Positive Affect May Influence the Rate of HIV Progression

SAN FRANCISCO — Depression and stress appear to be important considerations in the treatment of HIV-infected patients, Dr. Frederick Hecht said at a meeting on HIV management sponsored by the University of California, San Francisco.

Although research on the topic is not conclusive, available evidence suggests that a patient's ability to experience positive emotions may be somewhat protective against CD4 cell count loss, he said.

And, in a small pilot study of yoga practice, he obtained intriguing, but not definitive, evidence that there might be ways to mitigate depression and response to stress without writing a prescription.

The first studies that found an association between depression and CD4 cell loss were published in 1993, but they were not entirely convincing, said Dr. Hecht, research director of the UCSF Osher Center for Integrative Medicine.

Subsequent studies have suggested that it is not depression per se that is associated with rapid HIV disease progression, and that negative affective symptoms have little or no impact on HIV progression.

Instead, these studies have shown that positive affect—in other words, the ability to experience positive thoughts and emotions, and to enjoy some aspects of life despite also feeling sadness—can have a large effect, Dr. Hecht said.

One study, the San Francisco Men's Health Study, included 407 HIV-positive men who were followed over a period of 10 years. The relative risk of AIDS mortality was 0.89 in those who had high scores on positive affect measures. Negative affect, however, had little relationship to mortality (Psychosom. Med. 2003;65:620–66).

In another study, of 82 HIV-positive men followed for an average of 5 years, the presence of stress was associated with risk of progression. One major stressful event in a 6-month period, such as the dissolution of an intimate relationship or loss of a loved one, doubled the risk of disease progression.

Studies done by researchers at the University of California, Los Angeles, have hinted at how mood and affect might be tied to the immune system in the setting of HIV infection. That research has suggested that the connection might be through the CCR5 receptor, the major coreceptor of HIV on CD4 cells. Persons who have rapidly progressing disease may have more CCR5 receptors, and the researchers have shown that neurotransmitters such as norepinephrine can increase receptor expression in vitro.

In an intriguing study, those researchers found that a high level of autonomic nervous system activity, as would be seen in times of stress, impairs response to highly active antiretroviral therapy and increases virus levels (Proc. Natl. Acad. Sci. U.S.A. 2001; 98:12695–700).

In his unpublished study of yoga practice, Dr. Hecht assigned 23 HIV-infected patients to a group that practiced yoga three times a week, and 25 others to a control group.

At the end of 3 months, both groups had improvement in their positive and negative affect scores on a test known as the Positive and Negative Affect Schedule, but the mean improvement for the group that practiced yoga was eight times greater on positive affect and twice as great on negative affect.

The yoga group had an increase in average CD4 cell level, while the control group had a decrease, but the difference was not statistically significant, Dr. Hecht said.

“There's at least a little bit of preliminary evidence that interventions like this yoga intervention might have some effect on CD4 cell counts,” he said.

Dr. Hecht said that he uses this information when treating his own HIV patients. He advises them that withdrawing from life in order to avoid stressors is not advisable, but that chronic stress or depression do need to be addressed.

He does not mislead them into thinking that by developing positive affect they can prevent progression. “The issue here is really rate of progression, not whether you progress or not,” he said.

Antidepressant treatment probably does not have a benefit, Dr. Hecht added. In a study of HIV patients put on a selective serotonin reuptake inhibitor, there was no significant effect on T-cell levels (J. Clin. Psychiatry 1994;55:92–7).

That study may not have been large enough to detect an improvement. But it may also indicate that antidepressants have no appreciable impact on positive affect, he said.

SAN FRANCISCO — Depression and stress appear to be important considerations in the treatment of HIV-infected patients, Dr. Frederick Hecht said at a meeting on HIV management sponsored by the University of California, San Francisco.

Although research on the topic is not conclusive, available evidence suggests that a patient's ability to experience positive emotions may be somewhat protective against CD4 cell count loss, he said.

And, in a small pilot study of yoga practice, he obtained intriguing, but not definitive, evidence that there might be ways to mitigate depression and response to stress without writing a prescription.

The first studies that found an association between depression and CD4 cell loss were published in 1993, but they were not entirely convincing, said Dr. Hecht, research director of the UCSF Osher Center for Integrative Medicine.

Subsequent studies have suggested that it is not depression per se that is associated with rapid HIV disease progression, and that negative affective symptoms have little or no impact on HIV progression.

Instead, these studies have shown that positive affect—in other words, the ability to experience positive thoughts and emotions, and to enjoy some aspects of life despite also feeling sadness—can have a large effect, Dr. Hecht said.

One study, the San Francisco Men's Health Study, included 407 HIV-positive men who were followed over a period of 10 years. The relative risk of AIDS mortality was 0.89 in those who had high scores on positive affect measures. Negative affect, however, had little relationship to mortality (Psychosom. Med. 2003;65:620–66).

In another study, of 82 HIV-positive men followed for an average of 5 years, the presence of stress was associated with risk of progression. One major stressful event in a 6-month period, such as the dissolution of an intimate relationship or loss of a loved one, doubled the risk of disease progression.

