Stable partnership and progression to AIDS or death in HIV infected patients receiving highly active antiretroviral therapy: Swiss HIV cohort studyBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7430.15 (Published 01 January 2004) Cite this as: BMJ 2004;328:15
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very interesting paper, Young et al found that a stable partnership was
associated with a slower rate of disease progression in HIV-infected people
receiving highly active antiretroviral therapy. The Authors speculated that a
stable partnership may be linked to drug adherence and less depression.
They concluded that lack of a stablepartnership may be an important information for the clinical
progression of HIV infection.
We believe that characteristics of partners may differently influence the
health status of persons living with HIV. Moreover, particular attention must
be paid by gender-oriented approach when conducting analyses on social and psychological factors that may influence
In fact, in a study we conducted on
women of the Italian Cohort of HIV infection previously Naïve to
Antiretrovirals (ICONA Study) we found that having a current intravenous drug
user (IDU) partner was associated to significantly lower level of mental health
even when adjusted for several confounders.
ICONA is an Italian multicenter observational
study on the natural history of HIV disease among adults previously naïve to
antiretrovirals. Within the ICONA cohort, the Behavioural Epidemiology (BEHEPI)
Study investigates behavioural and health status of the enrolled HIV-infected
persons. Participants were asked to complete a self-administered questionnaire
including items on psychological well-being, personal behaviour (self-reported
HIV acquisition modality, lifetime number of sex partners, sexual intercourses
in the last two weeks, having a current IDU partner) as well as demographic
characteristics. The psychological well-being was measured through a five-item
scale with five-point responses (BEHEPI Psychological Well-being scale –
B-PWBS). Answers to the Scale were summed and the result was linearly
transformed in a 0 to 100 score. The scale included the most frequently used
items for measuring the psychological well-being and was built after a focus
discussion with HIV experts and people living with HIV. We aimed to obtain a
very brief tool for the screening of impaired psychological well-being.
From March 1998 to March 2000, 746 women
participated into the BEHEPI Study. Missing data for the B-PWB Scale ranged
from 4.6 to 5.5% among the five items and 7.4% for the whole Scale. The
validity of the B-PWB scale, evaluated through the internal consistency, was
good (Cronbach’s alpha: 0.81). Median of the B-PWB Scale was 55 (IQR 35-70);
0.5% of patients scored 0 (minimum) and 1.1% scored 100 (maximum).
age of enrolled women was 32 years (interquartile range, IQR, 28-36), 33% was
unemployed, 37% IDUs, 8% had CDC-defined AIDS: mean of CD4 was 460 (IQR
300-633) and median log of plasma HIV RNA was 4.1 (IQR 3.4-4.7). At enrolment,
no women were receiving antiretroviral therapies. Fifty-five out of 746 (9.7)
women reported a current IDU partner. Women with a current IDU partner has a
17-fold probability (95% CI 7.6-38.8; p<_.0001 to="to" be="be" currently="currently" idu="idu" themselves="themselves" compared="compared" women="women" who="who" did="did" not="not" reported="reported" a="a" current="current" partner.="partner." fifty-three="fifty-three" percent="percent" of="of" had="had" sexual="sexual" intercourses="intercourses" in="in" the="the" _2="_2" weeks="weeks" before="before" survey.span="survey.span" style="mso-spacerun: yes"/>
multiple linear regression analysis was performed to identify variables
independently associated with the B-PWB Scale scores (see Table). Having a
current IDU partner was associated with lowest values of the psychological
well-being scale. The multivariate analysis suggested that this association was
independent from past or current use of drugs .Results were similar when we
considered as IDU only current IDU women (n=37) (data not shown).
Our results suggest that a focused analysis of
familiar and social characteristics may be helpful in identifying determinants
of health status since even a stable partnership may be associated to a mental
health impairment if partner is a current IDU. We did not analyze the potential
association of type of partner with clinical course of HIV infection. However,
several published papers demonstrated that depression or mental health
impairment are associated to a suboptimal adherence to drugs and then to worse
outcomes of therapy. In conclusions, we believe that healthcare professionals
should concentrate their attention on further
relevant variables for clinical progression such as partner’s HIV status
social support and stress life events.
