Depressive symptoms, intrusive thoughts, sleep quality and sexual quality of life in women co-infected with human immunodeficiency virus and human papillomavirus

Abstract

Women infected with human immunodeficiency virus (HIV) experience major challenges and often report marked decreases in sexual functioning and quality of life (QOL). HIV-infected women also face challenges concerned with other commonly observed concomitant sexually transmitted organisms, such as human papillomavirus (HPV), which may further affect sexual QOL. Despite advances made in understanding factors that predict sexual functioning and QOL in men with HIV, relatively little is understood about the role of behavioural and emotional factors in women.
As a preliminary inquiry into this question, this study related depressive symptoms, AIDS-related intrusive thoughts and sleep quality with sexual QOL reports in 21 HIV+HPV+ women.
We found that depressive symptoms, intrusive thoughts and sleep quality individually predicted poorer sexual QOL. Further analyses suggested that depression mediated the relationship between intrusive thoughts and sexual QOL.
Implications for further work and clinical interventions to address depressive symptoms in this population are discussed.

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Chronic Illness
http://chi.sagepub.com/content/1/4/281
The online version of this article can be found at:
DOI: 10.1177/17423953050010041001
2005 1: 281Chronic Illness
Rachel C. Rose, Michele R. Peake, Nicole Ennis, Deidre B. Pereira and Michael H. Antoni
women co-infected with human immunodeficiency virus and human papillomavirus
Depressive symptoms, intrusive thoughts, sleep quality and sexual quality of life in
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© W. S. Maney & Son Ltd 2005 DOI: 10.1179/174239505X72032
Chronic Illness (2005) 1, 281–287
Reprint requests to: Michael H. Antoni.
Email: mantoni@miami.edu; fax: + 1 305 284 1366
R P
Depressive symptoms, intrusive thoughts, sleep quality
and sexual quality of life in women co-infected with
human immunodeficiency virus and human
papillomavirus
RACHEL C. ROSE*, MICHELE R. PEAKE*, NICOLE ENNIS*,
DEIDRE B. PEREIRA† and MICHAEL H. ANTONI*
*Department of Psychology, University of Miami, PO Box 248185, Coral Gables,
FL 33124-0751, USA
†
Department of Clinical and Health Psychology, University of Florida, PO Box 100165,
101 S. Newell Dr., Room 3137, Gainesville, FL 32610-0165, USA
Background: Women infected with human immunodeficiency virus (HIV) experience major challenges and often
report marked decreases in sexual functioning and quality of life (QOL). HIV-infected women also face challenges
concerned with other commonly observed concomitant sexually transmitted organisms, such as human papil-
lomavirus (HPV), which may further affect sexual QOL. Despite advances made in understanding factors that
predict sexual functioning and QOL in men with HIV, relatively little is understood about the role of behavioural
and emotional factors in women.
Methods: As a preliminary inquiry into this question, this study related depressive symptoms, AIDS-related
intrusive thoughts and sleep quality with sexual QOL reports in 21 HIV
+
HPV
+
women.
Results: We found that depressive symptoms, intrusive thoughts and sleep quality individually predicted poorer
sexual QOL. Further analyses suggested that depression mediated the relationship between intrusive thoughts and
sexual QOL.
Discussion: Implications for further work and clinical interventions to address depressive symptoms in this
population are discussed.
Keywords: Depressive thoughts, HIV/AIDS, Intrusive thoughts, Sexual quality of life, Sleep quality
INTRODUCTION
An illness that is embedded in sexual
behaviour and alters a woman’s sexual rela-
tionship, such as human immunodeficiency
virus (HIV) disease, may affect her sexual
quality of life (QOL). One of the most
intimate relationships between people is
sexual in nature. The concept of sexual QOL
involves reciprocal pleasure and exchange
as the primary modes of relating between
individuals.1 Optimal sexuality involves a
positive relationship between the individuals
involved, their own interpersonal issues, and
their emotions and beliefs. Relatively little
is known about the cognitive and emotional
factors that might contribute to sexual QOL
in women with HIV infection. Emotional
factors such as depression and anxiety may
influence the way in which a woman sees
herself sexually, her comfort with her own
bodily sensations, and her sexual desire.2 In
non-HIV
+
populations, depression is well
known to be associated with decreased levels
of sexual desire and satisfaction.3 Intrusive
thoughts that are associated with anxiety or
depressed affect are bothersome and may
prevent the woman from being able to relax
and enjoy her sexual experiences.
