HIV Patients Continue to Suffer From Severe Fatigue Despite HAART

Generalized fatigue can be a very debilitating symptom of HIV infection. Prior to the advent of highly active antiretroviral therapy (HAART) fatigue was a very common symptom associated with HIV/AIDS.¹ In the pre-HAART era, fatigue was often ascribed to profound immunosuppression from AIDS.
 
In a new study recently published in the journal HIV Medicine,² the investigators set out to examine the prevalence of fatigue in a population of HIV patients that was predominantly receiving HAART to determine whether significant fatigue continued to be as common as in the pre-HAART era. The investigators conducted cross-sectional surveys on 100 stable HIV-infected outpatients, 91% of which were receiving HAART with 78% achieving suppressed HIV viral loads (less than 40 HIV-1 RNA copies/mL). This group of patients was compared with 166 uninfected controls and 74 patients with chronic fatigue syndrome/myagalic encephalomyelitis. The severity of fatigue was assessed using the fatigue impact scale (FIS). The investigators also looked for symptoms of orthostasis using the orthostatic grading scale (OGS) to look for an association between orthostasis and HIV-associated fatigue as a potential pathophysiological mechanism.
 
It was striking to see in this paper that more than half of the HIV-infected patients reported excessive fatigue (FIS ≥ 40), and 28 (28%) reported severe fatigue (FIS ≥ 80). HIV-infected patients experienced high levels of fatigue similar to those experienced by patients with chronic fatigue syndrome/myagalic encephalomyelitis. Among HIV-infected patients, fatigue severity was not significantly associated with CD4 lymphocyte count, HIV plasma viral load, or whether the patients were on HAART or not. Prior dideoxynucleoside analogue (d-drug) exposure (P = 0.016) and the development of clinical lipodystrophy syndrome (P = 0.011) were associated with fatigue.

It was also interesting to see that HIV-infected patients had significant orthostatic intolerance and that fatigue severity correlated strongly with symptomatic orthostatic intolerance (r = 0.65; P < .001). The authors concluded that fatigue is very common and often severe in HIV-infected outpatients receiving HAART and that it is frequently associated with dysautonomia. They hypothesize that dysautonomia may also play a role in the pathophysiology of fatigue in HIV-infected patients.
 
For primary care physicians who treat HIV-infected patients, it is important to recognize the high prevalence of fatigue and orthostasis and to properly inquire about these symptoms for proper diagnosis and treatment.


References
1. Darko DF, McCutchan JA, Kripke DF, et al. Fatigue, sleep disturbance, disability, and indices of progression of HIV infection. Am J Psychiatry. 1992;149:514–520.
2. Payne BA, Hateley CL, Ong EL. HIV-associated fatigue in the era of highly active antiretroviral therapy: novel biological mechanisms? HIV Med. 2013;14:247-251.