w w w . e l s e v ie r . c o m / l o c a t e / b j i d
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Original
article
Quality
of
life,
risk
behaviors
and
depression
among
carriers
of
hepatitis
C
virus
and
human
T-cell
lymphotropic
virus
type
1:
a
comparative
study
Ricardo
Henrique-Araújo
a,b,c,∗,
Lucas
C.
Quarantini
d,e,
André
C.
Caribé
e,
Felipe
C.
Argolo
f,
Ana
Paula
Jesus-Nunes
d,e,
Mychelle
Morais-de-Jesus
d,e,
Adriana
Dantas-Duarte
e,
Tayne
Miranda
Moreira
e,
Irismar
Reis
de
Oliveira
a,daFederalUniversityofBahia,InstituteofHealthSciences,PostgraduatePrograminInteractiveProcessesofOrgansandSystems,
Salvador,BA,Brazil
bNovaEsperanc¸aMedicalSchool,JoãoPessoa,PB,Brazil
cHospitalComplexofInfectiousDiseasesClementinoFraga,JoãoPessoa,PB,Brazil
dFederalUniversityofBahia,PostgraduatePrograminMedicineandHealth,Salvador,BA,Brazil
eFederalUniversityofBahia,PsychiatryService,UniversityHospital(Com-HUPES),Salvador,BA,Brazil
fFederalUniversityofSãoPaulo,PostgraduatePrograminPsychiatryandMedicalPsychology,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received26February2019 Accepted8June2019 Availableonline22July2019
Keywords:
HepatitisCvirus
HumanT-celllymphotropicvirus type1 Qualityoflife Riskbehaviors Depression Suicide
a
b
s
t
r
a
c
t
HumanT-celllymphotropicvirustype1(HTLV-1)haslowprevalencerates,butisendemic insomeregionsoftheworld.Itisusuallyachronicasymptomaticinfection,butitcan beassociatedwithseriousneurologicandurinaryconditions.HepatitisCvirus(HCV)is broadlyspreadoutworldwide.Themajorityoftheseinfectionshaveachroniccoursethat mayprogresstocirrhosisandhepatocellularcarcinoma.
Objectives:Tocomparesociodemographicandmentalhealth(riskbehaviors,depression,
andsuicide)aspects,andqualityoflifeamongpatientswithHCVorHTLV-1.
Methods:Observational,comparativeandcross-sectionalstudyinvolvingoutpatientswith
HCVorHLTV-1infection.Sociodemographiccharacteristics,riskbehaviorsandqualityof lifewereassessedthroughthequestionnairesMiniInternationalNeuropsychiatricInterview– MINIPlus(depressionandsuicide)andMedicalOutcomesStudy36-ItemShort-FormHealth Survey(qualityoflife).Univariateandmultivariatestatisticalanalyses(hierarchicallogistic regression)wereconducted.
Results:143individualswithHCVand113individualswithHTLV-1infectionwereincluded.
MaleswerepredominantintheHCVgroup(68.8%)andfemalesintheHTLV-1group(71.7%). Thefrequency ofriskbehaviors (sexual anddrug use)wasgreater inthose with HCV (p<0.05).Apast depressiveepisodewasmorecommonintheHTLV-1group(p=0.037).
∗ Correspondingauthor.
E-mailaddress:ricardohsaraujo@gmail.com(R.Henrique-Araújo).
https://doi.org/10.1016/j.bjid.2019.06.013
1413-8670/©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Qualityoflifewassignificantlyworseinthephysicalfunctioning,vitality,mentalhealth, andsocialfunctioningdomainsinthosewithHTLV-1(p<0.05).HTLV-1infectionremained independentlyassociatedwithworsequalityoflifeinmultivariateanalysis.
Conclusions: Risk behaviors arefrequent amongthose infectedwith HCV.Additionally,
despiteHTLV-1beingconsideredaninfectionwithlowmorbidity,issuesrelatedtomental health(depressiveepisode)anddecreasedqualityoflifearerelevant.