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282 ROSE ET AL.
Among women with HIV infection, intru-
sive thoughts may involve concerns about
transmitting the infection to their partners,
and could decrease intimacy and feelings of
relaxation in a sexual situation. In addition,
Moneyham et al.4 showed that women
with HIV infection are more likely to be
depressed than their HIV
−
counterparts.
Interestingly, Bova and Durante5 found that
HIV
+
women continued to have sex after
testing positive, and that sexual functioning
was not altered as a result of HIV disease
progression. They also observed that those
women who had better mental health, more
positive meaning in their lives, better QOL
and fewer HIV-related symptoms, and who
never used injection drugs, had higher levels
of sexual functioning.
It is possible that behavioural factors play
a role in determining sexual QOL in these
women. Given that intrusive thoughts have
been associated with sleep disturbances,6 it
is also possible that anxiety-related thought
intrusions affect sexual QOL by way of sleep
disruptions. These factors may interact
within the individual and result in reduced
sexual QOL. This study’s primary focus
was on the interaction of HIV-specific intru-
sive thoughts, depressive symptoms and
sleep quality in predicting sexual QOL in
this population. We tested the hypothesis
that depressive symptoms, AIDS-related
intrusive thoughts and sleep quality were
associated with lower sexual QOL in HIV
+
women.
MATERIALS AND METHODS
Participants
The sample for this study consisted of HIV
+
women with human papillomavirus (HPV)
infection recruited from special immunology
clinics located at the University of Miami/
Jackson Memorial Hospitals. These women
were participating in a longitudinal study of
psychosocial and behavioural factors con-
tributing to the development of cervical neo-
plasia. To be considered eligible, women
had to meet the following study criteria.
Key inclusion criteria
1. HIV
+
HPV
+
, and age 18–60 years
2. history of two or more abnormal
cytological smears [atypical cells
of undetermined significance or
low-grade squamous intraepithelial
lesions (LGSIL)] during the 2 years
prior to study entry.
Key exclusion criteria
1. more than one negative cytological
smear during the 2 years prior to
study entry
2. history of SIL diagnostic or treatment
procedures in the 6 months prior to
study entry
3. current pregnancy or less than 6
weeks postpartum
4. history of high-grade SIL or cervical
cancer (unless high-grade SIL occurs
at study entry)
5. suicidality
6. drug dependence
7. psychoticism
8. antisocial/borderline personality dis-
order
9. HIV dementia
10. poor comprehension of English (less
than 6th grade level for reading or
writing).
Measures
Impact of Events Scale–Revised (IES-R)7
To assess for disease-specific stress-related
symptomatology, the Impact of Events
Scale–Revised (IES-R) was utilized. This
22-item questionnaire assessed the cognitive
responses of participants to having AIDS or
the threat of AIDS in their lives. The ques-
tions included items used to derive intrusive
thoughts and avoidant behaviours score.
