Factors associated with suboptimal antiretroviral therapy adherence to dose, schedule, and dietary instructions

Brief transdiagnostic group intervention for people living with HIV and emotional disorders: feasibility and clinical utility

Emotional regulation-based transdiagnostic interventions provide positive but limited evidence regarding efficacy with people living with human immunodeficiency virus (HIV). In the present study, 10 participants living with HIV with emotional disorders completed a five-session transdiagnostic group intervention to improve their emotional regulation skills (Unified Protocol). Changes at pre-treatment, post-treatment and three-month follow-up were explored at the population (mean-rank) and the individual level (reliable change index). Compared to pre-treatment, participants improved significantly in anxiety, depression, negative affect and quality of life. Changes were maintained at the three-month follow-up. Emotion regulation, particularly the confusion factor, improved when comparing pre-treatment with the three-month follow-up. At the three-month follow-up, the percentage of normalized scores was the largest in maladjustment (70%), followed by depression, negative affect, and lack of control (50%). All participants indicated high treatment satisfaction and perceived benefits. These promising results suggest that brief emotion regulation interventions might be feasible and effective in the public health settings for people living with HIV suffering emotional disorders.

Evaluation of the Sociodemographic, Behavioral and Clinical Influences on Complete Antiretroviral Therapy Adherence Among HIV-Infected Adults Receiving Medical Care in Houston, Texas

Introduction

Few studies have estimated complete antiretroviral therapy (ART) adherence following HIV infection since the advent of the new ART guidelines in 2012. This study determined the prevalence and influence of sociodemographic, behavioral, and clinical factors on complete ART adherence among people living with HIV (PLWH) receiving medical care in Houston/Harris County, Texas.

Methods

Data from the Houston Medical Monitoring Project survey collected from 2009 to 2014 among 1073 participants were used in this study. The primary outcome evaluated was combined adherence, defined as complete, partial, and incomplete combined adherence based on three ART adherence types—dose, schedule, and instruction adherence. The duration living since initial HIV diagnosis was classified as <5, 5–10 and >10 years. Rao–Scott Chi-square test and multivariable proportional-odds cumulative logit regression models were employed to identify the sociodemographic, behavioral, and clinical characteristics of complete combined adherence among the three groups of PLWH living with HIV infection.

Results

More than one-half (54.4%) of PLWH had complete, 37.4% had partial, and 8.3% had incomplete combined adherence. Among these PLWH, 52.2% had been infected with HIV for >10 years, and 26.5% and 21.4% were infected for <5 years and 5–10 years, respectively. PLWH who were diagnosed <5 and 5–10 years were two times (aOR=1.71, 95% CI=1.13–2.57; aOR=1.69, 95% CI=1.10–2.59; respectively) more likely to experience complete combined adherence than those with >10 years of infection. Multiple sociodemographic, behavioral, and clinical characteristics were significantly associated with complete adherence and varied by the duration of HIV infection.

Conclusion

Measures of adherence should include all adherence types (dose, schedule, instruction), as utilizing a single adherence type will overestimate adherence level in PLWH receiving medical care. Intervention efforts to maintain adherence should target recently infected PLWH, while those aimed at improving adherence should focus on longer infected PLWH.

Examining the association between stress and antiretroviral therapy adherence among women living with HIV in Toronto, Ontario

BACKGROUND

We aimed to identify the association between stress and antiretroviral therapy (ART) adherence among women in HIV care in Toronto, Ontario participating in the Ontario HIV Treatment Network Cohort Study (OCS) between 2007 and 2012.

MATERIALS AND METHODS

We conducted cross-sectional analyses with women on ART completing the AIDS Clinical Trial Group (ACTG) Adherence Questionnaire. Data closest to, or at the last completed interview, were collected from medical charts, through record linkage with Public Health Ontario Laboratories, and from a standardized self-reported questionnaire comprised of socio-demographic and psycho-socio-behavioral measures (Center for Epidemiologic Studies Depression Scale (CES-D), Alcohol Use Disorders Identification Test (AUDIT)), and stress measures (National Population Health Survey). Logistic regression was used to quantify associations with optimal adherence (≥95% adherence defined as missing ≤ one dose of ART in the past 4 weeks).

RESULTS

Among 307 women, 65.5% had optimal adherence. Women with suboptimal compared to optimal adherence had higher median total stress scores (6.0 [interquartile range (IQR): 3.0-8.1] vs. 4.1 [IQR: 2.0-7.1], p = 0.001), CES-D scores (16 [IQR: 6-28] vs. 12 [IQR: 3-22], p = 0.008) and reports of hazardous and harmful alcohol use (31.1% vs. 17.9%, p = 0.008). In our multivariable model, we found an increased likelihood of optimal adherence with the absence of hazardous and harmful alcohol use (Adjusted Odds Ratio (AOR)=2.20, 95% confidence interval (CI): 1.12-4.32) and a decreased likelihood of optimal adherence with more self-reported stress (AOR = 0.56, 95% CI: 0.33-0.94).

CONCLUSIONS

Interventions supporting optimal ART adherence should address stress and include strategies to reduce or eliminate hazardous and harmful alcohol use for women living with HIV.

Posttraumatic Stress Disorder and Nonadherence to Treatment in People Living With HIV: A Systematic Review and Meta-analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) is a commonly reported and serious complication among people living with HIV (PLWH). PTSD may significantly increase unintentional non-adherence to antiretroviral therapy. In this systematic review and meta-analysis, we aimed to pool the observational studies exploring the association between PTSD and medication adherence among PLWH.

METHODS

Comprehensive searches were conducted in PubMed/Medline, Web of Science, PsycINFO, Google Scholar, and ProQuest to identify relevant articles and dissertations. A random effects meta-analysis with inverse variance weighting was used to summarize the odds ratio (OR) across studies. Meta-regression and subgroup analyses were also carried out to assess the moderation effects for potential factors.

RESULTS

By synthesizing 12 studies comprising 2489 participants, the pooled odd ratio of non-adherence to antiretroviral therapy was 1.19 (95% confidential interval (CI), 1.03-1.37, p = 0.02). No significant publication bias was detected by Egger's test (Intercept = 0.842, p = 0.284). Factors moderating the association were mean age of participants, depression adjustment, and depression (all p < 0.05).

