title: Symptom Clusters in People Living with HIV Attending Five Palliative Care Facilities in Two Sub-Saharan African Countries: A Hierarchical Cluster Analysis.
abstract: BACKGROUND
  Symptom research across conditions has historically focused on single symptoms, and the burden of multiple symptoms and their interactions has been relatively neglected especially in people living with HIV. Symptom cluster studies are required to set priorities in treatment planning, and to lessen the total symptom burden. This study aimed to identify and compare symptom clusters among people living with HIV attending five palliative care facilities in two sub-Saharan African countries.
  
  
  METHODS
  Data from cross-sectional self-report of seven-day symptom prevalence on the 32-item Memorial Symptom Assessment Scale-Short Form were used. A hierarchical cluster analysis was conducted using Ward's method applying squared Euclidean Distance as the similarity measure to determine the clusters. Contingency tables, X2 tests and ANOVA were used to compare the clusters by patient specific characteristics and distress scores.
  
  
  RESULTS
  Among the sample (N=217) the mean age was 36.5 (SD 9.0), 73.2% were female, and 49.1% were on antiretroviral therapy (ART). The cluster analysis produced five symptom clusters identified as: 1) dermatological; 2) generalised anxiety and elimination; 3) social and image; 4) persistently present; and 5) a gastrointestinal-related symptom cluster. The patients in the first three symptom clusters reported the highest physical and psychological distress scores. Patient characteristics varied significantly across the five clusters by functional status (worst functional physical status in cluster one, p<0.001); being on ART (highest proportions for clusters two and three, p=0.012); global distress (F=26.8, p<0.001), physical distress (F=36.3, p<0.001) and psychological distress subscale (F=21.8, p<0.001) (all subscales worst for cluster one, best for cluster four).
  
  
  CONCLUSIONS
  The greatest burden is associated with cluster one, and should be prioritised in clinical management. Further symptom cluster research in people living with HIV with longitudinally collected symptom data to test cluster stability and identify common symptom trajectories is recommended.
authors.affiliation: King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom.
authors.forename: Katrien
authors.initials: K
authors.lastname: Moens
authors.affiliation: Auckland University of Technology, Auckland, New Zealand.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Siegert
authors.affiliation: Auckland University of Technology, Auckland, New Zealand.
authors.forename: Steve
authors.initials: S
authors.lastname: Taylor
authors.affiliation: African Palliative Care Association, Kampala, Uganda.
authors.forename: Eve
authors.initials: E
authors.lastname: Namisango
authors.affiliation: King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom.
authors.forename: Richard
authors.initials: R
authors.lastname: Harding
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D017954:Africa South of the Sahara; D023241:Antiretroviral Therapy, Highly Active; D001007:Anxiety / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology* / Q000473:pathology*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology / Q000473:pathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care