Each participant responded with one of five
answer choices regarding the degree to
which this statement applied to her (0=Not
at all to 4=Extremely). Only the intrusion
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DEPRESSIVE SYMPTOMS IN WOMEN CO-INFECTED WITH HIV AND HPV 283
subscale was included in this analysis. The
IES intrusion subscale has shown a mean
alpha across numerous studies equal to
0.86.8
Center for Epidemiological Studies–Depression
Scale (CES-D)9
Depressive symptoms were measured using
the CES-D scale, a 20-item self- rating scale
developed to screen for depression in pri-
mary care settings. Each item is scored 0–3,
to measure the frequency with which the
symptoms occurred in the last week, ranging
from ‘never to rarely’ to ‘most or all of the
time’. A score of 16 or higher is generally
used to denote a moderate level of depressive
symptoms. Internal consistency has been
shown to be high (alpha >0.85).10
Psychosocial Adjustment to Illness Scale
(PAIS)11
Women who were currently involved in a
sexual relationship completed the sexual
relationship domain of the PAIS, which
measures sexual QOL. Items in this measure
were designed in a progressive sequence,
beginning with a focus on the quality of
interpersonal relationships and concluding
with specific questions on the sexual rela-
tionship. The six questions were rated on
a four-point scale from 0 (no problem) to 3
(many difficulties). Higher scores indicated
poorer QOL. This sexual relationship scale
showed good internal consistency for per-
sons with breast cancer (alpha=0.86)12 and
Hodgkin’s disease (alpha=0.81).13
Pittsburgh Sleep Quality Index (PSQI)14
The PSQI measures seven components of
overall sleep quality: subjective sleep quality,
sleep latency, sleep duration, habitual sleep
efficiency, sleep disturbance, use of sleep
medication and daytime sleep dysfunction in
a 1-month period. In this study, one compo-
nent was used for analysis, subjective sleep
quality. This item is measured on a four-
point scale from 0 (‘very good’) to 3 (‘very
bad’). The PSQI has shown good internal
consistency (alpha=0.83).15
Immunological assessment
Immune status was determined by measur-
ing CD4
+
CD3
+
cell number (helper–inducer
T-cells). A trained phlebotomist performed
all the blood draws at the Women’s Health
Initiative Program (WHI) at the University
of Miami School of Medicine. Blood
samples were taken to the EM Papper
Clinical Immunology Laboratory within 2 h
of the draw. The number of CD4
+
CD3
+
cells was determined by four-colour immun-
ofluorescence analysis on whole blood using
a single laser flow cytometer (Coulter XL
Cytometer, Coulter Corporation, Hialeah,
FL, USA).
Procedures
The measures used in this study form part
of a larger psychosocial battery. Three
psychology graduate students and a post-
doctoral clinical psychologist administered
the in-person assessments. The participant
was provided with the measures in a private
interview room that offered a private and
supportive environment in which any ques-
tions that the participant may have had
could be answered, in order to establish and
build rapport.
Data Analysis
Descriptive statistics were computed for
demographic characteristics (e.g. age,
income, marital status, number of children),
disease status (presence/absence of AIDS),
health behaviours (e.g. smoking) and
psychosocial variables (e.g. life stress,
depression history). Zero-order Pearson cor-
relations were calculated between potential
control variables and immune parameters
and outcome variables (e.g. depression,
sexual QOL). Those control variables that
were significantly correlated with the out-
come variables in the present sample were
controlled for with the following statistical
procedures. Using the Baron and Kenny16
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284 ROSE ET AL.
method, mediation was tested by regressing
sexual QOL scores on the predictor (e.g. IES
intrusion scale) and two separate mediator
variables (e.g. depressive symptomatology
and sleep quality).
RESULTS
Of the initial 46 women recruited, only 21
(46% of the sample) were sexually active
(had sex within the past month). Only this
sub-sample was included in the study analy-
ses. The women’s mean age was 28.76 years
(SD=8.70), and mean duration of educa-
tion was 11.39 years (SD=1.27). The
majority of the women were Black (92%),
3.4% were Hispanic, and 2.7% were of
mixed racial heritage. The ethnic distribu-
tion of the sample was 73% African-
American, 8.1% Caribbean Islander, 2.7%
Cuban-American, 2.7% Nicaraguan, and
2.7% multiple ethnicities. A majority of
the participants were single/never married
(52.1%), and 22.9% were divorced or sepa-
rated. Fifty-eight per cent of the women
had a yearly income of $10,000 or less, and
52% were currently unemployed. The mean
yearly income was $11,365 (SD=6501).
The mean number of children for each
woman was 1.72 (SD=1.37); 52% had at
least two children, and 19% had no children.
The mean age for their first pregnancy was
17.94 (SD=4.26). The mean length of time
since HIV diagnosis was 8.16 years (SD=
3.95). Sixty-seven per cent of the women
reported ongoing use of antiretroviral HIV
medications.
