HIV-positive people in a "stable relationship" do better than single people, according to preliminary results of the first ever study to show the impact of relationships on hard clinical outcomes in HIV disease, presented this week at the Ninth European AIDS Conference in Warsaw.
Researchers from Switzerland undertook a five year prospective cohort study in 3736 patients with HIV who were part of the 11867-strong Swiss HIV Cohort Study, and included all those who started HAART prior to 2002, and who had answered their questionnaire.
The median age of those included in this study was 36 and 29% were women. The main measurement was the time to AIDS or death (the primary endpoint), but CD4 cell counts and viral load were also measured, and the median follow-up time was 3.6 years.
When asked in a questionnaire if they had had a stable sexual partner during the past six months, 2985 (80%) responded 'yes' on at least one occasion. The researchers reported that women were more likely than men to be in a stable relationship, and that people over 40 were more likely to be single.
Multivariate analysis found that the adjusted hazard ratio for progression to AIDS or death was 0.79 [95 % CI 0.63 - 0.98 p= 0.04] for those with a stable partnership compared to those without.
The researchers also reported that those in a stable relationship were almost half as likely to die during the study (HR=0.59 [0.44 - 0.79])and more likely to have a CD4 increase of 100 cells/mm3, (HR=1.15 [1.06 - 1.24]compared to single people. Having an undetectable viral load, however, did not appear to be significantly associated with being in a stable partnership (HR=1.06 [0.98-1.14]).
The study raised more questions than it could answer, however, and was subject to various limitations, including having only one question about stable sexual partnerships to measure relationships. For example, the study did not differentiate between people who were serial monogamists with long-term partnerships, nor did it differentiate between those who answered 'yes' once or on every occasion.
The authors also suggested that it was primarily the social support provided by the partner that was the significant factor in the beneficial outcome, and said that they felt single people were more likely to be depressed and therefore non-adherent to medication. However, this conflicts with their own evidence that found no relationship between successful viral suppression (the only possible measure of adherence in the study) and a stable partnership.
When asked by aidsmap about lifestyle factors that could have contributed to the outcome of this study, the author noted that one in four people in this cohort were intravenous drug users - many of whom are not in stable relationships - and that death by homicide or overdose could have played a role in the study's outcome.
Whilst this study, which will be presented in full in a future issue of the British Medical Journal, is a good start, is does not begin to identify the myriad reasons why HIV-positive people in relationships might do better than those who are not. One obvious area for further research would be sexual and lifestyle factors. For example, the assumption that those with a partner are monogamous and less likely to be exposed to other sexual pathogens than single people needs to be examined, particularly in the context of gay relationships. Furthermore, the assumption that only single people are depressed, and therefore non-adherent, is arguably false, and needs further exploration and elucidation.
Bucher H.C. et al. Stable partnership and progression to AIDS or death in HIV-infected individuals receiving Highly Active Antiretroviral Therapy: the Swiss HIV Cohort Study Ninth European AIDS Conference, Warsaw, abstract F9/8, 2003.