 65% of who were defined by the questionnaires as fatigued (95% CI 57-73%). Significant psychological distress (86% vs 34%, p<0.001) and functional impairment were both significantly associated with fatigue, but there was no association with HAART use or demographics.

There was a trend for patients reporting fatigue to have higher CD4 counts – which was not explained by use of HAART – and neither HAART use, nor particular regimens were strongly associated with fatigue. There was also a trend towards fatigued patients perceiving the impact of their illness more seriously than non-fatigued patients. This also registered as a poorer quality of life, and suggested that fatigued patients feel they have little control over their condition.

The figure of 65% is at the higher end of prevalence reported in previous HIV studies, but is similar to levels seen in other chronic illnesses including heart disease, lupus and rheumatoid arthritis. Sixty-eight per cent of the participants were identified as psychologically distressed and this was strongly associated with fatigue.

The study volunteers compared to the clinic population were more likely to be male (78% vs 68%), gay or bisexual (60% vs 38%) or on HAART (81% vs 68%), and less likely to be black African or black Caribbean (35% vs 43%).

The authors commented that the strong association between psychological distress and markers of quality of life has implications for the clinical management of fatigue in HIV-positive patients. Firstly, it suggests that the symptom of fatigue should elicit not only a search for physical mechanisms, but also detailed questioning about depression and anxiety. Secondly, the high rates of psychological distress described here suggest that a proportion of patients have significant depression or anxiety that may benefit from specific interventions, such as antidepressant medication, which may also improve fatigue. Thirdly, there is growing evidence that non-pharmacological treatments such as cognitive behaviour therapy and graded exercise therapy are effective in the treatment of medically unexplained fatigue occurring in chronic fatigue syndrome [50-52]. Such treatments aim to help improve functioning by giving patients strategies for managing fatigue. Given the high prevalence, and apparently serious consequences for functional capacity, of fatigue in individuals with HIV infection, there is a need for further evaluation of these interventions in the HIV-positive patient population.

Comment

Selection bias could have influenced these finding either way – with fatigued patients being more inclined to participate or conversely, and perhaps indicated by these results, feeling less motivated in their general healthcare. Patient management and outcome would ideally need to be reported in a prospective study following patients over time, that this cross-sectional study could not access. Fatigue is additionally a symptom of hepatitis C disease and hepatitis coinfection was not recorded in this study.

Henderson M, Safa F, Easterbrook P et al. Fatigue among HIV-infected patients in the era of highly active antiretroviral therapy. HIV Medicine Volume 6 Issue 5 Page 347, September 2005. Text available:
http://www.natap.org/2005/HIV/091505_03.htm