Control Variables
Zero-order Pearson correlations were used
to calculate relationships between the main
study variables (depressive symptoms, intru-
sive and avoidant thoughts, sexual QOL,
sleep quality) and continuous control vari-
ables. Analysis of variance (ANOVA) was
utilized to explore the relationships between
the study variables and categorical control
variables: In particular, demographic fac-
tors, including income, marital status, edu-
cation and number of children, and health
factors, including smoking, exercise, HIV
disease progression and length of time on
HIV medication, were looked at as potential
confounding variables. Single or never-
married women reported more depressive
symptoms than those who were married;
F(4,40)=2.71, p=0.043. Reported sexual
QOL tended to be lower in women diag-
nosed with more advanced stages of HIV/
AIDS (e.g. higher CDC clinical axis;
F(2,27)=2.68, p=0.087).
Depressive Symptoms, Intrusive
Thoughts and Sexual Quality of Life
For the main regression analysis, sexual
QOL was regressed on the IES intrusion
subscale score. After CD4
+
CD3
+
number
and PSQI sleep quality were controlled for,
intrusive thoughts significantly predicted
poorer sexual QOL (b=0.485, p=0.033).
We also found that depressive symptoms
were correlated with IES intrusion scores
(r=0.310, p=0.041) and sexual QOL (r=
0.456, p=0.010). Since both the CES-D
and IES intrusion subscale scores were
related to sexual QOL, we tested depressive
symptoms as a mediator between the intru-
sive thoughts and sexual QOL. Following
Baron and Kenny’s 16 mediation procedure,
we showed that intrusive thoughts no longer
significantly predicted sexual QOL when
depressive symptoms were added to the
regression equation (b=0.233, p=0.256).
This suggested that depressive symptoms
acted as a mediator of the association
between intrusive thoughts and sexual QOL.
Because the physical symptoms of HIV dis-
ease may mimic some depressive symptoms,
such as poor appetite and fatigue, additional
analyses were performed to address this
issue in the present sample. Two somatic
items (‘I did not feel like eating; my appetite
was poor’ and ‘My sleep was restless’)
were removed from the CES-D to evaluate
whether disease-relevant depressive symp-
toms may have accounted for the present
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DEPRESSIVE SYMPTOMS IN WOMEN CO-INFECTED WITH HIV AND HPV 285
findings. In this equation, sexual QOL was
regressed on depressive symptoms (with
these somatic items removed) after control-
ling for CD4
+
CD3
+
number and subjective
sleep quality. With hierarchical linear regres-
sion, the presence of depressive symptoms
with the somatic items removed still pre-
dicted sexual QOL (b=0.623, p=0.003).
Sleep Quality, Depressive Symptoms
and Sexual Quality of Life
We ran one more set of mediator analyses —
these focused on sleep quality. Since sleep
disruptions may form part of the clinical pic-
ture in depression, we tested whether lower
sleep quality mediated the association that
we had observed between depression and
poorer sexual QOL. After controlling for
CD4
+
CD3
+
number, better subjective sleep
quality was found to significantly predict
better sexual QOL (b=0.523, p=0.034)
and was correlated with fewer depressive
symptoms (r=–0.527, p < 0.05). Since both
the sleep quality and depression scores were
related to sexual QOL, we tested sleep
quality as a mediator between the depression
and sexual QOL. Following Baron and
Kenny’s15 mediation procedure, we estab-
lished first that depression symptoms were
a significant predictor of poorer sexual QOL
(b=0.753, p<0.001) (without controlling
for sleep quality). Depressive symptoms had
a weaker though still significant effect when
sleep quality was added to the regression
equation (b=0.671, p=0.002). This sug-
gested that sleep quality did not mediate the
association between depression and sexual
QOL in this population.
DISCUSSION
The present study investigated whether
depressive symptoms, AIDS-related intru-
sive thoughts and sleep quality were ass-
ociated with decreased sexual QOL in
HIV
+
HPV
+
women. We found that women
who have greater depressive symptoms and
greater intrusive thoughts report poorer
sexual QOL. In addition, we found that
depressive symptoms mediated the associa-
tion between intrusive thoughts and lower
sexual QOL.