©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Human T-cell lymphotropic type 1 virus (HTLV-1) is an endemicvirusinsomeregionsoftheworld,includingsome states of Brazil. In the city of Salvador, the prevalence is 1.35–1.76%.1–3
HTLV-1 is transmitted by routes such as sexual rela-tions,verticaltransmission(primarilybybreastfeeding),blood transfusion,and sharingneedlesbyintravenousdrugusers (IVDU).2,3Itisaninfectionoflowmorbidity,asatleast90%of
theinfectedindividualsremainasymptomatic.Twotothree percentofpatientsdevelopsymptomsofHTLV-1associated myelopathy/tropicalspastic paraparesis(HAM/TSP),4 which
includemuscleweakness,gaitdisturbances,lowerbackpain, paresthesiaandhyperreflexia inthe lowerlimbs,intestinal constipation,urinaryretentionorincontinenceanderectile dysfunction. HAM/TSPhas apoor prognosis and adversely impactssurvivalandfinancialandsocialcostsduetoits pro-longedand progressivecourse and absence ofaneffective treatment.3
Manyaspectsofthediseasehavebeenpoorlyexplored,and thereisalackofhealthpoliciesandcaredirectedatpreventing silenttransmission(throughasymptomaticindividualswho areunaware oftheir seropositivity)aswell asascarcity of effectivetreatmentsforthosewhodevelopmorbidities.3
Itisestimatedthatmorethan70millionpeopleare chron-icallyinfectedbyhepatitisCvirus(HCV)worldwide,andclose to400thousanddieeach year duetocomplicationsofthe infection.5Itisconsideredapublichealthproblem,because
HCV isan importantcause ofcirrhosis and hepatocellular carcinoma, leading to liver transplantation.6 In Brazil, the
prevalenceofchronicinfectionisestimatedat1.38%,7 with ahigherprevalenceinmalesandasexratioof1.3:1.8
In addition to manifestations involving the liver, many extrahepaticmanifestationscanoccur,including neuropsy-chiatric disorders. This infection is associated with risk behaviorssuchas useofinjected or inhaleddrugs, unpro-tectedsex,multiplesexualpartners,andsexualactivitywith sexworkers.9Currently,treatmentsareavailablewithahigh
ratesofsustainedvirologicresponse.10
Healthrelatedqualityoflife(QoL)isanindividual assess-ment of a range of conditions and aspects that affect a personalperceptionofahealthcondition.11QoLisan
impor-tant measure associated with health and can deteriorate amongHTLV-1andHCVcarriers,especiallywhentheydevelop symptomaticstagesoftheseinfections.Theexistenceof emo-tional,behavioralorsocialadversitiesalsopredisposesthose infectedtoworseQoLmeasures.11–17
Studies havereportedmany aspectsoftheseinfections; however, HTLV-1 still remains an under-studied infection around the world. There has not been a real-world study comparingQoLandthefrequencyofdepression,suicide,and riskbehaviorsamongHTLV-1andHCVinfectedpatients.This study aimedtocompare theseaspectsinthesetwogroups ofinfectedindividuals.Althoughthetwoinfectionsareviral andhaveachroniccourse,itisimporttocomparequalityof life,behavioralaspectsandoutcomesrelatedtomentalhealth asthey maybedifferent, and thuscallforspecific consid-erationsand treatmentsettings.Bearinginmindthat HCV receivesnoticeablygreaterattentionfromthestandpointof publicpoliciesandinvestmentsingeneral,andthatHTLV-1 isacommonlyneglectedinfectionforitslowmorbidityand mortality, the resultsof thesestudy may flag up the need forchangingthisscenarioofdisregardfromthehealthcare systemandfromtheacademiccommunityregardingHTLV-1.