CONCLUSIONS

This meta-analysis supports that PTSD is related to adherence in PLWH. The hypothesized mechanisms (avoidant behavior and cognitive impairment) underlying this association need further investigation. Overall, this study highlights that clinicians should thoughtfully integrate timely mental health intervention into routine care.

Coverage and adherence of antiretroviral therapy among Chinese HIV-positive men who have sex with men with high CD4 counts in the era of 'Treat all'

OBJECTIVES

HIV-positive men who have sex with men (MSM) with CD4 cell counts> 350 cells/mm³ in China recently became eligible for free antiretroviral therapy (ART) due to updated national guidelines. This study aimed to investigate ART coverage and adherence among a large sample of HIV-positive MSM in China.

METHODS

A cross-sectional survey was conducted in Chengdu and Hangzhou, China, from February to November 2016. Participants were 277 MSM who had received a confirmatory HIV diagnosis and had CD4 levels of> 350 cells/mm³ . Trained staff of collaborating non-governmental organizations contacted all HIV-positive MSM listed in their service records and invited them to join the study. The ART initiation, ART adherence and interactions between healthcare professionals and the patients were assessed.

RESULTS

ART coverage was 60.3%. Among those who were on ART (n = 167), no participants reported missing any doses in the last four days, but 25.7% reported non-compliance to either ART dosing schedule or dosage instructions. After adjusting for background variables and perceived eligibility for ART, two variables were significant factors of higher ART coverage: (i) receiving a recommendation from healthcare professionals for immediate ART initiation and (ii) perceiving having received an adequate explanation of potential harms of ART. Being prescribed> 3 pills per dose and not having a temporary resident permit were associated with non-compliance.

CONCLUSIONS

Significant efforts are needed to increase ART coverage among HIV-positive MSM with high CD4 counts in China. Although prevalence of missing doses was low, non-compliance to dosing schedule/instructions should not be neglected. Interactions between healthcare professionals and MSMs play an important role in facilitating ART initiation.

Pharmacologic Treatment of Psychiatric Disorders and Time With Unsuppressed HIV Viral Load in a Clinical HIV Cohort

OBJECTIVE

To evaluate associations of mood, anxiety, stress-/trauma-related, and psychotic disorders, both treated and untreated, with duration of unsuppressed HIV viral load (VL) among persons living with HIV (PLWH).

SETTING

The DC Cohort, an observational clinical cohort of PLWH followed from 2011 to 2018 at 14 sites in Washington, DC.

METHODS

Among PLWH ≥18 years old who received primary care at their HIV clinic, we determined in a time-updated manner whether participants had diagnoses and pharmacologic prescriptions for mood, anxiety, stress-/trauma-related, and/or psychotic disorders. Associations between psychiatric disorders/treatments and the proportion of subsequent days with VL ≥200 copies/mL were assessed using multivariable Poisson regression with generalized estimating equations.

RESULTS

Among 5904 participants (median age 51; 70% men; 82% Black), 45% had ≥1 psychiatric disorder, including 38% with mood disorders (50% treated), 18% with anxiety or stress-/trauma-related disorders (64% treated), and 4% with psychotic disorders (52% treated). Untreated major depressive disorder (adjusted rate ratio = 1.17; 95% confidence interval: 1.00 to 1.37), untreated other/unspecified depressive disorder (1.23; 1.01 to 1.49), untreated bipolar disorder (1.39; 1.15 to 1.69), and treated bipolar disorder (1.25; 1.02 to 1.53) (vs. no mood disorder) predicted more time with VL ≥200 copies/mL. Treated anxiety disorders (vs. no anxiety disorder) predicted less time (0.78; 0.62 to 0.99). Associations were weaker and nonsignificant for treated depressive disorders (vs. no mood disorder) and untreated anxiety disorders (vs. no anxiety disorder).

CONCLUSIONS

PLWH with depressive and bipolar disorders, particularly when untreated, spent more time with unsuppressed VL than PLWH without a mood disorder. Treatment of mood disorders may be important for promoting sustained viral suppression.

Trajectory of change in anxiety sensitivity in relation to anxiety, depression, and quality of life among persons living with HIV/AIDS following transdiagnostic cognitive-behavioral therapy

Persons living with HIV/AIDS (PLHIV) disproportionately suffer from anxiety and depressive symptoms and disorders. Although past work has examined the efficacy of cognitive-behavioral therapy (CBT) for depression, and to a lesser extent anxiety, among PLHIV, little is known regarding potential mechanisms underlying improvement in anxiety/depression among this group. Anxiety sensitivity is a well-established risk/maintenance factor for anxiety and depressive disorders and is hypothesized to play an important role in maintaining anxiety among PLHIV. Past work has identified anxiety sensitivity as a mechanism of action underlying changes in various anxiety domains yet it is unknown whether changes in anxiety sensitivity relate to changes in anxiety symptoms among PLHIV undergoing transdiagnostic CBT for anxiety. The current study sought to examine treatment-related changes in anxiety sensitivity and how the trajectory of change relates to anxiety and depressive symptoms as well as overall quality of life. Individuals (n = 35) with HIV/AIDS and elevated anxiety symptoms received CBT for anxiety. Results indicated that reductions in anxiety sensitivity were significantly related to changes in anxiety, depression, and quality of life. Together, these data suggest that changes in anxiety sensitivity are significantly related to changes in anxiety/depression and quality of life among PLHIV seeking treatment.

Social support, stigma, and the mediating roles of depression on self-reported medication adherence of HAART recipients in China

Discrimination of people living with HIV/AIDS (PLWHA) is a persistent issue in China, which affects their psychological health. However, the association between psychological factors and adherence to highly active antiretroviral therapy (HAART) has not been systematically investigated before. Therefore, this study examined the impact of social support, depression, and medication-taking self-efficacy on ART adherence among PLWHA based on Cha et al.'s model, and included "stigma" to the original model to explain the psychological mechanism. Of the 504 participants receiving HAART, 37.8% had mild-to-severe depression. According to structural equation modeling, social support was directly associated with depression, stigma, and adherence; depression partially mediated the positive relationship between social support and adherence self-efficacy and the negative association between stigma and self-efficacy. The modified and extended Cha et al.'s model had a satisfactory fit. Interventions to improve mental health through mental health services, social support, and enhancement of adherence self-efficacy beliefs are required.

