摘要：Objectives. We compared level of psychosocial distress of HIV-infected women living in New York City before the advent of highly active antiretroviral therapy (HAART) with level of psychosocial distress reported by women living with the disease after the use of HAART became widespread. Methods. Data were from HIV-positive New York City women aged 18 to 50 years, enrolled through outreach and self-referral. We compared scores on measures of psychological state and psychosocial adjustment to illness of 74 women interviewed in 1994–1996 with scores of a matched group of 74 women interviewed in 2000–2002. Results. A significant difference between groups was found only with regard to adjustment to illness in their domestic environment, with poorer adjustment reported, on average, by women in the 2000–2002 sample. Conclusions. Although new treatments have significantly improved the physical health of those living with HIV/AIDS, no evidence was found that these treatments significantly improved psychological health for women, regardless of history of protease inhibitor use. It is widely assumed that highly active antiretroviral therapy (HAART) has greatly altered the psychological experience of living with HIV/AIDS. HIV disease is now commonly viewed as being a chronic illness rather than acute and life-threatening as new antiviral agents dramatically reduce viral load and increase CD4 cell counts, thereby reducing the risk of opportunistic infections and extending survival. 1, 2 For others who do not yet need these medications, their existence nonetheless may offer psychological reassurance that effective therapies will be available when needed. As a result, it has been argued that recent treatment advances have “reinserted the word ‘hope’ into discussions about AIDS” 3(p161) and afforded many infected individuals the opportunity for a “second life.” 4 The prospect of extended survival and reduced symptomatology has allowed many people to consider returning to work or school and to contemplate either entering into or leaving relationships. 3, 5 Although the effect of new treatments on pregnancy decision making remains relatively unexplored, in light of the demonstrated efficacy of the medications, HIV-positive women may now be more likely to choose to become pregnant. 6 At the same time, opportunities created by new treatments have created new, potentially stressful uncertainties. 4, 7 For example, people benefiting from treatments may worry that returning to work will jeopardize their receipt of health insurance and their chances of regaining disability entitlements should their health again begin to deteriorate. In addition, contemplating having a baby might raise concerns that the demands of parenting could compromise one’s health. Furthermore, a substantial proportion of infected individuals will not benefit from new antiviral medications, will do so for only a short period, or will have to terminate treatment because of intolerable side effects. People who do benefit may experience a kind of “survivor guilt” when other people do not benefit. 5, 7 Patients unable to tolerate the side effects may engage in self-blame. 5 Furthermore, it has been argued that when treatment benefits are not realized or sustained, patients may experience hopelessness and anger or feel that they were misled about the medications’ potential efficacy and may experience even greater psychological distress than in the past. 5, 8 Despite much speculation about the potential effect of HAART availability on the psychosocial well-being of infected individuals, empirical investigations of this issue are recent and few. In one study, investigators interviewed a group of 173 gay/bisexual men with symptomatic HIV/AIDS before and after the availability of protease inhibitors. 9 The sample as a whole showed a clinically modest but statistically significant decline on all measures of psychological distress over time after control for CD4 cell count, HIV symptoms, physical limitations, and social support. When the investigators further compared participants with improved medical markers (i.e., higher CD4 counts or lower viral load) with participants without improvement, they found no significant differences in hopelessness or quality of life. Furthermore, the improved group showed no change in depressive symptoms, whereas the unimproved group exhibited fewer depressive symptoms over time. The investigators offered several possible explanations for these counterintuitive findings: (1) individuals in the improved group were more immunosuppressed at baseline and thus despite showing improvement may have remained more cautious about their medical outlook; (2) the unanticipated opportunity for a “second life” may have created a greater sense of uncertainty; or (3) more of the individuals in the improved group were taking combination therapy, regimens of which are onerous and have distressing side effects. In another investigation 10 of 456 HIVinfected individuals (433 of whom were men) receiving antivirals, among participants who had completed at least 2 annual surveys (1 before initiating treatment with a protease inhibitor and 1 after), the percentage of patients with a score indicative of probable clinical depression declined, from 52% to 46%. Although this change was not statistically significant, there were also significant declines in scores on the total Center for Epidemiological Studies–Depression Scale (CES-D), as well as improved scores on the Depressive Affect, Positive Affect, and Somatic/Vegetative State subscales. In still another study, 11 this time of 125 HIV-infected adults (mostly homosexual or bisexual men), depressive symptoms were assessed at 6-month intervals over a 2-year period. The investigators found a pattern of declining scores (denoting less depression) on the Beck Depression Inventory over time, especially after the third assessment (12 months after baseline), by which time 51% of study participants were receiving HAART. These findings, however, must be interpreted with caution because of study limitations (e.g., substantial dropout by the 6-month assessment) and because of the different number of cases included at each assessment point (although the investigators argue that the same pattern was seen among the 27 cases for which data were available at each assessment point). The question of whether individuals currently living with HIV experience levels of psychosocial distress comparable to the levels experienced by individuals living with the disease before the advent of HAART is an important one because the widespread perception that such distress has significantly diminished among infected individuals may prompt a reduction in mental health resources targeted to this population. In the case of HIV-infected women, this situation could have particularly unfortunate consequences, given the recently demonstrated association between depressive symptomatology and survival. 12 To investigate this issue, we compared 2 matched samples of women living with HIV/AIDS, the first interviewed between 1994 and 1996 and the second interviewed between 2000 and 2002.
