The relationship between distress and risk of progression to AIDS early versus later in the natural history of HIV disease has not been well studied. Most studies of depressive symptoms and HIV progression have focused on long-term outcomes, with five years to eight years of follow-up. More transient factors such as psychological distress may warrant a shorter follow-up period because its effects may only be relevant in the shorter term.

Regardless of length of follow-up, the association between psychological factors and progression to AIDS has not been well documented among cohorts of male and female injection drug users (IDUs), despite the fact that psychiatric disturbance is highly prevalent in this population. Researchers investigated whether distress was independently associated with more rapid progression to AIDS among HIV-infected IDUs.

Study subjects were IDUs enrolled in the AIDS Link to Intravenous Experiences Study, an ongoing prospective cohort study of HIV infection among IDUs in Baltimore. Followed from 1988 through 1999, a total of 451 IDUs met the eligibility criteria of being HIV-positive but AIDS-free at baseline. A follow-up questionnaire included 11 items designed to assess recent psychological distress, with a score of "1" indicating a distress factor and a score of "0" indicating the lack thereof, for each item. Three items considered possibly related to HIV symptoms were removed. Because distress is widely viewed as a transient state and its predictive potential over the long term was unclear, the researchers also restricted the primary outcome (time to clinical AIDS through December 31, 1999) to within the first two years of follow-up.

Of the sample, 76.3 percent were male and 95.8 percent were African-American. The mean age was 34.2 years (median 33.9). Among the 451 participants, 106 were distressed at baseline, corresponding to a distress score more than or equal to three (0= minimally distressed, 8= maximally distressed). Low baseline CD4 lymphocyte count (below 200 cells/mm3) and female gender were significantly associated with psychological distress. There were 32 cases of clinical AIDS diagnosed within two years of the baseline visit in this cohort, corresponding to a 7.1 percent cumulative incidence rate.

The distribution of scores showed that 43.7 percent of the AIDS participants were distressed, whereas only 22 percent of the non-AIDS patients were distressed. Kaplan-Meier survival curves showed participants who were distressed were significantly more likely to develop AIDS within two years than were those who were not distressed.

Univariate analysis showed that those who developed clinical AIDS within two years of baseline were significantly more likely to have both lower baseline CD4 cell counts and a higher baseline HIV-1 viral load. In addition, psychological distress was independently associated with a shorter time to AIDS (relative hazard [RH]=2.65).

In multiple regression analysis, when controlling for CD4 cell count and HIV-1 viral load, those who were distressed had a significantly shorter time to AIDS than did those who were not distressed (adjusted RH=2.64). When controlling for CD4 cell count, viral load and oral candidiasis, the association between distress and HIV progression was slightly diminished but significant (RH=2.39). Stratified by baseline CD4 count, distress was only significantly associated with time to AIDS among those with CD4 counts less than 200 x 106/L (adjusted RH=4.94).

Distress was not independently associated with time to death within two years of baseline (RH=.90), within three years of baseline (RH=1.41), or through December 1999 (RH=.88). Controlling for CD4 count and viral load in multiple regression models, psychological distress was not associated with time to death within two years of baseline (adjusted RH=.84), within three years of baseline (adjusted RH=1.31) or through December 1999 (adjusted RH=.94).

"The major finding of this study was that psychological distress was significantly associated with more rapid onset of AIDS among IDUs over a 2-year follow-up period, even when controlling for CD4 cell count, HIV viral load, and oral thrush," the study authors wrote. However, psychological distress "was not predictive of mortality in this cohort. Further study of the effects of psychological distress on AIDS progression within this population is warranted," they concluded.

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