Material
and
methods
Studydesign
Thiswasaquantitative,observationalandcomparative cross-sectional studyofHCV orHTLV-1 infectedindividualswho werereceivingcareinthemultidisciplinaryoutpatientclinic attheUniversityHospitalComplexProfessorEdgardSantos -Com-HUPES(FederalUniversityofBahia)from2010to2014. Ethicsaspects
ThisresearchwassubmittedtoandapprovedbytheResearch Ethics Committee of the Maternity Hospital Climério de OliveiraattheFederalUniversityofBahia(MCO-UFBA- pro-cessnumber14/2002)beforethestartoftheinterviewsand datacollection.Allparticipatingpatientsreadandsignedthe informedconsentform.Thestudywasconductedaccordingto theprinciplesexpressedintheDeclarationofHelsinki,version 2013.
Subjects
All study participantswere diagnosed withHCVor HTLV-1 infectionbythehealthservicesteamaswellastheresearch group.During theirregular medicalappointments,patients receivingoutpatientcareattheparticipatingcentersof Com-HUPESdiagnosedwithHCVorHTLV-1infectionwereinvited toparticipateinthestudy.
Aconveniencesampleof171HCVinfectedindividualsand 119HTLV-1infectedindividualssignedtheinformedconsent formandmettheeligibilitycriteriawereincludedinthestudy.
Group1:HCVinfectedindividuals
Tobeincluded,HCVinfectedpatientshadtobeaged18years ormore,haveachronicinfection,asdeterminedbyapositive anti-HCVtestbyenzyme-linkedimmunosorbentassayIIIand confirmedbyqualitativedeterminationofHCV RNA.Those coinfectedwithhepatitisBvirus(HBV)(eightpatients),human immunodeficiencyvirus(HIV)(twopatients),orHTLV-1(one patient)wereexcluded.Inaddition, currenttreatmentwith interferonalfa(17patients),withmissingdata(twopatients) werealsoexcluded.Afterexclusions,141patientsremainedin thestudy.Inthisgroup,89(63.1%)patientswereonthewaiting list forliver transplantation and 52 (36.9%) had no indica-tionforhepatictransplantation(controlledinfectionwithout expressivedamageorhavingacontraindicationforthis pro-cedure; of these, only 14.3% presented, upon liver biopsy, absenceofinflammatoryactivityandnofibrosisaccordingto theMETAVIRclassification,besidesshowingtransaminasesat slightlyelevatedlevels)atthetimeoftheinterview.
Group2:HTLV-1infectedindividuals
Theinclusioncriteriawere ageover 18yearsand infection byHTLV-1,asdeterminedbyserologicaldiagnosisperformed byELISA(CambridgeBiotechCorp.,Worcester,MA,USA)and confirmedbyWesternblot (HTLVblot 2.4,Genelabs, Singa-pore). Were excluded those with HCV (five patients), HBV (onepatient),orHIV(nopatient)coinfection,aswellasthose withmissingdata(nopatient).Afterexclusions,113patients remainedinthe study.Inthisgroup, therewere43 (38.1%) asymptomatic patients, 36 (31.9%)with overactivebladder, and 34 (30.1%) with HAM/TSP. Symptomaticpatients com-prised62%ofthesample.
Thesamplesizeofbothgroupswasconsideredsuitable forthetaskofconductingthestatisticalanalysesusedinthis study.
Instruments
Sociodemographicquestionnaire
Includeddatasuchasage,sex,maritalstatusandrisk behav-iorsthroughoutlife(sexwithsexworker,morethanthreesex partnersinthepreviousyear,useofinhaledorinjecteddrugs).
