09-P09 - SESSTIM

Background: Fatigue is a major component of quality of life (QOL) and is associated with depression in HIV-HCV co-infected individuals. Our aim was to assess whether treating depression could mitigate the impact of fatigue on daily functioning even in patients
with advanced HIV or HCV disease.
Methods: The analysis was conducted on enrolment data of 328 HIV-HCV co-infected patients recruited in the French nationwide HEPAVIH cohort, neither presenting opportunistic infections nor receiving HCV treatment. Data collection was based on medical records and self-administered questionnaires which included socio-behavioural data, the fatigue impact scale (FIS) on three domains (cognitive, physical and social functioning), self-reported and depressive symptoms (DS) (CES-D) and use of antidepressants (AD).
A multivariate analysis of variance (MANOVA) was used to identify factors associated with the impact of fatigue on the three domains.
Results: Median[IQR] FIS scores were 9[2-18] for cognitive impact of fatigue and 10[4-21] and 17[4-37] respectively for physical and social impact of fatigue. Median[IQR] CD4 cell count was 444[292-643]/mm3, 86% of patients had undetectable HIV viral load, 91%
were receiving HAART and 41% presented DS.
After adjustment for gender and unemployment, CD4 cell count<200/mm3 was associated with a negative impact of fatigue (p=0.002) on the physical functioning dimension. A higher number of symptoms causing discomfort significantly predicted a higher
impact of fatigue on all dimensions (p<0.001). This was also true for patients with no DS receiving AD when compared with those with DS treated with AD. A significant decreasing linear trend (p<0.001) of the impact of fatigue was found across the categories
“DS/AD”, “DS/no AD”, “no DS/AD” and “no DS/no AD”.
Conclusion: Systematic screening for depression followed by combined management of depression, fatigue and perceived symptoms can potentially improve the QOL of HIV-HCV co-infected patients and relieve the burden of living with a dual infection.
Key words: depression, fatigue, HIV, HCV, HAART, self-reported symptoms, maintenance therapy.
ABSTRACT
CDB044
Role of antidepressants in relieving the impact of fatigue in HIV-HCV
co-infected patients: results from the HEPAVIH French cohort (ANRS Co13)
L. Michel1,2,3, V. Villes4,5,6, F.Dabis7, B. Spire4,5,6, M. Winnock7,
MA. Loko7, I. Poizot-Martin8, MA. Valantin9, P. Bonnard10,
D. Salmon-Ceron11, MP. Carrieri4,5,6
AUTHORS
Statistical methods and patients
The 3 fatigue scores were used as a multiple response
variable in a MANOVA (multivariate analysis of variance)
to take into account the inter-correlations between them
1 INSERM U669, Paris, France
2 Université Paris-Sud and Université Paris Descartes, UMR-S0669, Paris, France
3 AP-HP, Hôpital Emile Roux, Centre de Traitement des Addictions, Limeil-Brévannes, France
4 INSERM, U912 (SE4S), Marseille, France
5 Université Aix-Marseille, IRD, UMR-912, Marseille, France
6 ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d’Azur, Marseille, France
7 INSERM U897, Bordeaux, France
8 CHU Sainte Marguerite, Marseille, France
9 CHU de la Pitié Salpétrière, Paris, France
10 Hôpital Tenon, Paris, France
11 Hôpital Cochin-Port-Royal, Paris, France
Explanatory variables were considered eligible for the
final model when their p-value based on F-test (Wilks’
lambda) was lower than 0.25 for at least one dimension of
the FIS
Fatigue is one of the most frequently reported symptoms in
patients with VHC, its prevalence ranging between 50% and 67%
Background
Fatigue is functionally associated with depression and is a core