Posttraumatic stress disorder and nonadherence to medications prescribed for chronic medical conditions: A meta-analysis

BACKGROUND

Patients with posttraumatic stress disorder (PTSD) are at increased risk for adverse consequences from comorbid medical conditions. Nonadherence to medications prescribed to treat those comorbid conditions may help explain this increased risk. We sought to determine the association between PTSD and medication nonadherence and whether it varied according to the type of event inducing the PTSD.

METHODS

Prospective observational cohort or cross-sectional studies relating PTSD and nonadherence among adults prescribed medications for a chronic medical illness were identified by searching MEDLINE, EMBASE, PsycINFO, the Cochrane Library, CINAHL, SCOPUS, and the PILOTS Database and by hand-searching bibliographies from selected articles. Individual estimates of odds ratios were pooled using random effects meta-analysis with inverse variance weighting. Articles were pooled separately according to whether PTSD was induced by a medical versus non-medical event.

OUTCOMES

Sixteen articles comprising 4483 patients met eligibility criteria. The pooled effect size of the risk of PTSD to medication nonadherence was OR 1.22 (95% CI, 1.06-1.41). Among the 6 studies of medical event-induced PTSD, the OR was 2.08 (95% CI, 1.03-4.18); p = 0.04. Among the 8 studies in which PTSD was not induced by a medical event, the OR was 1.10 (95% CI, 0.99-1.24); p = 0.09.

INTERPRETATION

Patients with PTSD were more likely to be nonadherent to medications prescribed for chronic medical conditions - an association that may exist specifically when PTSD was induced by a medical event. Medications may serve as aversive reminders among survivors of acute medical events, magnifying avoidance behaviors characteristic of PTSD.

FUNDING

NHLBI.

Impact of a massive earthquake on adherence to antiretroviral therapy, mental health, and treatment failure among people living with HIV in Nepal

INTRODUCTION

The April 2015 Nepal earthquake resulted in more than 8,700 deaths and 22,000 casualties including damage to health facilities. The impact of this situation on chronic conditions such as human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) may become a long-lasting public health threat. Therefore, the objectives of this study were i) to assess the association of antiretroviral therapy (ART) adherence with mental health problems, and social behaviors, ii) to examine factors affecting treatment failure, and iii) to investigate changes in ART adherence and post-traumatic stress disorder (PTSD) among people living with HIV 6 and 12 months after the disaster.

METHODS

Study was conducted 6 months after the earthquake in 2015 with a sample size of 305 earthquake victims with HIV and followed after 12 months of the earthquake. A logistic regression analysis was used to examine relationships, while a paired t-test analysis was conducted to assess changes in adherence to ART and PTSD level at 6 months and 12 months after earthquake.

RESULTS

In the earthquake, 5.2% of the participants lost their family member. Approximately 44% of participants had earthquake-PTSD symptoms and 50% experienced HIV stigma. PTSD and HIV status disclosure were significantly associated with adherence to ART, while HIV stigma and religion were associated with treatment failure. PTSD and adherence levels to ART were significantly improved over the 6-month period.

CONCLUSION

Awareness programs for general public to eliminate HIV stigma; promote psychosocial counseling to earthquake victims living with HIV in order to reduce PTSD will contribute to maintaining optimal ART adherence and to prevent treatment failure.

Framing Mechanisms Linking HIV-Related Stigma, Adherence to Treatment, and Health Outcomes

We present a conceptual framework that highlights how unique dimensions of individual-level HIV-related stigma (perceived community stigma, experienced stigma, internalized stigma, and anticipated stigma) might differently affect the health of those living with HIV. HIV-related stigma is recognized as a barrier to both HIV prevention and engagement in HIV care, but little is known about the mechanisms through which stigma leads to worse health behaviors or outcomes. Our conceptual framework posits that, in the context of intersectional and structural stigmas, individual-level dimensions of HIV-related stigma operate through interpersonal factors, mental health, psychological resources, and biological stress pathways. A conceptual framework that encompasses recent advances in stigma science can inform future research and interventions aiming to address stigma as a driver of HIV-related health.

Anxiety symptoms and disorders among adults living with HIV and AIDS: A critical review and integrative synthesis of the empirical literature

There are over 35 million people worldwide infected with the Human Immunodeficiency Virus (HIV) and its progression to Acquired Immunodeficiency Syndrome (AIDS; WHO, 2014). With the advent of combined antiretroviral therapy (i.e., cART) in 1996, persons living with HIV/AIDS (PLWHA) now have much longer life expectancies. However, living with HIV remains challenging, as it is associated with a number of significant and recurrent (chronic) stressors including physical pain, side effects of cART, social stigma, and discrimination, among other social stressors. Presumably, as a result of these types of stressors, a disproportionately high number of PLWHA struggle with clinically-significant psychiatric symptoms and disorders. Although much scientific and clinical attention has focused on depressed mood and psychopathology among PLWHA, there has been comparably less focus on anxiety and its disorders. The paucity of work in this area is concerning from a public health perspective, as anxiety symptoms and disorders are the most common class of psychiatric disorders and often maintain a large negative impact on life functioning.

What Time is it? Adherence to Antiretroviral Therapy in Ethiopia

This study assessed adherence to antiretroviral therapy (ART) among people living with HIV/AIDS in Ethiopia and explored the sociocultural context in which they relate to their regimen requirements. Data were collected through semi-structured in-depth interviews with 105 patients on ART and observations held at the study clinic. We analyzed data using both qualitative and quantitative methods. Our findings indicate that study participants are highly adherent to dose but less adherent to dose schedule. Strict dose time instructions were reported as stressful and unrealistic. The discrepancy between adherence to dose and dose schedule could be explained by time perception, difficulty with the strictness of medication regimens, or beliefs about dose timing adherence. Care providers should acknowledge the complexities of medication practices and engage in shared decision-making to incorporate patients' perspectives and identify effective interventions.