MiniInternationalneuropsychiatricinterview-M.I.N.I.plus 5.0.0(MINIplus)
Brazilian version of the psychiatric interview (hetero-evaluation questionnaire)18 to explore the main mental
disorderslistedinDiagnosticandStatisticalManualofMental Disorders,fourthedition,textrevision(DSM-IV-TR)and Inter-nationalClassificationofDiseases,tenthrevision(ICD-10).19
Medicaloutcomesstudy36-Itemshort-formhealthsurvey (SF-36)
Brazilian version of the validated instrument,20 which
measures eight domains of QoL: physical functioning, role-physical, role-emotional vitalit, mental health, social functioning,pain,andgeneralhealth.21
Interviewswere carriedout byresearcherswithan aca-demic background in Psychology or Medicine/Psychiatry (properlytrainedfortheapplicationoftheinstruments).The patients were identified by the outpatient clinic staff and referred to the research group for evaluation bythe same researcheruntiltheendoftheinterviews.Consideringthat MINIPlusisahetero-evaluationinstrumentanditwasapplied firstandthatSF-36isanauto-evaluationscale,itwasnot nec-essaryfortheinterviewertobeblindedtothementalstatus ofthesubjects.
Dataanalysis
Collected datawerestoredusingtheStatistical Packagefor Social Sciences (SPSS win, version 21) and analyzed using thestatisticalsoftwareR(RDevelopmentCoreTeam,2011). Quantitativevariableswererepresentedbytheirmeansand standarddeviationswhentheirdistributionswerenormaland bymediansandinterquartilerangeswhennotnormal.The definition ofnormality was made through graphical anal-ysis and the Shapiro–Wilk test. Categorical variables were representedbyfrequenciesandpercentages.Univariate com-parisonsbetweengroupsweremadeusingStudent’st-testfor normallydistributedvariablesandtheMann-Whitneytestfor non-normallydistributedvariables.Forcategoricalvariables, thechisquaretestorFisher’sexacttestwereusedwhen nec-essary.Thetestswereperformedwithasignificancelevelof p<0.05.
Themultivariateanalysiswasconductedthrough hierar-chicallogisticregression,sequentiallyevaluating thepower ofthevariablesthatmightbeconsideredconfounders.The increaseofpredictivepowerofthemodelsignalsthat addi-tionalvariableshavetheirownpredictivepowerregardlessof theformerlyaddedvariables.
Results
Consideringsociodemographiccharacteristics,malesexwas morecommonintheHCVgroup(68.8%HCVvs.28.3%HTLV-1; p<0.001).Themajorityofpatientsfrombothgroupswere mar-riedorinastablerelationship(58.4%HTLV-1and66%HCV). There were no significant differences between the groups regardingageandmaritalstatus(Table1).
Weanalyzedriskbehaviorsassociatedwithsexpractices anduseofdrugs.Thevariablessexwithsexworkeratleast onceinalifetime,morethanthreesexpartnersinthe pre-vious year,use ofinhaled orinjectable drugsatleastonce werealwaysmoreprevalentintheHCVgroup(p<0.05). HTLV-1patientsdevelopedsignificantlymoredepressiveepisodesin thepast(26.5%HTLV-1vs.17.7%HCV;p=0.037).Riskofsuicide tendedtobehigherintheHTLV-1group,butthedifferencewas didnotreachthelevelofsignificance(p=0.08)(Table2).
Additionally, theHTLV-1grouphadasignificantlyworse QoLinfouroftheeightdomainsevaluatedbySF-36,asfollows: physical functioning (p=0.001), vitality, mental health and socialfunctioning(p<0.001fortheselastthreedomains).The remainingdomains(role-physical,role-emotional,pain and generalhealth)wereequivalentornon-significantlyworsein thetwogroups(Table3).
Table1–SociodemographicaspectsbetweentheHCVandHTLV-1infectedgroups.Salvador,Brazil,2017. Total HTLV-1 HCV p-value (n=254) (n=113) (n=141) Agea 56.0(49.0–63.0) 55.0(45.0–64.0) 57.0(51.0–63.0) 0.165 Male 129(50.8) 32(28.3) 97(68.8) <0.001 MaritalStatus 0.132 Single 41(16.1) 24(21.2) 17(12.1) Married/stablerelationship 159(62.6) 66(58.4) 93(66.0) Divorced 33(13.0) 12(10.6) 21(14.9) Widower 20(7.9) 11(9.7) 9(6.4)
Testsused:Mann–WhitneytestandChisquaretest.Thetestswereperformedwithasignificancelevelofp<0.05. AlldataarearrangedasN(%).
a Mean±standarddeviation.