Studies done by researchers at the University of California, Los Angeles, have hinted at how mood and affect might be tied to the immune system in the setting of HIV infection. That research has suggested that the connection might be through the CCR5 receptor, the major coreceptor of HIV on CD4 cells. Persons who have rapidly progressing disease may have more CCR5 receptors, and the researchers have shown that neurotransmitters such as norepinephrine can increase receptor expression in vitro.

In an intriguing study, those researchers found that a high level of autonomic nervous system activity, as would be seen in times of stress, impairs response to highly active antiretroviral therapy and increases virus levels (Proc. Natl. Acad. Sci. U.S.A. 2001; 98:12695–700).

In his unpublished study of yoga practice, Dr. Hecht assigned 23 HIV-infected patients to a group that practiced yoga three times a week, and 25 others to a control group.

At the end of 3 months, both groups had improvement in their positive and negative affect scores on a test known as the Positive and Negative Affect Schedule, but the mean improvement for the group that practiced yoga was eight times greater on positive affect and twice as great on negative affect.

The yoga group had an increase in average CD4 cell level, while the control group had a decrease, but the difference was not statistically significant, Dr. Hecht said.

“There's at least a little bit of preliminary evidence that interventions like this yoga intervention might have some effect on CD4 cell counts,” he said.

Dr. Hecht said that he uses this information when treating his own HIV patients. He advises them that withdrawing from life in order to avoid stressors is not advisable, but that chronic stress or depression do need to be addressed.

He does not mislead them into thinking that by developing positive affect they can prevent progression. “The issue here is really rate of progression, not whether you progress or not,” he said.

Antidepressant treatment probably does not have a benefit, Dr. Hecht added. In a study of HIV patients put on a selective serotonin reuptake inhibitor, there was no significant effect on T-cell levels (J. Clin. Psychiatry 1994;55:92–7).

That study may not have been large enough to detect an improvement. But it may also indicate that antidepressants have no appreciable impact on positive affect, he said.

SAN FRANCISCO — Depression and stress appear to be important considerations in the treatment of HIV-infected patients, Dr. Frederick Hecht said at a meeting on HIV management sponsored by the University of California, San Francisco.

Although research on the topic is not conclusive, available evidence suggests that a patient's ability to experience positive emotions may be somewhat protective against CD4 cell count loss, he said.

And, in a small pilot study of yoga practice, he obtained intriguing, but not definitive, evidence that there might be ways to mitigate depression and response to stress without writing a prescription.

The first studies that found an association between depression and CD4 cell loss were published in 1993, but they were not entirely convincing, said Dr. Hecht, research director of the UCSF Osher Center for Integrative Medicine.

Subsequent studies have suggested that it is not depression per se that is associated with rapid HIV disease progression, and that negative affective symptoms have little or no impact on HIV progression.

Instead, these studies have shown that positive affect—in other words, the ability to experience positive thoughts and emotions, and to enjoy some aspects of life despite also feeling sadness—can have a large effect, Dr. Hecht said.

One study, the San Francisco Men's Health Study, included 407 HIV-positive men who were followed over a period of 10 years. The relative risk of AIDS mortality was 0.89 in those who had high scores on positive affect measures. Negative affect, however, had little relationship to mortality (Psychosom. Med. 2003;65:620–66).

In another study, of 82 HIV-positive men followed for an average of 5 years, the presence of stress was associated with risk of progression. One major stressful event in a 6-month period, such as the dissolution of an intimate relationship or loss of a loved one, doubled the risk of disease progression.

Studies done by researchers at the University of California, Los Angeles, have hinted at how mood and affect might be tied to the immune system in the setting of HIV infection. That research has suggested that the connection might be through the CCR5 receptor, the major coreceptor of HIV on CD4 cells. Persons who have rapidly progressing disease may have more CCR5 receptors, and the researchers have shown that neurotransmitters such as norepinephrine can increase receptor expression in vitro.

In an intriguing study, those researchers found that a high level of autonomic nervous system activity, as would be seen in times of stress, impairs response to highly active antiretroviral therapy and increases virus levels (Proc. Natl. Acad. Sci. U.S.A. 2001; 98:12695–700).

In his unpublished study of yoga practice, Dr. Hecht assigned 23 HIV-infected patients to a group that practiced yoga three times a week, and 25 others to a control group.

At the end of 3 months, both groups had improvement in their positive and negative affect scores on a test known as the Positive and Negative Affect Schedule, but the mean improvement for the group that practiced yoga was eight times greater on positive affect and twice as great on negative affect.

The yoga group had an increase in average CD4 cell level, while the control group had a decrease, but the difference was not statistically significant, Dr. Hecht said.

“There's at least a little bit of preliminary evidence that interventions like this yoga intervention might have some effect on CD4 cell counts,” he said.

Dr. Hecht said that he uses this information when treating his own HIV patients. He advises them that withdrawing from life in order to avoid stressors is not advisable, but that chronic stress or depression do need to be addressed.

He does not mislead them into thinking that by developing positive affect they can prevent progression. “The issue here is really rate of progression, not whether you progress or not,” he said.

Antidepressant treatment probably does not have a benefit, Dr. Hecht added. In a study of HIV patients put on a selective serotonin reuptake inhibitor, there was no significant effect on T-cell levels (J. Clin. Psychiatry 1994;55:92–7).

That study may not have been large enough to detect an improvement. But it may also indicate that antidepressants have no appreciable impact on positive affect, he said.