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EDITORIAL |
Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (Leserman)
Department of Medicine, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD (Temoshok)
Address correspondence and reprint requests to Jane Leserman, Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160. E-mail: JLes{at}med.unc.edu
A quarter of a century ago, the fields of psychosomatic and behavioral medicine were roads less traveled in medicine. Psychological and behavioral factors must have seemed irrelevant to the early biomedical researchers and clinicians working fervently to understand the mystifying set of symptoms and diseases composing what would eventually be called Acquired Immunodeficiency Syndrome (AIDS). The potential role of psychological factors appeared even less germane after the 1984 discovery that AIDS was an infectious disease caused by the Human Immunodeficiency Virus (HIV). Despite the odds against finding more than a minor role for psychosocial variables in HIV/AIDS progression, intrepid researchers embarked on what was then a lonely footpath to study the psychoneuroimmunology of this disease. Without defined disease markers, reliable prognostic indicators, or known immune mechanisms of progression, it was a dubious journey at the onset.
Still, it is undeniable that there is considerable individual variability in HIV disease progression. Why do some people stay healthy for so many years that they are called "long-term survivors" or "long-term nonprogressors" (persons with known HIV infection of 8–10 years who maintain a CD4+ cell count over 500 in the absence of therapy), while others show a rapid decline in immunity and succumb within a year or two of first showing symptoms to opportunistic infections? Could psychological factors such as stress and depression shed some light on these individual differences in disease course? In the past two decades, there has been a plethora of research documenting the effects of psychosocial variables (eg, depression, stress, coping) on HIV disease progression, prognostic disease indicators, adherence to medications, risky sexual behavior, and other behavioral factors relevant to HIV disease course and transmission. The goal of this issue of Psychosomatic Medicine is to acquaint researchers and clinicians caring for HIV-infected persons with what has become a well-traveled road of research that documents the critical importance of psychological, social, and behavioral influences on biomedical aspects of HIV/AIDS.
Psychosomatic and behavioral medicine research in HIV includes studies ranging from the importance of stress and depression on HIV disease progression to the efficacy of behavioral interventions on disease markers and behavioral risk factors. Despite this impressive literature, most of these studies have been published in psychologically oriented journals, and as a result, have had a limited impact on therapeutic strategies in biomedical research, and the day-to-day care of HIV-infected patients. Too often, researchers in behavioral medicine and psychoneuroimmunology talk among ourselves and not with our intended audience—or potential collaborators and colleagues. Thus, by publishing this compendium of comprehensive, yet succinct reviews of important biobehavioral literature, we aim to have an impact on the clinical care of HIV infected patients. We hope that this issue will serve as a catalyst to broaden the treatment of HIV-infected patients to include routine monitoring of mental health and behavioral risk factors, and referrals for psychological, behavioral, and psychiatric interventions when appropriate. Ideally, we hope to stimulate collaborations between biomedical and biobehavioral clinicians and researchers, working as a team to investigate both psychosocial and biological factors contributing to HIV disease progression, thereby improving quality and quantity of life for HIV-infected persons.
This issue begins, appropriately, with an overview of HIV/AIDS so that readers of Psychosomatic Medicine who are unfamiliar with the biological intricacies of the disease can get a basic orientation (1). The overview includes such issues as HIV/AIDS prevalence, the HIV virus and its life cycle, HIV disease progression, transmission, testing, antiretroviral therapies, and drug resistance. Next, Whetten and colleagues describe the HIV patient population in terms of the alarming prevalence of past trauma including sexual and physical abuse, depression, post-traumatic stress disorder, and anxiety (2). Issues of social stigma faced by HIV-infected persons and the particular challenges faced by women with HIV infection are also discussed. Given the high prevalence of psychosocial disturbance, Leserman reviews the extensive evidence that stress, depression, and past trauma are related to worsening of immune parameters, progression of HIV infection, and faster mortality, both before and after the advent of highly active antiretroviral therapies (HAART) (3). From the other side of the coin, Ironson and Hayward show that positive psychosocial factors including optimism, positive affect, active coping, and spirituality can have protective effects on the course of HIV infection (4). Taking this another step, Temoshok and colleagues describe how chronic patterns of coping with stress (eg, denial, avoidance, Type C or reduced expression of emotions, and physiological reactivity) are related to HIV disease progression and/or prognostic indicators, and potential progression and antiprogression factors that may mediate these relationships (5). Cole explores possible neuroendocrine mechanisms that might contribute to or mediate the relationships between psychosocial variables and HIV disease progression (6). Behavioral mechanisms (eg, adherence, alcohol/substance abuse, risky sexual behavior) that might contribute to or mediate the relationships between psychosocial variables and disease progression in HIV are reviewed by Gore-Felton and Koopman (7).
Having documented the relationship of positive and negative psychosocial factors with HIV disease progression and the possible physiological and behavioral mediators, we next turn to interventions. What can we do about stress and depression, and how can we encourage positive coping? Carrico and Antoni provide an authoritative summary of the randomized controlled studies testing the efficacy of psychological interventions (eg, cognitive behavioral, meditation/relaxation, bereavement) on neuroendocrine and immune parameters in HIV (8). Repetto and Petitto review what is known about using psychotropic medications to treat depression and other neuropsychiatric disorders in HIV-infected persons, including medication side effects and interactions with HIV treatments and disease markers (9).
Psychosocial variables are also associated with poor adherence to HIV medications and risky transmission behaviors. Kalichman reviews the commonalties between HIV treatment nonadherence and risky transmission behaviors among HIV positive persons, and recommends combined intervention approaches to address both of these problems (10). DiClemente and colleagues focus on the psychosocial factors that may explain why adolescents engage in risky sexual behavior, and evaluate the effectiveness of theory-based programs to prevent sexually transmitted infections in this population (11). From the onset of the HIV epidemic, substance use and abuse have been inexorably linked with the spread of HIV, and may have an impact on the clinical course of this disease. Des Jarlais and Semaan describe and evaluate the current state of the problem, current interventions, and proposed solutions to dealing with risky transmission behaviors among injecting drug users (12). Finally, Temoshok and Wald discuss recent findings that support the integration in primary care settings of behavioral prevention programs with biomedical interventions and approaches designed to reduce HIV infectiousness (5).
We hope that this special HIV issue will be a useful roadmap to help guide biomedical researchers and clinicians to an understanding of the significance and relevance of psychosocial and psychoneuroimmunological factors in HIV infection. Just as monitoring CD4+ counts and viral load are standard HIV care today, we envision a time when asking about past trauma, current stress, depression, and coping become routine parts of a multidisciplinary and comprehensive approach to HIV treatment.
NOTES
Jane Leserman and Lydia R. Temoshok served as Guest Editors for this special issue.
DOI:10.1097/PSY.0b013e31817b8ef9
REFERENCES
This article has been cited by other articles:
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  B. W. Pence The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS J. Antimicrob. Chemother., April 1, 2009; 63(4): 636 - 640. [Abstract] [Full Text] [PDF]
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