Table2–Riskbehaviors,depressionandsuicideriskbetweentheHCVandHTLV-1groups.Salvador,Brazil,2017.
Total HTLV-1 HCV p-value
(n=254) (n=113) (n=141)
Riskbehaviors 96(37.8) 18(15.9) 78(55.3) <0.001
Sexual
Sexwithsexworker 75(29.5) 14(12.4) 61(43.3) <0.001
Morethan3sexualpartnersinthelastyear 23(9.1) 4(3.5) 19(13.5) 0.011
Druguse
Injectabledrug 20(7.9) 1(0.9) 19(13.5) 0.001
Inhaleddrug 27(10.6) 2(1.8) 25(17.7) <0.001
Majordepressiveepisode(current/past) 69(27.2) 33(29.2) 36(25.5) 0.609
Currentmajordepressiveepisode 0.361
Absent 227(89.4) 105(92.9) 122(86.5)
Notspecified 18(7.1) 7(6.2) 11(7.8)
Duetomedicalcondition 1(0.4) 0(0.0) 1(0.7)
Withmelancholiccharacteristics 8(3.1) 1(0.9) 7(5.0)
Total 27(10.6) 8(7.1) 19(13.5)
Pastmajordepressiveepisode 0.037
Absent 199(78.3) 83(73.5) 116(82.3)
Notspecified 39(15.4) 25(22.1) 14(9.9)
Duetomedicalcondition 3(1.2) 1(0.9) 2(1.4)
Withmelancholiccharacteristics 13(5.1) 4(3.5) 9(6.4)
Total 55(21.7) 30(26.5) 25(17.7) Suiciderisk 0.149 Absent 190(74.8) 78(69.0) 112(79.4) Low 39(15.4) 20(17.7) 19(13.5) Moderate 3(1.2) 1(0.9) 2(1.4) High 22(8.7) 14(12.4) 8(5.7)
Suiciderisk(low,moderateorhigh–reference:absent) 64(25.2) 35(31.0) 29(20.6) 0.08
Testsused:Mann–WhitneytestandChisquaretest.Thetestswereperformedwithasignificancelevelofp<0.05. AlldataarearrangedasN(%).
Table3–QualityoflifeaccordingtoSF-36amongHCVandHTLV-1groups.Salvador,Brazil,2017.
Total HTLV-1 HCV p-value (n=254) (n=113) (n=141) Physicalfunctioning 70.0(45.0–90.0) 60.0(20.0–90.0) 80.0(52.5–95.0) 0.001 Role-physical 50.0(0.0–100.0) 50.0(0.0–100.0) 50.0(0.0–100.0) 0.554 Role-emotional 100.0(33.3–100.0) 100.0(33.3–100.0) 100.0(33.3–100.0) 0.727 Vitality 55.0(45.0–70.0) 50.0(45.0–60.0) 65.0(45.0–80.0) <0.001 Mentalhealth 64.0(56.0–80.0) 60.0(51.0–64.0) 80.0(64.0–92.0) <0.001 Socialfunctioning 50.0(50.0–75.0) 50.0(37.5–50.0) 75.0(50.0–100.0) <0.001 Pain 77.5(55.0–100.0) 87.5(87.5–87.5) 70.0(55.0–100.0) 0.392 Generalhealth 60.0(45.0–80.0) 60.0(45.0–70.0) 60.0(45.0–80.0) 0.817
Testsused:Mann–WhitneytestandChisquaretest.Thetestswereperformedwithasignificancelevelofp<0.05. Alldataarearrangedasmedian(25thpercentile-75thpercentile).
Table4–Multivariateanalysis(hierarchicallogisticregression)Salvador,Brazil,2017.
