AIDS and HIV: Stress

The Centers for Disease Control and Prevention estimates that 850,000 to 950,000 U.S. residents are living with HIV, with about 40,000 new HIV infections each year. HIV is the fifth leading cause of death among those ages 25–44; it is the leading cause of death among African American males in this same age range. The development of potent combination antiretroviral therapies for HIV has lengthened life expectancy for HIV-infected persons in the United States. A person with HIV can live for many years without getting AIDS, that is, the occurrence of severe medical symptoms and/or decline in the immune system's helper cells. Despite advances in HIV treatment, there is wide variability in the length of time before a person dies, develops clinical symptoms, or has a weakening in their immune system. Evidence has been mounting that chronic stress may have an adverse effect on the immune system of those infected with HIV, leading to faster disease progression and death.

The Coping in Health and Illness Project (CHIP), conducted by researchers at the University of North[Page 30] Carolina at Chapel Hill, has reported some of the most consistent and compelling data on the deleterious effects of stressful life events and difficulties in HIV infection. CHIP is a 9-year longitudinal study following 96 HIV-infected gay men who began the study without HIV-related symptoms or HIV medications. To measure stress, the CHIP study uses interviewer-based ratings assessing the severity of patients' stressful life events and difficulties taking into account the circumstances surrounding events (e.g., financial impact, life threat, personal involvement). The objective threat rating is made independently from the subject's rating, to reduce the possibility that worsening disease might lead to poor coping and thus higher stress scores. The measure also excludes stresses that could have resulted from disease progression (e.g., retirement due to HIV worsening). This methodology is one way to avoid the chicken-egg issue of whether stress leads to worsening disease or whether those with declining health rate their stressful events as more unpleasant.

Leserman, Evans, and colleagues from the CHIP study found that men with more stresses during a 9-year period had faster progression to AIDS and faster development of serious HIV-related illnesses (such as pneumocystis pneumonia, Kaposi's sarcoma). Men who had a severe stress at every visit had about twice the risk of progressing compared to men who never had a severe stress. The AIDS progression rate at the end of 8 years for those above average in stress was 74% versus 40% for those below average. The investigators reported similar findings during earlier time periods of the study. Their findings were not explained by differences among patients on such variables as age, race, education, number of HIV medications, or entry levels of helper cells or HIV viral load (amount of virus in the blood).

Another approach to establishing a causal relationship between stress and disease progression has been to study patients who have experienced a major stressor, such as death of a loved one. These types of stressors can clearly be documented before changes in disease status, making the direction of such a relationship less ambiguous (e.g., changes in disease status are more likely to be a result of a major stressor than vice versa). In studying HIV-infected gay men, Kemeny and researchers at the University of California, San Diego, reported that the stress of bereavement prior to their study (having a close friend or lover who died of AIDS) was associated with more rapid decline in helper cell count during a 3- to 4-year period. These findings were not explained by differences in health habits, HIV medication use, or age; however, bereavement was not related to faster development of AIDS medical symptoms or mortality. In a later study of men during 2- to 3-year follow-up, these researchers showed that those who found meaning in bereavement had less rapid decline in helper cell levels and lower rates of mortality due to AIDS. In studying another stress, being notified of being HIV positive, researchers at the University of Miami found that men with more distress at notification had a greater chance of developing HIV-related clinical symptoms 2 years later.

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