Depression and anxiety were low amongst virally suppressed, long-term treated HIV-infected individuals enrolled in a public sector antiretroviral program in Thailand

HIV/AIDS and anxiety/depression are interlinked. HIV-infected patients suffering from depression may be at risk for poor adherence which may contribute to HIV disease progression. Additionally, an HIV diagnosis and/or using certain antiretroviral agents may trigger symptoms of anxiety/depression. The objective of the study was to assess the prevalence and factors associated with anxiety and depression in HIV-infected patients from the Thai National HIV Treatment Program. This cross-sectional study was performed from January 2012 to December 2012 in HIV-infected out-patients, aged ≥18 years, from three HIV referral centers. Symptoms of anxiety and depression were measured using the Thai-validated Hospital Anxiety and Depression Scale (HADS). A score of ≥11 was defined as having anxiety and depression. Associated factors were assessed by multivariate logistic regression. Totally 2023 (56% males) patients were enrolled. All patients received antiretroviral therapy (ART) for a mean duration of 7.7 years. Median CD4 was 495 cells/mm³. Ninety-five percent had HIV-RNA < 50 copies/ml. Thirty-three percent were currently on efavirenz (EFV)-based ART. The prevalence of anxiety and depression were 4.8% and 3.1%, respectively. About 1.3% had both anxiety and depression. In multivariate logistic models, the female sex [OR = 1.6(95%CI 1.1-2.3), p = .01], having adherence <90% [OR = 2.2(95%CI 1.5-3.4), p < .001], fair/poor quality of life (QOL) [OR = 7.2 (95%CI 3.6-14.2), p < .001] and EFV exposure [OR = 1.6(95%CI 1.1-2.3), p = .01], were independently associated with having anxiety or depression. Our findings demonstrated that prevalence of depression and anxiety was low amongst virally suppressed, long-term antiretroviral-treated HIV-infected individuals. Some key characteristics such as the female sex, poor adherence, poor/fair QOL and EFV exposure are associated with anxiety and depression. These factors can be used to distinguish who would need a more in-depth evaluation for these psychiatric disorders.

Alexithymia, Assertiveness and Psychosocial Functioning in HIV: Implications for Medication Adherence and Disease Severity

Psychosocial function and adherence to antiretroviral regimen are key factors in human immunodeficiency virus (HIV) disease management. Alexithymia (AL) is a trait deficit in the ability to identify and describe feelings, emotions and bodily sensations. A structural equation model was used to test whether high levels of AL indirectly relate to greater non-adherent behavior and HIV disease severity via psychosocial dysfunction. Blood draws for HIV-1 viral load and CD4 T-lymphocyte, along with psychosocial surveys were collected from 439 HIV positive adults aged 18-73 years. The structural model supports significant paths from: (1) AL to non-active patient involvement, psychological distress, and lower social support, (2) psychological distress and non-active involvement to non-adherent behavior, and (3) non-adherence to greater HIV disease severity (CFI = .97, RMSEA = .04, SRMR = .05). A second model confirmed the intermediary effect of greater patient assertiveness on the path from AL to social support and non-active patient involvement (CFI = .94, RMSEA = .04, SRMR = .05). Altogether, AL is indirectly linked with HIV disease management through it's association with poor psychosocial function, however greater patient assertiveness buffers the negative impact of AL on relationship quality with healthcare providers and members of one's social support network.

Barriers to HIV Medication Adherence: Examining Distinct Anxiety and Depression Symptoms among Women Living with HIV Who Experienced Childhood Sexual Abuse

Experiencing sexual violence in childhood or adolescence is highly prevalent among some women living with HIV, often resulting in anxiety and depression symptoms in adulthood. Anxiety and depression have been associated with HIV medication nonadherence, yet little research has assessed distinct components of anxiety and depression as risk factors of HIV medication nonadherence. The current study examined distinct symptom components of anxiety and depression as predictors of HIV medication non-adherence among women living with HIV and childhood sexual abuse enrolled in a coping intervention. This secondary analysis included a sample of 85 women living with HIV and childhood sexual abuse and being prescribed antiretroviral medication who completed measures on anxiety, depression, and medication adherence. Results from a logistic regression analysis suggest that distinct components of anxiety may be related to medication nonadherence among this population. Targeted mental health interventions for this population may increase adherence to antiretroviral medication.

Viral suppression and antiretroviral medication adherence among alcohol using HIV-positive adults

BACKGROUND

Substance use is a known predictor of poor adherence to antiretroviral therapies (ART) in people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. Less studied is the association between substance use and treatment outcomes, namely, suppression of HIV replication.

METHODS

Adults living with HIV (N = 183) who reported alcohol use in the previous week and receiving ART were observed over a 12-month period. Participants completed computer interviews, monthly unannounced pill counts to monitor ART adherence, and daily cell-phone delivered interactive-text assessments for alcohol use. HIV viral load was collected at baseline and 12-month follow-up from medical records. Analyses compared participants who had undetectable HIV viral loads at baseline and follow-up (sustained viral suppression) to those with unsustained viral suppression. Analyses also compared participants who were adherent to their medications (>85 % pills taken) over the year of observation to those who were nonadherent.

RESULTS

Fifty-two percent of participants had unsustained viral suppression; 47 % were ART nonadherent. Overall results failed to demonstrate alcohol use as a correlate of sustained viral suppression or treatment adherence. However, alcohol use was associated with nonadherence among participants who did not have sustained viral suppression; nonadherence in unsustained viral suppression patients was related to drinking on fewer days of assessment, missing medications when drinking, and drinking socially.

CONCLUSIONS

Poor HIV treatment outcomes and nonadherence were prevalent among adults treated for HIV infection who drink alcohol. Drinking in relation to missed medications and drinking in social settings are targets for interventions among alcohol drinkers at greatest risk for poor treatment outcomes.