Group1(Riskbehavior) Group2(Sex) Group3(Currentdepressiveepisode) Group4(Qualityoflife)
NagelkerkeR2 0.212 0.256 0.295 0.619
Likelihood-ratio – 10.2 9.2 109
pvalue <0.001 <0.001 0.02 0.01
AIC 309.2 300.9 297.7 205.7
AUROC(95%CI) 0.697(0.644–0.750) 0.740(0.682–0.794) 0.766(0.710–0.821) 0.907(0.869–0.943)
Themultivariateanalysisconductedthroughhierarchical logisticregressionshowedthatthepresenceofHTLV-1was consideredanindependentfactor forworse resultsinQoL. ThisevidencestemsfromprogressingvaluesofNagelkerkeR2 anddecreasingAkaikeinformationcriterion(AIC),whichare measuresformodelquality,insofarasthevariablesthoughtto beconfounderswerebeingaddedtotheanalysis:risk behav-iors,sex,andcurrentdepressiveepisode(Table4).
Discussion
ThisstudyfoundthatHTLV-1infectedindividualshavea sig-nificantly higherrate ofpastdepression and worseQoL in physicalfunctioning,energy,emotionalwell-beingandsocial functioningdomainsofSF-36.Thesefourdomainsrepresent notonlyphysicalbutalsopsychosocialelements,showinga broadnegativerepercussioninthelifeofthesesubjects.Thus, itwasshownthatpeoplewithHTLV-1mayhaveaworsehealth statusdespitetheideathat,duetothelowmorbidityofthe virus,thisinfectiondoesnotneedtoreceiveextraattentionin healthpolicies.Thestudycomparedrelevanthealthaspects (especiallymental)ofpatientswithHTLV-1 andthose with HCV.Thislatterinfectionreceivesgreatinvestmentsin pre-ventioncampaigns,screening,effectivetreatment,andaccess tocare.
Regarding sex, this sample is consistent with previous reports.There weremoremales intheHCVgroup withan M:Fratio(2.2:1)whichexceedstheratioinBraziliangeneral population(1.3:1).22Beingmaleisariskfactorfor progress-ingtothe symptomaticstage,23,24 whichmight explainthe
higherratesofdiagnosesandfollow-upinmen,alsoshownin thisstudy.AmongHTLV-1patients,thereweremorefemales (71.7%),inlinewithotherstudies(66.6–83%).14–16,25–27
Evolu-tion toHAM/TSPhasbeen described tobeassociatedwith femalesex.4
Reviewstudieshavereportedtherelationshipbetweenrisk behaviors and HCV infection. Giunta et al.28 showed high
rates, between 50% and 90%, ofpositive serology forHCV amongIVDU. Cucciareet al.29 foundthat 58–78% ofthose
withHCVhadacurrentorpasthistoryofproblematicuseof psychoactivesubstances.LucaciuandDumitrascu30showed
asignificantpresenceofriskbehaviorsamongHCVinfected subjects (intravenous drug use, alcohol consumption, and riskysexualactivities),suchaswasfoundinthispresentstudy. Depressionratesinthecompletesample(27.2%)orineach groupseparately(29.2%HTLV-1vs.25.5%HCV)werehigher thanBrazilianrates:SãoPaulocity—16.8%duringlifeand4.5% inthelastmonth.31
DepressionprevalenceintheHCVgroupisalsoconsistent withpreviousstudies.32–34Tavakkolietal.35reportedahigher
prevalenceofcurrentdepression,whichisprobablyexplained
by higher rates of intravenous drugs use (53% vs. 13.5%). Anotheritemofinterferencemighthavebeentheevaluation method(self-administeredinstrumentPatientHealth
Question-naire-PHQ-9–vs.MINIPlusself-reportpsychiatricinterview).
