Gastrointestinal Symptoms and Microbial Translocation in HIV+ Veterans

Birmingham Va Medical Center, Birmingham AL

Investigators

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Abstract

DESCRIPTION (provided by applicant): Gastrointestinal (GI) symptoms are prevalent among people living with Human Immunodeficiency Virus (HIV) and are often a reason for discontinuation of and non-adherence to combination antiretroviral therapy (cART). Interventions targeting symptoms and healing the GI barrier are important nursing strategies to improve health outcomes. It is crucial to evaluate and describe the patient experience, prevalence of symptoms, and the impact of those symptoms on the quality of life in Veterans. Improved information related to GI-related symptoms will have a positive impact on healthcare provided to Veterans in terms of symptom management and helping to develop new strategies focused on increasing cART adherence. The VHA has nearly 64,000 Veterans living with HIV infection and more than 50% receive their care in the South. Currently, there are 346 patients enrolled in care at the Birmingham VAMC HIV Clinic. Over half of HIV-infected Veterans report that GI symptoms such as diarrhea, bloating, and abdominal pain are frequent and bothersome. Over 30% of patients living with HIV are likely to discontinue effective cART due to GI symptoms. However, it is not clear how many HIV-infected Veterans are non-adherent to cART as a result of GI symptoms experienced and if GI symptoms may extend beyond medication toxicity. For example, inflammatory effects on the GI epithelial barrier lead to microbial products leaking from the gut lumen into bloodstream and may contribute to the perception of symptoms. Soluble CD14 (sCD14) is an established and commonly used surrogate biomarker of microbial translocation and strongly correlates with severity of epithelial barrier dysfunction in HIV disease. sCD14 has been identified as independently improving the predictability of mortality risk when added to the Veterans Aging Cohort Study Index but it is not clear if it is associated with GI symptoms prevalence. Although GI symptoms in HIV-infected patients resemble symptoms experienced with Inflammatory Bowel Diseases (IBD) and Irritable Bowel Syndrome (IBS), providers may attribute GI symptoms experience to depression or medications. However, there is no significant association between symptom prevalence and depression, and medication side effect profiles have improved. There are similarities with loss of Th17 type CD4 cells in the gut associated lymph tissue, gut inflammation, GI symptoms, and microbial translocation in both HIV-uninfected IBD/IBS and in those with HIV disease. Furthermore, given the similarities with IBD/IBS in pathophysiology, GI symptoms may be an indication of underlying HIV immune-mediated inflammation of the GI epithelial barrier. There are many gaps in our knowledge related to variable types of GI symptoms associated with HIV disease. Therefore, we aim to understand GI symptoms and examine factors that may contribute to the difficulties in cART adherence in the context of GI-related symptoms. The purpose of this Sequential Explanatory mixed methods study is to examine the relationship between patient-reported GI symptoms and microbial translocation and to explore how these symptoms influence cART adherence decision-making in a convenience sample of 120 HIV-infected Veterans seeking care in a clinical ambulatory setting in Birmingham, AL. Symptoms will be identified by the HIV Signs and Symptoms Checklist. Microbial translocation will be measured by levels of sCD14. Adherence to cART will be measured using the AIDS Clinical Trial Group Adherence Survey. Quality of life will be measured by the GI Quality of Life Index (GIQLI). To explore whether the GIQLI is predictive of barrier dysfunction, we will triangulate continuous summation scores with levels of sCD14 adjusting for disease status severity assessing for association. Persons reporting GI symptoms will be stratified by cART adherence and interviewed to explore factors affecting cART adherence decision-making.