symptom in the diagnosis of major depressive disorder (DSM-IV)
Selection criteria
Patients neither presenting opportunistic infections nor
receiving HCV treatment and who filled in the
self-administered questionnaire (N=328)
In HIV-HCV co-infected patients, fatigue may be aggravated by
additional factors such us the burden of HIV disease, the
psycho-social vulnerability of this group (mainly drug users) and
their exposure to multiple treatments and drugs (Braitstein,
2005)
No significant differences, except for age, were found
between socio-demographic and clinical characteristics of
patients with complete data (N=328) compared to those
with incomplete data (N=194)
For these patients, fatigue is also a major component of quality
of life (Marcellin, 2007)
Objecti ve
To assess whether treating depression could mitigate
the impact of fatigue on daily functioning even in
patients with advanced HIV or HCV disease
HEPAVIH French Cohort Study (ANRS CO13): design
Started in 2006, participating of 17 different
hospital out-patient facilities providing care for
people living with HIV and HCV with a follow-up of
at least 5 years
Individuals can be enrolled at any time during their
HIV-HCV history
Exclusion criteria: undetectable HCV viral load for
more than 6 months after commencing treatment
for HCV (SVR)
Methods
Data collection
Clinical and biological data including plasma HIV
RNA, CD4 cell count, and liver fibrosis were obtained
from medical records
The self-administered questionnaire included items
on sociodemographic characteristics, treatment
history and ongoing treatments, alcohol and
tobacco consumption and drug use
The self-administered questionnaire also collected
psychosocial data such as depressive symptoms (DS)
(CES-D) and use of antidepressants (AD), patients’
perceptions concerning the impact of fatigue on
their daily functioning (FIS) and self-reported side
effects
Outcome
Patients’ perceptions about the “impact” of fatigue
on their daily lives over the previous month were
collected using the self-reported Fatigue Impact
Scale (FIS)
3 fatigue scores: cognitive, physical and social
impacts of fatigue ranging from 0 to 40 (0 to 80
for social impact)
Higher scores denote higher perceived impact of
fatigue
Explanatory variables
Depression was measured by using the validated
CES-D scale with a cut-off of 17 for men and 23 for
women (Fuhrer and Rouillon, 1989)
Self-reported side effects included 39 different
symptoms over the previous four weeks and the
discomfort they caused (Justice, Holmes et al. 2001)
Re sults
Characteristics of participants (n=328)
Age (years)
Men
HIV transmission group
IDU
Homosexual
Heterosexual
Other
Having children
High school certificate
Employment
Living in a couple
Comfortable housing conditions
Cognitive impact of fatigue (0-40)
Physical impact of fatigue (0-40)
Social impact of fatigue (0-80)
No DS* and no AD
No DS* and AD
DS* and no AD
DS* and AD
Number of self-reported side effects
Number of self-reported side effects causing discomfort
Polydrug use (>=1)
Daily alcohol consumption
Cannabis use
CD4 cell count/mm3
Nadir CD4 cell count/mm3
Undetectable plasma HIV RNA
ASAT (UI/l)
ALAT (UI/l)
Cirrhosis
n (%) or Median [IQR]
42 [40-46]
229 (69.8)
206 (63.6)
42 (13.0)
38 (11.7)
38 (11.7)
104 (32.4)
93 (30.5)
151 (47.3)
147 (45.7)
264 (81.0)
9 [2-18]
10 [4-21]
17 [4-37]
173 (53.2)
21 (6.5)
89 (27.4)
42 (12.9)
7 [1-14]
2 [0-8]
37 (11.3)
29 (9.0)
150 (45.7)
444 [292-643]
153 [69-244]
277 (85.5)
50 [36-73]
59 [36-88]
90 (27.4)
* Cut-off of 17 for men and 23 for women
Factors not associated with the 3 fatigue impact scores (p>0.25)
Daily alcohol consumption