Even though the PHQ-9 is a validated instrument for this population,33assessmentbywayofpsychiatricinterviewsby
anexperiencedevaluatoristhemostaccuratemethod.36
In theHTLV-1 group,current depressionrate(7.1%) was similar tothatfoundbyGuiltinan etal.37 (5.4%). Boa-Sorte
et al.27 and Galvão-Castroet al.15 reported 38% and34.1%, respectively,ofrecurrentdepression,whileourresearchfound 29.2% ofmajordepressionas awhole(current and/orpast episodes). In these studies the rates of depression maybe slightly overestimated as more subjects were affected by HAM/TSP(43.5%and36.4%,respectively)comparedtothe cur-rentstudy(30.1%).Thisreasoningcanbeupheldaccordingto Gascónetal.14whoshowedanassociationbetweenpresence
ofHAM/TSPandmarkedlyelevatedratesofdepression com-paredtoasymptomaticpatients(59.3%inHAM/TSPsubjects and22.4%inasymptomaticsubjects;p<0.001).Itshouldbe notedthattherateofHAM/TSPappearstobeinsufficientto fullyexplainthecleardifferenceincurrentdepressionrates tootherstudies,15,26,27,38evenwhenconsideringthat
Rocha-FilhoandGonc¸alves39foundelevatedratesofdepressionin
individualswithHTLV-1,withaslightvariationamong symp-tomatic(70%)thanamongasymptomaticpatients(60.5%)and innon-infectedcontrols(15.6%),bywayoftheself-assessment instrumentHospitalAnxietyandDepressionScale—HADS).Other unidentifiedfactorsmayhavecontributedtothisdivergence. Pastdepressiveepisodesweresignificantlymorefrequent intheHTLV-1group.Thefrequenciesofdepressionasawhole (pastand/orcurrent)werealsohigherintheHTLV-1group, althoughitdidnotreachstatisticalsignificance.Thechronic course ofthe two infections, withchanges inthe scale of decades,andthecross-sectionstudydesignmadethe eval-uationofchronologytobeadequatelyascertained.Therefore, theinvestigationoftheroleoftheviralinfectionincausing depressioncouldbefirmlyestablished.
Alltheindividualswerereceivingmulti-professional assis-tanceatthetimeofthestudy.Thismaysignalthatthistypeof supportiscapableofdecreasingtheincidenceofdepression (giventhelowerratesofpastandcurrentdepressioninboth groups),mainlyinthosewithHTLV-1infection(theratesof depressioninthisgroupreducedfrom26.5%to7.1%,whereas intheHCVgroupitonlyreducedfrom17.7%to13.5%).Suicide riskwasgenerallyhigherintheHTLV-1group;however,itdid notreachstatisticalsignificance,onlyatrendwhen consider-ingallthelevelsofseveritytogether(p=0.08).
QoL measures should receive special attention,as they broadly evaluate the elements that interfere with and contributetothepersonalperceptionofaspecificindividual’s
healthstatus.11AmongthosewithHTLV-1,thedecliningQoL
measureshighlightthe detrimentalrepercussionsof HTLV-1infection onthe patients’ physicaland psychic health. A highadverseimpactonthelevelsoflifesatisfactioncouldbe observed,consideringthatthescoreswereworsecompared tothose ofindividuals with HCV,who also sufferfrom an infectionwithmanyadversities.
ComparedtothestudybyCoutinhoetal.,25inourstudy
thedomainsphysicalaspects,functionalcapacity,andpainof HTLV-1infectedpatientshadmorefavorablelevels(Coutinho etal.foundscoresof24.2,27.1and41.7respectively).However, inthereportedstudy,allpatientshadsymptomsofHAM/TSP, comparedtoonly30.1%inourstudy.Gonc¸alvesetal.40found
verysimilar ratesfor almostall QoLdomains according to SF-36comparedtothisstudy.Theratesofindividuals with HAM/TSPineitherstudy were reasonablysimilar (36%and 30.1%).Nonetheless,theauthorsdidnotmentionwhetherthe restofthesamplewascompletelyasymptomaticorifthere werealsosomeurinarysymptoms.