The relationship between ART adherence and smoking status among HIV+ individuals

Smoking is highly prevalent among HIV+ individuals and studies indicate that it may be associated with poor ART adherence, though the relationship is poorly understood. In addition little is known about interest in quitting among HIV+ smokers who are having adherence difficulties. We examined smoking and ART adherence among 203 HIV+ individuals enrolled in a randomized trial of interventions to increase ART adherence. Prior analyses indicated there were no overall treatment group effects. Smoking status and motivation to quit was assessed at baseline and ART adherence was assessed at week 12, 24, 36, and 48. Longitudinal generalized estimating equation analysis that controlled for treatment group revealed that smoking status was not significantly related to adherence over time. Motivation to quit was high with 58 % intending to quit in the next 6 months and 25 % intending to quit in the next 30 days. Findings suggest that smoking is not associated with adherence among those with adherence difficulties. However it does not diminish importance of addressing both behaviors especially given HIV+ smokers substantial interest in changing smoking behavior.

Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: a systematic review and meta-analysis

We investigated the associations between depressive symptoms and adherence to antiretroviral therapy (ART) among people living with HIV (PLHIV). We searched the PubMed, EMBASE and Cochrane CENTRAL databases for studies that reported an association between depression and adherence to ART as a primary or secondary outcome. We used a random-effect model to pool the risk estimates from the individual studies. The odds ratio (OR) with their 95 % CIs were used as summary estimates. Of 2861 citations, 111 studies that recruited 42,366 PLHIV met our inclusion criteria. When reported, the rate of PLHIV with depressive symptoms ranged from 12.8 to 78 % and the proportion of PLHIV who achieved good adherence (≥ 80 %) ranged from 20 to 98 %. There were no significant differences in rate of depressive symptoms in PLHIV by country income group; however, the proportion of PLHIV who achieved good adherence was significantly higher in lower-income countries (as defined in the 2012 World Bank Country Income Groups) (pooled rate=86 %) compared to higher-income countries (pooled rate=67.5 %; p< .05). We found that the likelihood of achieving good ART adherence was 42 % lower among those with depressive symptoms compared to those without (pooled OR=0.58, 95 % CI 0.55 to 0.62). The relationship between depressive symptoms and adherence to ART was consistent across the country's income group, study design and adherence rates. We found that the magnitude of the association significantly decreases with more recent publications and increasing study sample size. The higher the prevalence of depressive symptoms of PLHIV recruited in the studies, the lower the likelihood of achieving good adherence to ART. In conclusion, the likelihood of achieving good adherence was lower among those with depressive symptoms compared to those without.

Factors associated with anxiety disorders among HIV-positive attendees of an HIV clinic in Lagos, Nigeria

Anxiety disorders (ADs) occurring in people living with HIV/AIDS (PLWHA) are often poorly identified in spite of the untold consequences that may result if not diagnosed and treated promptly. This study aimed to describe factors associated with ADs among PLWHA. Three hundred participants were administered sociodemographic/clinical profile questionnaires, and diagnoses of ADs were made using Schedule for Clinical Assessment in Neuropsychiatry (SCAN) based on International Classification of Diseases, 10th edition (ICD-10) criteria. In this study, 65 (21.7%) participants were diagnosed with ADs. A lack of family support, unemployment, younger mean age and being unmarried (P < 0.05) were factors associated with ADs in PLWHA; however, lack of family support (odds ratio [OR] = 0.458, 95% confidence interval [CI] = 0.254-0.827, P = 0.010), being unmarried (OR = 1.930, 95% CI = 1.046-3.560, P = 0.035) and unemployment (OR = 0.495, 95% CI = 0.264-0.926, P = 0.028) were the only factors that remained significant following logistic regression analysis. Prompt identification with active management of ADs and their associated factors among PLWHA are advocated. Further research on the risk factors for ADs is also warranted.

The impact of DSM-IV mental disorders on adherence to combination antiretroviral therapy among adult persons living with HIV/AIDS: a systematic review

This is a systematic review of eighty-two published studies investigating the impact of DSM-IV mental disorders on combination antiretroviral therapy (cART) adherence and persistence among persons living with HIV/AIDS (PLWHA). Sixty-two articles examined depression, with 58 % (N = 32/62) finding lower cART adherence and persistence. Seventeen articles examined one or more anxiety disorders, with the majority finding no association with cART adherence or persistence. Eighty percent of the studies that evaluated the impact of psychotic (N = 3), bipolar (N = 5) and personality disorders (N = 2) on cART adherence and persistence also found no association. Seven out of the nine studies (78 %) evaluating the impact of antidepressant treatment (ADT) on cART adherence found improvement. Adherence and depression measurements varied significantly in studies; common research measurements would improve data harmonization. More research specifically addressing the impact of other mental disorders besides depression on cART adherence and RCTs evaluating ADT on cART adherence are also needed.

Patient communication tools to enhance ART adherence counseling in low and high resource settings

OBJECTIVE

Few articles have examined specific counseling tools used to increase antiretroviral therapy (ART) adherence. We present communication tools used in the context of Project MOTIV8, a randomized clinical trial.

METHODS

We developed, piloted, and evaluated pictorial images to communicate the importance of consistent dose timing and the concept of drug resistance. Electronic drug monitoring (EDM) review was also used to provide visual feedback and facilitate problem solving discussions. Adherence knowledge of all participants (n=204) was assessed at baseline and 48 weeks. Participant satisfaction with counseling was also assessed.

RESULTS

Adherence knowledge did not differ at baseline, however, at 48 weeks, intervention participants demonstrated significantly increased knowledge compared to controls F(1, 172)=10.76, p=0.001 (12.4% increase among intervention participants and 1.8% decrease among controls). Counselors reported that the tools were well-received, and 80% of participants felt the counseling helped them adhere to their medications.

CONCLUSIONS

Counseling tools were both positively received and effective in increasing ART adherence knowledge among a diverse population.

PRACTICE IMPLICATIONS

While developed for research, these counseling tools can be implemented into clinical practice to help patients; particularly those with lower levels of education or limited abstract thinking skills to understand medical concepts related to ART adherence.

Use of and Adherence to Antiretroviral Therapy in a Large U.S. Sample of HIV-infected Adults in Care, 2007-2008

Background:

Antiretroviral therapy (ART) is the cornerstone of HIV clinical care and is increasingly recognized as a key component of HIV prevention. However, the benefits of ART can be realized only if HIV-infected persons maintain high levels of adherence.

