Research Article: Symptom Status Predicts Patient Outcomes in Persons with HIV and Comorbid Liver Disease

Date Published: October 3, 2012

Publisher: Hindawi Publishing Corporation

Author(s): Wendy A. Henderson, Angela C. Martino, Noriko Kitamura, Kevin H. Kim, Judith A. Erlen.


Persons living with human immunodeficiency virus (HIV) are living longer; therefore, they are more likely to suffer significant morbidity due to potentially treatable liver diseases. Clinical evidence suggests that the growing number of individuals living with HIV and liver disease may have a poorer health-related quality of life (HRQOL) than persons living with HIV who do not have comorbid liver disease. Thus, this study examined the multiple components of HRQOL by testing Wilson and Cleary’s model in a sample of 532 individuals (305 persons with HIV and 227 persons living with HIV and liver disease) using structural equation modeling. The model components include biological/physiological factors (HIV viral load, CD4 counts), symptom status (Beck Depression Inventory II and the Medical Outcomes Study HIV Health Survey (MOS-HIV) mental function), functional status (missed appointments and MOS-HIV physical function), general health perceptions (perceived burden visual analogue scale and MOS-HIV health transition), and overall quality of life (QOL) (Satisfaction with Life Scale and MOS-HIV overall QOL). The Wilson and Cleary model was found to be useful in linking clinical indicators to patient-related outcomes. The findings provide the foundation for development and future testing of targeted biobehavioral nursing interventions to improve HRQOL in persons living with HIV and liver disease.

Partial Text

Since the introduction of highly active antiretroviral therapy (HAART), survival of persons living with human immunodeficiency virus (HIV) has dramatically improved. Five-year survival rate among patients following World Health Organization (WHO) standard therapies reaches approximately 75% [1]. The result is that persons living with HIV are more likely to suffer significant morbidity and mortality from other disorders such as liver disease (LD) and its related complications (anemia, end stage liver disease, lipodystrophy, and hepatocellular carcinoma) than from HIV [2]. Because of the toxic and metabolic effects of antiretroviral medications on the liver and coinfection with LD, the number of persons living with HIV and LD is increasing [3–6].

A total of 532 individuals living with HIV (305 with HIV and 227 with HIV and LD) were included in the study. There were no significant differences between the groups with regard to gender, race, employment status, and household income. However, subjects with HIV and LD were significantly older and less educated than the HIV group without LD (Table 1). Participants had a mean CD4 count of 455 cells/mm3 (range 44–1540 cells/mm3) and 59% of the overall sample had an undetectable HIV viral load (Table 2). The classifications of types of comorbid LD are noted in Table 3. All others without evidence of LD were classified as HIV.

This study applied a sophisticated statistical analysis, SEM, to test a theoretical model of HRQOL as described by Wilson and Cleary. The assessment of HRQOL is useful not only for capturing important facets of a person’s self-perception of how illness affects daily functioning, but also as a valid measure of clinical outcome when assessing interventions. This model, as initially conceptualized by Wilson and Cleary, has been found useful to describe HRQOL in persons living with HIV. However, persons living with HIV have an increased risk of developing liver disease as related to toxic effects of antiretroviral therapy yielding hepatitis and other liver disease. These findings are similar to other studies that have used the Wilson and Cleary model in clinical samples with heart failure, gastrointestinal bleeding, diabetes, and Hodgkin’s lymphoma. Therefore, the model proposed by Wilson and Cleary has now been supported in a sample of individuals with HIV and LD.

The findings of this research show that both health-related factors, such as CD4 count and HIV viral load, and social factors, such as self-reported mental health and depressive symptoms, are important indicators of HRQOL in this sample of persons living with HIV (N = 532). These findings imply that symptom status, specifically depressive symptoms and altered mental function, is a key issue in determining HRQOL in persons with HIV without LD and in persons with HIV and LD.