Vahidniaetal.41conductedastudyinvolvingblooddonors
andfoundworselevelsofQoLamongHCVindividuals com-pared with HTLV individuals (the study did not specify whetherthestudyincludedHTLV-1aloneorifitalsoincluded HTLV-2),countering the findings ofourstudy. Itshould be pointedout that thestudy samplehad different character-istics,sincethe subjectshad no significantsymptoms and theinfections were diagnosedbychance.Thisdiffersfrom thesampleofthecurrentstudy,whichwasaclinicalsample withmanysubjectswithadvancedsymptoms.Furthermore, adifferentinstrumentwasused,theEuroQolFiveDimension (EQ-5D).
Shublaqetal.16evaluatingasampleexclusivelycomposed
ofHAM/TSPpatients,foundscoresbelow20forthedomains physicalfunctioning,physicalaspectsand emotional func-tioning,muchlowerthanthecurrentresults.Ourstudy did notevaluateQoLofHTLV-1infectedpatientsstratifiedby clin-icalpicture,which does notallowcomparisonswiththese previouslypublisheddata.
Although the studies by Galvão-Castro et al.15 and by
Gascónetal.14 evaluatedQoLofstudyparticipantsaffected
by HTLV-1, these researchers used a different instrument (WHOQOL-Bref),makingitdifficulttocompareresults. How-ever,thesestudiesseemtobeconsistentwiththedatafrom ourstudy regardingtheunfavorableQoLinHTLV-1infected patients.
ResultsofourstudysuggestthatHTLV-1infectedpatients, withanadverseprognosisanddegradingcourseofdisease, progressivelyevolvetodysfunctionality.3,25,27Theabsenceof
effective viral treatment, with only symptomatictherapy,3
wouldresultinincreasedstressandhopelessnesscompared toHCVpatients.Futurestudiesthatspecificallyevaluatedata suchashopelessnessamongHTLV-1carriers,throughspecific instruments,willbenecessaryforfurtherclarificationofthis subject.
Some limitations of this study should be taken into account. This was a cross-sectional study, which hinders theevaluationofcausality.Aconveniencesamplewasused, makingit difficulttoextrapolatethe resultstothe general infectedpopulation.Due tothelimited samplesize,itwas
impossibletostratifyallinfectedindividualsintodifferent lev-elsofclinicalimpairmentseverity,forthiswouldcompromise statistical power todetect importantimportantdifferences betweengroups.Inaddition,therewasnocontrolgroupwith otherclinicalillnesses.Futurelongitudinalstudies,withlarge probabilitysamplesandbroadercontrolforconfounding vari-ables,willhopefullyofferamorecomprehensiveevaluation oftheissuespresentedinthispublication.
Insummary,theresultsofthisstudyshowthatpatients with HTLV-1 had unfavorable outcomes regarding mental healthandQoLwhencomparedtothosewithHCV.Patients withHCV,inturn,hadhigherfrequenciesofriskbehaviors.In viewofthiscomparativescenario,moreinvestments regard-ingpublichealthpoliciestotackleHTLV-1-relatedproblems arenecessarysothatpatientswithsuchcompromisedhealth indicatorscanreceivethenecessarytherapeuticsupport.One should alsobe aware of the need for the development of studiestocomplementthescarceliteratureonthisinfection, especially regarding aspects ofmental health. Thus, these studies should aimto determine whatother health mark-ers ofHTLV-1carriers are negatively affected.In thesame way,supportand treatmentmethodsmustbedevelopedto improve QoL and overall health during the course of the disease,includingpreventivestrategiesfortheseoutcomes. This supportshouldbe based onspecialized care environ-mentswithmulti-professionalteams,involvingrehabilitation and physicalactivity,provisionoforthoticsandsuppliesto facilitatemotorfunction,painmanagement,psychiatricand psychologicalsupport,andsocialsupportandcare.
Financial
support
ThisprojectwaspartiallysupportedbytheNational Coun-cil of Technological and Scientific Development (CNPq): 462014/2014-2-EditalUniversalMCT/CNPQ2014.Thefunders hadnoroleinstudydesign,datacollectionandanalysis,the decisiontopublish,orpreparationofthemanuscript.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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