Heroin use
Polydrug use
Receiving HAART
ASAT
Factors associated with the 3 fatigue impact scores (p<0.25)
Women
No child(ren)
No high school certificate
Unemployed
Not living in a couple
Uncomfortable housing conditions
No DS and no AD
No DS and AD
DS and no AD
DS and AD (reference)
Cannabis use
History of IDU
Receiving OST
Nb. of self-reported side effects causing
discomfort
CD4<200 cell count/mm3
HCV genotype 1 or 4
ALAT (UI/l)
B Coefficients:
Cognitive
Physical
Social
Impact
Impact
Impact
3.1 **
3.1 **
6.6 **
4.3 **
4.5 **
8.4 **
2.2 *
5.2 **
1.9 N
5.5 **
6.1 **
12.7 **
2.9 **
3.4 **
6.7 **
4.5 **
4.1 **
10.9 **
-14.3 **
-14.3 **
-30.1 **
-9.5 **
-11.0 **
-20.3 **
-4.6 **
-5.2 **
-10.2 **
2.7 **
1.4 N
3.8 **
2.6 **
2.3 *
5.9 **
5.9 **
5.2 **
10.4 **
0.92 **
2.0 N
1.9 N
-0.008 N
1.04 **
4.2 **
2.3 N
-0.014 N
1.76 **
4.3 N
4.4 *
-0.028 *
** p<0.05; * p<0.10; N=not associated
Factors independently associated with
the 3 fatigue impact scores
Women
Unemployed
No DS and no AD
No DS and AD
DS and no AD
DS and AD (reference)
CD4<200 cell count/mm3
Nb. of self-reported side effects causing
discomfort
Adjusted B Coefficients:
Cognitive
Physical
Social
Impact
Impact
Impact
1.8 **
2.0 **
4.3 **
1.6 *
2.1 **
5.0 **
-10.8 **
-9.9 **
-23.3 **
-6.6 **
-7.5 **
-15.6 **
-3.5 **
-4.1 **
-8.4 **
1.6 N
4.3 **
3.7 N
0.71 **
0.85 **
1.27 **
** p<0.05; * p<0.10; N=not associated
C O N C L U S I O N S
- Women and individuals with severe immunosuppression seem to perceive the impact to fatigue to a
greater extent
- Special individualised interventions to limit the impact of fatigue should be envisaged in these
populations before and during HCV treatment
- Systematic screening for depression followed by combined management of depression and
perceived symptoms can improve the QOL of HIV-HCV co-infected patients and relieve the burden of
living with a dual infection
Acknowledgements
Principal investigators: D. Salmon-Ceron, F. Dabis
Methodology: F. Dabis, M. Winnock
Management Center: M. Winnock, MA. Loko, L. Dequae Merchadou, S. Gillet
Hepatology: Y. Benhamou, P. Sogni
Virology: J.Izopet, M-E.Lafon
Social Sciences: B. Spire, MP. Carrieri, P. Roux, L. Michel, V. Villes, M. Mora, P. Kurkdji
List of participating groups: (ANRS CO13 HEPAVIH)
AC7 cohorts: AQUITAINE (F. Dabis), RIBAVIC (F. BaniSadr), SEROCO/HEMOCO (L. Meyer)
Clinical Centers: Paris: Hôpital Cochin - Service de Médecine Interne 2, Hôpital Tenon - Service des Maladies Infectieuses, Hôpital Pitié-Salpêtrière - Service des Maladies Infectieuses, Hôpital Avicenne - Service de Médecine Interne, Hôpital
Bichat-Claude Bernard - Service des Maladies Infectieuses A, Hôpital de Bicêtre - Service de Médecine Interne , Hôpital Necker-Enfants Malades - Service des Maladies Infectieuses, Hôpital Saint Antoine - Service des Maladies Infectieuses, Hôpital
Saint Louis - Service de Médecine Interne, Hôpital Paul Brousse - Service des Maladies Infectieuses ;Marseille: Hôpital Sainte Marguerite - Service Hématologie et VIH ; Nice: Hôpital de l'Archet - Services des Maladies Infectieuses et de Médecine
Interne ; Toulouse: Hôpital Purpan - Services des Maladies Infectieuses et de Médecine Interne, Hôpital Joseph Ducuing - Service de Médecine Interne; Bordeaux: Hôpital Pellegrin - Services des Maladies Infectieuses A et B, Hôpital Saint André
Service de Médecine Interne, Hôpital Haut Lévêque Service de Médecine Interne A
Associated team: UMR912 INSERM-IRD-Université de la Méditerranée
A special thank to all people living with HIV and HCV
who accepted to participate in the study
Financial Support:
Agence Nationale de Recherche sur le SIDA et les hépatites virales (ANRS)