Methods:

We present interview data (collected from June 2007 through September 2008) from a national HIV surveillance system in the United States—the Medical Monitoring Project (MMP)—to describe persons taking ART. We used multivariate logistic regression to assess behavioral, sociodemographic, and medication regimen factors associated with three measures that capture different dimensions of nonadherence to ART: dose, schedule, and instruction.

Results:

The use of ART among HIV-infected adults in care was high (85%), but adherence to ART was suboptimal and varied across the three measures of nonadherence. Of MMP participants currently taking ART, the following reported nonadherence during the past 48 hours: 13% to dose, 27% to schedule, and 30% to instruction. The determinants of the three measures also varied, although younger age and binge drinking were associated with all aspects of nonadherence.

Conclusion:

Our results support the measurement of multiple dimensions of medication-taking behavior in order to avoid overestimating adherence to ART.

Longitudinal study of emerging mental health concerns in youth perinatally infected with HIV and peer comparisons

OBJECTIVE

Cross-sectional research indicates high rates of mental health concerns among youth with perinatal HIV infection (PHIV), but few studies have examined emerging psychiatric symptoms over time.

METHODS

Youth with PHIV and peer comparisons who were HIV-exposed but uninfected or living in households with HIV-infected family members (HIV-affected) and primary caregivers participated in a prospective, multisite, longitudinal cohort study. Groups were compared for differences in the incidence of emerging psychiatric symptoms during 2 years of follow-up and for differences in psychotropic drug therapy. Logistic regression models were used to evaluate the association of emerging symptoms with HIV status and psychosocial risk factors.

RESULTS

Of 573 youth with study entry assessments, 92% attended at least 1 annual follow-up visit (PHIV: 296; comparisons: 229). A substantial percentage of youth who did not meet symptom criteria for a psychiatric disorder at study entry did so during follow-up (PHIV = 36%; comparisons = 42%). In addition, those who met criteria at study entry often met criteria during follow-up (PHIV = 41%; comparisons = 43%). Asymptomatic youth with PHIV were significantly more likely to receive psychotropic medication during follow-up than comparisons. Youth with greater HIV disease severity (entry CD4% <25% vs 25% or more) had higher probability of depression symptoms (19% vs 8%, respectively).

CONCLUSIONS

Many youth in families affected by HIV are at risk for development of psychiatric symptoms.

Prevalence of psychological trauma and association with current health and functioning in a sample of HIV-infected and HIV-uninfected Tanzanian adults

BACKGROUND

In high income nations, traumatic life experiences such as childhood sexual abuse are much more common in people living with HIV/AIDS (PLWHA) than the general population, and trauma is associated with worse current health and functioning. Virtually no data exist on the prevalence or consequences of trauma for PLWHA in low income nations.

METHODOLOGY/PRINCIPAL FINDINGS

We recruited four cohorts of Tanzanian patients in established medical care for HIV infection (n = 228), individuals newly testing positive for HIV (n = 267), individuals testing negative for HIV at the same sites (n = 182), and a random sample of community-dwelling adults (n = 249). We assessed lifetime prevalence of traumatic experiences, recent stressful life events, and current mental health and health-related physical functioning. Those with established HIV infection reported a greater number of childhood and lifetime traumatic experiences (2.1 and 3.0 respectively) than the community cohort (1.8 and 2.3). Those with established HIV infection reported greater post-traumatic stress disorder (PTSD) symptomatology and worse current health-related physical functioning. Each additional lifetime traumatic experience was associated with increased PTSD symptomatology and worse functioning.

CONCLUSIONS/SIGNIFICANCE

This study is the first to our knowledge in an HIV population from a low income nation to report the prevalence of a range of potentially traumatic life experiences compared to a matched community sample and to show that trauma history is associated with poorer health-related physical functioning. Our findings underscore the importance of considering psychosocial characteristics when planning to meet the health needs of PLWHA in low income countries.

HIV symptom distress and anxiety sensitivity in relation to panic, social anxiety, and depression symptoms among HIV-positive adults

Although past work has documented relations between HIV/AIDS and negative affective symptoms and disorders, empirical work has only just begun to address explanatory processes that may underlie these associations. The current investigation sought to test the main and interactive effects of HIV symptom distress and anxiety sensitivity in relation to symptoms of panic disorder (PD), social anxiety disorder (SA), and depression among people with HIV/AIDS. Participants were 164 adults with HIV/AIDS (17.1% women; mean age, 48.40) recruited from AIDS service organizations (ASOs) in Vermont/New Hampshire and New York City. The sample identified as 40.9% white/Caucasian, 31.1% black, 22.0% Hispanic, and 6.1% mixed/other; with more than half (56.7%) reporting an annual income less than or equal to $10,000. Both men and women reported unprotected sex with men as the primary route of HIV transmission (64.4% and 50%, respectively). HIV symptom distress and anxiety sensitivity (AS) were significantly positively related to PD, SA, and depression symptoms. As predicted, there was a significant interaction between HIV symptom distress and anxiety sensitivity in terms of PD and SA symptoms, but not depressive symptoms. Results suggest that anxiety sensitivity and HIV symptom distress are clinically relevant factors to consider in terms of anxiety and depression among people living with HIV/AIDS. It may be important to evaluate these factors among patients with HIV/AIDS to identify individuals who may be at a particularly high risk for anxiety and depression problems. Limitations included recruitment from ASOs, cross-sectional self-report data, and lack of a clinical diagnostic assessment.

Utilization of psychiatric services among low-income HIV-infected patients with psychiatric comorbidity

INTRODUCTION

HIV-infected individuals face a tremendous burden of psychiatric comorbidity. This study evaluates a community health care system's effort to screen for psychiatric disorders among patients at an HIV clinic and evaluate adherence to psychiatric service utilization.

METHODS

Standardized screening measures were used to identify participants who met diagnostic symptom criteria for post-traumatic stress disorder (PTSD), acute stress disorder (ASD) and depression. All participants who screened positive were referred for psychiatric follow-up. Rates of utilization were measured and barriers to adherence were investigated.