Disease-related intrusive thoughts may
prevent an HIV-infected woman from being
able to relax and enjoy her sexual experi-
ences. The present study suggested that
women with depressed mood may ruminate
about such stressors and this may, in turn,
detract from the quality of their sexual rela-
tionships. Intrusive thoughts are a common
symptom of both anxious and depressed
affect. It is no surprise that women with HIV
disease may have illness-related intrusive
thoughts. The intrusive thoughts may be a
result or symptom of depression and anxiety
and may be increased by sexual activity
because of fear of transmission. Intrusive
thoughts focused on fears of transmitting the
disease to her partner may decrease intimacy
and feelings of relaxation in a sexual situa-
tion. Meyer-Bahlburg et al.17 found that the
most salient reasons for HIV
+
women to
have a decrease in their sexual desire after
testing positive were fear of transmission,
depression, stress, street drug use, problems
with partners, and alcohol consumption.
Alternatively, the findings of depression,
disease-related intrusive thoughts and sexual
QOL may simply reflect a direct relationship
between depression and poorer sexual QOL
in this sample, as intrusive thoughts may be
a specific symptom of the depressive condi-
tion. It is well established that depression
is associated with decreased levels of sexual
desire, sexual arousal problems, orgasm dif-
ficulties, reduced sexual satisfaction, and
sexual pain.3 There are only a few published
studies that address sexual functioning
and satisfaction in HIV
+
women. Meyer-
Bahlburg et al.17 found that, in contrast to
findings with HIV
+
men, HIV
+
women had
higher rates of problems in sexual function-
ing even at the earliest stage of HIV disease
progression, suggesting that this decrease in
satisfaction may be related not solely to the
physical aspects of the illness but also to the
psychosocial and emotional problems that
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286 ROSE ET AL.
are associated with having HIV, resulting in
decreased sexual desire. Whether this asso-
ciation is intensified by the fact that these
women were co-infected with HPV, another
sexually transmitted infection, cannot be
determined from this study, but should be
explored in future work.
Lack of sexual desire is an often over-
looked but common occurrence in medical
populations, but these relationships can be
difficult to elucidate in view of the physical
symptoms of the disease process.18 The
physical symptoms of HIV disease, such as
poor appetite and fatigue, may mimic some
depressive symptoms. Therefore, follow-up
analyses were performed to address this
issue in the present sample. However, the
presence of depressive symptoms with the
somatic items removed still predicted sexual
QOL. This suggests that physical disease
status probably did not account for the rela-
tionship between depressive symptoms and
sexual QOL in these women.
The results of this study are limited by its
small sample and cross-sectional design. It is
therefore unclear whether the psychosocial
factors investigated in this study would be
associated with sexual QOL over time. Addi-
tionally, it is impossible to conclude whether
changes in depressive symptoms, intrusive
thoughts, sleep quality and sexual QOL
follow, precede or coincide with each other.
Prospective or longitudinal designs are
needed to address these concerns.
CONCLUSIONS
To summarize, one area of life that is often
overlooked in medical and therapeutic set-
tings is an HIV-infected woman’s sex life.
This research points to the importance of
assessing sexual QOL and mood state in
clinical settings. If a depressive condition or
anxiety state is identified, psychosocial or
pharmacological interventions should be
offered in a culturally sensitive fashion.
Raising the level of sensitivity among care
providers to the relationships between mood
and sexual QOL in HIV-infected women
may begin to bridge the gap between
healthcare providers and this understudied
population, in order to help make these
women’s lives more physically, mentally and
emotionally fulfilling.
. This work was
supported by grants T32-MH18917, P01-
MH49548, P30CA14395 and P50CA84944
from the National Institutes of Health. The
authors would like to acknowledge the
contributions of nurse practitioners, social
workers and caseworkers within the Depart-
ment of Obstetrics and Gynecology at the
University of Miami.
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