Variables associated to the B-PWB Scale scores. Multiple linear regression
General and clinical characteristics
1.36 ; 9.05
-20.81 ; -7.90
In his remarkable paper, Young and colleagues (1) documented, using
data from a large cohort of HIV-infected persons, that a stable
partnership is associated with a slower rate of progression to AIDS or
death in persons taking highly active antiretroviral therapy.
In our opinion, it would be of great interest to know the
serological status for HIV infection of the partner/s. Although this data
is not always recorded in large cohort populations, its relevance,
considering the favorable impact of stable partnership on HIV progression,
is supported by two main considerations: first, in stable sero-concordant
couples, sharing the same experience, feelings, doubts and worries about
HIV-infection and its therapy could have a positive effect on adherence
and tolerability of antiretrovirals. Secondly, patients with unstable
partnerships might expose themselves to a greater risk for HIV super-
infection if they engage unprotected intercourse with other HIV-infected
persons (2). Even if no studies have investigated HIV super-infection in
large patient populations, it has been shown that it may favor viral
synergism (3). Moreover, for HAART-treated patients HIV super-infection
could turn into the generation of recombinat viruses with increased
resistance to antiretroviral drugs leading to limited future therapeutic
options and faster rate of disease progression (4).
Adriana Ammassari*, Maria Paola Trotta§, Andrea Antinori#
* Clinical Researcher in Infectious Diseases. Clinic of Infectious
Diseases, Catholic University, L.go A. Gemelli 8, 00168 Rome, Italy
§ Clinical Researcher in Infectious Diseases. National Institute for
Infectious Diseases “Lazzaro Spallanzani” IRCCS, Rome, Italy
# Chief of Clinical Department. National Institute for Infectious Diseases
“Lazzaro Spallanzani” IRCCS, Rome, Italy
1. Young J, De Geest S, Spirig R, Flepp M, Rickenbach M, Furrer H, et al.
Stable partnership and progression to AIDS or death in HIV infected
patients receiving highly active antiretroviral therapy: Swiss HIV cohort
study. BMJ 2004;328(7430):15
2. Jost S, Bernard MC, Kaiser L, Yerly S, Hirschel B, Samri A, et al. A
patient with HIV-1 superinfection. N Engl J Med 2002;347:731-736.
3. Wang B, Lal RB, Dwyer DF, Miranda-Saksena M, Boadle R; Cunningham Al,
Saksena NK. Molecular and biological interactions between two HIV-1
strains from a coinfected patient reveal the first evidence in favor of
viral synergism. Virology 2000;274:105-109.
4. Blackard JT, Cohen DE, Mayer KH. Human Immunodeficiency virus
superinfection and recombination: current state of knowledge and potential
clinical consequences. Clin Infect Dis 2002;34:1108-14.
Competing interests: No competing interests
It is my hypothesis (1985) that low DHEA produces vulnerability to
the AIDS virus. (The term "HIV" did not exist at the time.)
Subsequently, I decided that the symptoms of AIDS actually represent loss
of DHEA. The first reports of low DHEA in AIDS appeared in 1989. Since
that time the symptoms of AIDS have been connected with low DHEA.
It is also my idea that cortisol and testosterone antagonize the
effects of DHEA. There are numerous reports of the adverse effects of a
high cortisol to DHEA ratio in AIDS / HIV disease. These effects of
cortisol and testosterone may explain the findings of Young, et al. In
2003, Burnham, et al., repoted: "Results revealed that men in committed,
romantic relationships had 21% lower testosterone levels than men not
involved in such relationships." (Hormones and Behavior 2003; 44(2): 119-
Now, if the subjects of Young, et al., are of higher testosterone
and, therefore, do not remain in committed relationships, then their
increased testosterone would adversely affect their levels of DHEA. If
the partners of the subjects of Young, et al., have high testosterone and,
therefore, leave the relationship, then the cortisol which occurs as a
result would adversely affect their levels of DHEA. Also, any loss of
partnership will also increase cortisol. These situations, or
combinations thereof, will reduce the effects of DHEA.
I suggest the findings of Young, et al., reflect a more stable level
of DHEA in the subjects of this study.
Competing interests: No competing interests