HIV Symptom Management and Quality of Life

Since the advent of highly active antiretroviral therapy, persons with human immunodeficiency virus (HIV) are generally living longer. Viral loads have diminished to undetectable levels, CD4 cell counts have in-creased, and opportunistic infections have become more manageable. However, persons with HIV frequently reported increased medical and disease-related symptomatology (Kirksey et al., 2002). Therefore, client-initiated or provider-directed symptom management has become an increasingly important component of care. The primary objective of nursing interventions is to enhance health related quality of life (HRQOL) for persons with HIV.

Symptoms are primary reasons why individuals seek health care (Lee, K., & Carrieri, 2003). A symptom is “any condition accompanying or resulting from a disease or physical disorder and serving as an aid in diagnosis” (Webster’s New World College Dictionary, 2001, p. 1451). Symptoms are subjective phenomena that indicate a departure from normal functioning, sensation, or appearance. These entities are a person’s perception of abnormal physical, emotional, or cognitive states. I. B. Wilson and Cleary (1995) described symptom reporting as an expression of subjective experiences that summarize and integrate data from an array of different sources. Several authors have noted that when symptom control is not achieved, quality of life can be adversely affected (Holzemer, Spicer, Wilson, Kemppainen, &Cole-man, 1998; Lee, K., & Carrieri).


The University of California, San Fran-cisco, School of Nursing Symptom Management Faculty Group (1994) defined symptoms as subjective experiences based upon cognitive changes, sensation, or biopsychosocial function. The model is comprised of three interrelated dimensions: symptom experience, management strategies, and outcomes.
The first category reflects an individual’s perception of a symptom. The second category, management strategies, includes self-care behaviors. And the last category, symptom outcomes, may include entities like HRQOL. The University of California, San Francisco (UCSF) International HIV Nursing Re-search Network has conducted a number of multisite studies in order to identify the pervasive symptoms and self-care management strategies used by persons with HIV. Among the most frequently reported symptoms were: anxiety, depression, fatigue, and neuropathy. The following sections contain brief summaries of recent scientific studies related to each of these symptoms.
According to Kemppainen and others(2003), anxiety is one of the most prevalent symptoms experienced by persons with HIV. Dew and colleagues (1997) noted that clients with a prior history of an anxiety disorder prior to being diagnosed with HIV were at greater risk of recurrence of symptoms. Precipitating factors may include lack of partner support and inability to master or control life events. J. G. Johnson, Williams, Rabkin, Goetz, and Remien (1995) found a relationship between preexisting personality disorder and the onset of HIV-related anxiety. The researchers compared 52 HIV-negative and 110 HIV-positive men, 19% of whom had a preexisting personality disorder. Participants in the HIV-positive group displayed greater levels of anxiety than those persons in the HIV-negative group. In another study with a similar premise, Ferrando and colleagues (1998) noted a relationship among depression, substance use, and prevalence of anxiety in an ethnically-diverse sample of 267 HIVnegative and HIV-positive males. HIV-positive participants (n = 183) who continued to use illegal substances reported higher levels of emotional stress. Neidig, Smith, and Brashers (2003) postulated that aerobic training may assist in reducing or preventing depression symptoms experienced by persons living with HIV. Sixty HIV-infected adults participated in a randomized controlled trial where clients were subjected to a 12-week aerobic exercise training program. When compared with the control group, participants in the exercise group showed significant reductions in depressive symptoms.
In another study using a telephone support group for HIV-positive persons over the age of 50 years, Nokes, Chew, and Altman (2003) determined that identifying symptoms and exploring the use of effective medications and treatments aided in reducing depression.
Fatigue is a common symptom of HIV and is associated with impaired physical functioning and poor HRQOL(Breitbart et al., 1998). Piper, Lindsey, and Dodd (1987) defined fatigue as “a subjective feeling of tiredness that is influenced by circadian rhythm. It can vary in unpleasantness, duration and intensity” (p. 19). Some researchers (Capaldini, 1998; Perkins, D. O., et al., 1995; Walker, K., McGowan, Jantos, &Anson, 1997) have postulated that there is a correlation between depression and fatigue in persons with HIV infection.
However, others (Breitbart et al., 1998; Fer-rando et al., 1998) disagreed and observed that although it is associated with depression, fatigue makes a separate contribution to morbidity in HIV-infected persons. Nicholas and colleagues (2002) stated that peripheral neuropathy is “the most commonneurological complication in HIV disease” . These investigators noted that neuropathy was the third most frequently reported symptom in a convenience sample of422 persons living with HIV. Forty-four percent of the self-care management strategies were categorized as complementary or alternative therapies; however, there was lack ofconsensus about the efficacy of these interventions. Quality of life is a perception of circumstances which is dependent upon psychological makeup. The central assumption is that individuals are the best sources of judgment about HRQOL, and it cannot be assumed that everyone will value life circumstances in the same way. Burgoyne and Saunders (2001) stated that quality-of-life assessment involves an appraisal of one’s current state against some ideal. Goal attainment, coping, decision-making assessment, and value systems are examples of predictors of HRQOL. Kemppainen (2001) examined whether or not variables relating to sociodemographic attributes, illness severity, and psychological status predict quality of life in persons with HIV. Using a convenience sample (n = 162), the author found that the strongest predictor of decreased HRQOL scores was depression.
Additionally, the investigator noted that the number of symptoms also had a profound effect on HRQOL. In another study, Sousa, Holzemer, Henry, and Slaughter (1999) performed a secondary analysis (n = 142) to empirically test the influence of symptom status, functional status, and general health perceptions on overall HRQOL in persons living with HIV. Analysis suggested that these variables were key dimensions of HRQOL. The investigators concluded that focusing nursing interventions on decreasing symptoms or assisting the client in identifying self-care management strategies positively affects general health perceptions and enhances overall HRQOL. Douaihy and Singh (2001) noted that “physical manifestations, antiretroviral therapy, psychological well-being, social support systems, coping strategies, spiritual well-being, and psychiatric comorbidities are important predictors of QOL...”.

This review presented select articles addressing symptom identification and management as correlates to HRQOL in persons with HIV infection. Scholarly endeavors concerning quality of life have helped shape standards of care by broadening conceptualizations of outcome measures. However, additional scientific studies designed to explore the efficacy of complementary and alternative therapies, as well as public discourse on symptom management strategies related to quality-of-life enhancement, are still needed.