RESULTS

Of the 210 participants, 118 patients met screening criteria for PTSD, ASD, and/or depression, and 116 of these had medical records available for review. Of the 116 patients with psychiatric comorbidity, 46.6% saw a psychiatrist and/or were prescribed a psychiatric medication. Thirty-two percent of Latinos, 40.5% of African Americans, and 38.5% of heterosexuals utilized referred psychiatric services, and these rates were significantly less than their counterparts. One hundred patients were seen by a social worker.

DISCUSSION

While a large burden of psychiatric comorbidity exists among this population of HIV-positive patients, only half adhered to recommended psychiatric services referrals. Further research is warranted to examine cost-effective interventions to maximize psychiatric screening, referral, and follow-up with mental health services in this vulnerable population.

Common mental health problems and antiretroviral therapy adherence

This paper reviews the literature on various mental health problems and their impact on adherence to antiretroviral therapy (ART). Depression, anxiety disorders, and disorders related to substance abuse were identified as key role-players influencing adherence. The severity of symptoms related to these disorders was found to be inversely related to ART adherence, with the possible exception of post-traumatic stress disorder (PTSD). PTSD was found to have both positive and negative implications for adherence, with severity of symptoms ranging from health-protective concern to disabling distress. Possible solutions aimed at addressing the adverse effects of mental health problems on adherence are discussed. Routine screening in ART settings is suggested in settings where follow-up of positive screen scores are possible, along with the necessary interventions to resolve the disorder of concern. Suggested interventions include utilising psychotherapeutic treatment, both in isolation and in conjunction with medication, to address mental health problems. Furthermore, finding effective ways of marshalling social support is recommended for ensuring optimal adherence, and possibly mitigating the adverse effects of mental health problems. Further research is needed to find feasible ways of identifying, assessing and treating patients with mental health problems in resource-constrained settings where HIV prevalence is highest.

Baseline predictors of ninety percent or higher antiretroviral therapy adherence in a diverse urban sample: the role of patient autonomy and fatalistic religious beliefs

The role of patient autonomy and influence of religious/spiritual beliefs on antiretroviral therapy (ART) adherence is to date not fully understood. This study assessed baseline predictors of high ART adherence (≥90%) measured by electronic drug monitors (EDM) at 12 and 24 weeks after enrollment in a randomized controlled trial testing behavioral interventions to improve ART adherence. Baseline data were collected with audio computer-assisted self interviews (ACASI) surveys among a diverse urban sample of HIV-infected participants (n = 204) recruited from community clinics in a large midwestern city. Baseline variables included a range of established ART adherence predictors as well as several less frequently studied variables related to patient autonomy and religious/spiritual beliefs. Statistically significant (p < 0.05) variables identified in univariate analyses were included in subsequent multivariate analyses predicting higher than 90% adherence at 12 and 24 weeks. Several baseline predictors retained statistical significance in multivariate analysis at 24 weeks. Baseline levels of autonomous support from friends and family, motivation to adhere, and having an active coping style were all positively associated with adherence, while the belief that God is in control of one's health was negatively associated with adherence. Results indicate that effective interventions should include a focus on promoting patients' autonomous regulation and religious/spiritual beliefs regarding ART adherence.

The mechanism of LPS-induced HIV type I activation in transgenic mouse macrophages

In the course of the development of acquired immunodeficiency syndrome (AIDS), bacterial infection causes deleterious effects on the progression of the disease; bacterial LPS in the circulation activate immune cells, resulting in the acceleration of HIV replication. However, the precise HIV activation mechanisms in infected hosts remain largely unknown. Previously, we generated transgenic (Tg) mice carrying the HIV type I (HIV-1) genome and showed that LPS induces the activation of HIV-1 in splenocytes through the induction of tumor necrosis factor (TNF) and IL-1, although similarly induced IFN-gamma and IL-6 are not involved. In this study, we analyzed the mechanisms of HIV-1 activation in macrophages using these HIV-1 Tg mice, because macrophages are one of the major reservoirs of HIV-1. In contrast to splenocytes, direct Toll-like receptor (TLR) 4 signaling rather than TLR-induced pro-inflammatory cytokines was responsible for the LPS-induced activation of HIV-1 in macrophages, because the time course of HIV-1 activation was earlier than that observed in splenocytes and TNF neutralization did not inhibit the activation. p38 mitogen-activated protein kinase (MAPK) and nuclear factor kappa B (NF-kappaB) activation, but neither extracellular signal-regulated kinase nor c-Jun N-terminal kinase activation, were required for the activation, because only inhibitors for p38 MAPK and NF-kappaB suppressed activation of HIV-1. Furthermore, we showed that myeloid differentiation primary response gene (MyD) 88, rather than Toll/IL-1R domain-containing adaptor inducing IFN-beta (TRIF), was required as an adaptor molecule for this activation using Myd88(-/-) mice and Dynasore, a specific inhibitor for TRIF, and small interfering RNAs specific for Myd88 and Trif. These observations suggest that suppression of these molecules, which are involved in the TLR4-MyD88 pathway and the downstream p38 MAPK and NF-kappaB pathways, should be beneficial to prevent development of AIDS in HIV-1-infected people.

The effect of post-traumatic stress disorder on HIV disease progression following hurricane Katrina

Post-traumatic stress disorder (PTSD) is a common psychological outcome of any disaster. The purpose of this study was to examine the effects of PTSD on disease progression among HIV-infected persons in metropolitan New Orleans post-hurricane Katrina. One-year post-storm, a convenience sample of 145 HIV-infected patients who returned to care at the HIV Outpatient Program clinic in New Orleans were interviewed. Clinical factors pre and one and two years post-disaster were abstracted from medical records and compared by PTSD status. Of the 145 participants, 37.2% had PTSD. Those with PTSD were more likely than those without PTSD to have detectable plasma viral loads at both follow-up time points post-disaster and more likely to have CD4 cell counts <200/mm(3) two years post-disaster. They were also more likely to have had medication interruptions immediately post-disaster. Our findings corroborate the findings of others that PTSD accelerates HIV disease progression. Disaster planners should consider the special counseling and medication safeguards needs of HIV-infected persons.

Treatment considerations for psychiatric syndromes associated with HIV infection

Psychiatric syndromes associated with HIV disease were recognized early in the AIDS epidemic. Public education, new technologies and antiretroviral therapies have resulted in earlier recognition and therapautic interventions of HIV infection, improving the physical health for individuals living with HIV. While HIV-associated psychiatric symptoms have been recognized for more than 20 years, our understanding of the mechanisms underlying psychiatric symptoms among HIV-infected individuals and treatments for these symptoms have not kept pace with advances in HIV therapies. In this article, we discuss current knowledge of the psychiatric symptoms occurring with HIV disease, specifically mood, anxiety and psychotic disorders, evidence-based treatments and treatment considerations, new strategies for the treatments of psychiatric symptoms in HIV disease are also discussed.

An evidence-based review of treatment-related determinants of patients' nonadherence to HIV medications

Patients' adherence to antiretroviral medications is a primary determinant of both the effectiveness of treatment and the clinical course of HIV/AIDS. This empirical review is intended to compare the relative importance of patient and treatment characteristics on nonadherence behavior and the impact of nonadherence on treatment failure. Articles cited in PubMed and published between 2006 and June 2008 (n = 200) were reviewed to select those that address patient or treatment characteristics associated with nonadherence. Twenty-two articles were selected that provided odds ratio or hazard ratio statistics that quantified predictors of patients' level of nonadherence (e.g., <80%, 80%-95% and >95%). Results were summarized using random effects meta-analytic models. Predictors of nonadherence were divided into four predictive clusters (clinical predictors, comorbid predictors, treatment competence predictors, and dosing predictors). The summary odds ratios (ORs) of nonadherence for each cluster (in order of strength) were treatment competence 2.0 (95% confidence interval [CI]: 1.6-2.6), clinical predictors 1.6 (95% CI: 1.4-1.8), comorbid predictors 1.6 (95% CI: 1.4-1.8), and dosing predictors 1.5 (95% CI: 1.3-1.7). The effect of nonadherence on treatment failure supported the findings of two prior empirical reviews (OR 2.0, 95% CI: 1.6-2.5). Within dosing predictors, a pill burden of more versus less than 10 pills per day was associated with a much higher odds of nonadherence than twice versus once daily dosing or small differences in the number of types of antiretroviral treatments in a regimen. These results provide insight into the relative importance of various determinants of patient nonadherence that may inform the design of patient educational initiatives and initiatives to simplify treatment regimens.

Staged introduction of antiretroviral therapy into a family with multiple HIV-infected members

Children and families bear a significant burden of human immunodeficiency virus disease globally, particularly in sub-Saharan Africa. Care of severely affected families can be adversely impacted by high medication burdens and overwhelmed caregivers, who themselves may be human immunodeficiency virus infected. Family-centered care involving joint clinic days, treatment preparation, adherence counseling, and community-based follow-up may improve the care of family units. We describe the successful treatment of a single family composed of 6 infected members living in a rural African setting.

Simplification Strategies to Reduce Antiretroviral drug Exposure: Progress and Prospects

Current US guidelines for initial therapy of HIV type-1 (HIV-1) infection recommend daily, lifelong treatment with a combination of three antiretroviral drugs consisting of two nucleoside analogue reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor or a protease inhibitor. Although this approach has been successful in reducing morbidity and mortality from HIV-1 infection, concerns remain about adverse events from chronic drug exposure, the requirement for daily medication adherence, the risk of HIV-1 drug resistance and high treatment costs. The availability of antiretrovirals that are coformulated and dosed once daily have reduced pill burden and have simplified dosing schedules, but have not lowered drug exposure or cost. These limitations have stimulated research into drug-sparing strategies including intermittent therapy and simplified maintenance regimens. Randomized clinical trials have shown greater mortality with intermittent therapy compared with continuous therapy leading to rejection of this strategy. Pilot studies of simplified maintenance therapy with a ritonavir-boosted protease inhibitor alone have shown more promise, although concerns remain. This article reviews progress in the simplification of antiretroviral therapy, recent clinical trial results and prospects for the future.

Increasing age at HIV seroconversion from 18 to 40 years is associated with favorable virologic and immunologic responses to HAART

BACKGROUND

Studies evaluating the effect of age on response to highly active antiretroviral therapy (HAART) have been limited by their inability to control for duration of human immunodeficiency virus (HIV) infection. We examined the effect of age at HIV seroconversion on response to HAART.

METHODS

A retrospective analysis of a longitudinal US military cohort of HIV-infected subjects. Time to and maintenance of viral suppression, rate of CD4 cell increase, and rate of progression to acquired immunodeficiency syndrome or death were compared across age groups using time-to-event methods.

RESULTS

Five hundred sixty-three HIV-infected adults who seroconverted after January 1, 1996, and started HAART were included. Increasing age at seroconversion was significantly associated with faster time to viral suppression (P = 0.002). Increasing age also correlated with duration of suppression, with a 35% reduction in risk of viral rebound for every 5-year increase in age above 18 years (hazard ratio: 0.65, 95% confidence interval 0.55 to 0.75). The rate of CD4 cell increase from 6 to 84 months post-HAART was significantly greater in those who seroconverted at older ages (P = 0.0002). Rates of progression to acquired immunodeficiency syndrome or death did not differ between groups.

CONCLUSIONS

Increasing age at seroconversion was associated with shorter time to and longer maintenance of viral suppression and a faster increase in CD4 cell count.

Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care

Individuals living with HIV often have complicated histories, including negative experiences such as traumatic events, mental illness, and stigma. As the medical community in the United States adapts to managing HIV as a chronic disease, understanding factors such as these negative experiences that may be associated with poorer adherence to treatment regimens, greater HIV risk behavior, and lower patient quality of life becomes critical to HIV care and prevention. In less wealthy nations, these issues are also critical for addressing quality of life as well as medication adherence in the areas where antiretroviral therapies are being made available. This article presents a review of the literature regarding the following psychosocial factors as they relate to HIV/AIDS in the US and globally: traumatic events; mental illness, including depression, anxiety, and posttraumatic stress disorder; lack of trust in the healthcare system and government; and experiences of stigma among individuals with HIV disease. These factors have been found to be prevalent among individuals with HIV/AIDS, regardless of gender or race/ethnicity. Traumatic events, mental illness, distrust, and stigma have also been linked with poorer adherence to medication regimens and HIV risk behavior.