HIV-infected individuals with co-occurring bipolar disorder evidence poor antiretroviral and psychiatric medication adherence

Adherence to antiretroviral therapy in people living with HIV with moderate or severe mental disorder

Human immunodeficiency virus (HIV) infection remains a serious public health concern, with an estimated 38 million people living with HIV (PLHIV). PLHIV are often affected by mental disorders at higher rate than the general population. One challenge in the control and prevention of new HIV infections is adherence to antiretroviral therapy (ART), with PLHIV with mental disorders having seemingly lower adherence than PLHIV without mental disorders. This cross-sectional study assessed adherence to ART in PLHIV with mental disorders who attended the Psychosocial Care Network health facilities in Campo Grande, Mato Grosso do Sul, Brazil, from January 2014 to December 2018. Data from health and medical databases were used to describe clinical-epidemiological profiles and adherence to ART. To assess the associated factors (potential risk or predisposing factors) with ART adherence, we used logistic regression model. Adherence was extremely low (16.4%). Factors associated with poor adherence were lack of clinical follow-up, particularly in middle-aged PLHIV. Other apparently associated factors were living on the streets and having suicidal ideation. Our findings reinforce the need for improvements in the care for PLHIV with mental disorders, especially in the integration between specialized mental health and infectious disease health facilities.

The prevalence of mental health disorders in people with HIV and the effects on the HIV care continuum

OBJECTIVE

To describe the prevalence of diagnosed depression, anxiety, bipolar disorder, and schizophrenia in people with HIV (PWH) and the differences in HIV care continuum outcomes in those with and without mental health disorders (MHDs).

DESIGN

Observational study of participants in the North American AIDS Cohort Collaboration on Research and Design.

METHODS

PWH (≥18 years) contributed data on prevalent schizophrenia, anxiety, depressive, and bipolar disorders from 2008 to 2018 based on International Classification of Diseases code mapping. Mental health (MH) multimorbidity was defined as having two or more MHD. Log binomial models with generalized estimating equations estimated adjusted prevalence ratios (aPR) and 95% confidence intervals for retention in care (≥1 visit/year) and viral suppression (HIV RNA ≤200 copies/ml) by presence vs. absence of each MHD between 2016 and 2018.

RESULTS

Among 122 896 PWH, 67 643 (55.1%) were diagnosed with one or more MHD: 39% with depressive disorders, 28% with anxiety disorders, 10% with bipolar disorder, and 5% with schizophrenia. The prevalence of depressive and anxiety disorders increased between 2008 and 2018, whereas bipolar disorder and schizophrenia remained stable. MH multimorbidity affected 24% of PWH. From 2016 to 2018 (N = 64 684), retention in care was marginally lower among PWH with depression or anxiety, however those with MH multimorbidity were more likely to be retained in care. PWH with bipolar disorder had marginally lower prevalence of viral suppression (aPR = 0.98 [0.98-0.99]) as did PWH with MH multimorbidity (aPR = 0.99 [0.99-1.00]) compared with PWH without MHD.

CONCLUSION

The prevalence of MHD among PWH was high, including MH multimorbidity. Although retention and viral suppression were similar to people without MHD, viral suppression was lower in those with bipolar disorder and MH multimorbidity.

Prevalence and factors associated with depression in people living with HIV/AIDS in a Brazilian metropolitan region

The frequent association between mental disorders and HIV infection may be related to several risk factors. The present study aims to determine the prevalence of depression and its associated factors in people living with HIV/AIDS (PLWHA) who attended four outpatient clinics in Fortaleza, Brazil, between September 2014 and April 2015. In addition to the Mini International Neuropsychiatric Interview questionnaire, which was used to identify the prevalence of depressive disorder, the researchers applied a sociodemographic questionnaire, and the Hamilton Depression Scale to classify the severity of depression. In all, 257 participants were included in the analyses. The overall lifetime prevalence of depression was identified to be 29.2% (19.5% in men and 44.9% in women). The prevalence of a current depressive episode was 18.7%. Mild, moderate, and severe depression was identified in 2.1%, 12.5%, and 85.4%, respectively. The factors related to depression were: gender, marital status, income, educational level, current employment status, and family history of depression. This study highlights the importance of lifetime depression as a disorder of high prevalence in PLWHA, and associated with risk factors that are difficult or impossible to be modified. Early diagnosis and treatment of depression may improve quality of life in PLWHA.

Clinical characteristics and impacts of HIV infection in people with bipolar disorders

BACKGROUND

People with bipolar disorders (BD) may be at increased risk of Human Immunodeficiency Virus (HIV) infection but our understanding of the impacts of HIV infection on psychiatric outcomes is poor. This study aimed to examine the prevalence, temporal relationship, and clinical impact of HIV infection in people with BD.

METHODS

In this retrospective case-control study, anonymised electronic case records of patients with BD who had been under the care of South London and Maudsley mental health services were used for data extraction. 54 HIV+ people with BD were identified and compared to a matched control group of 54 HIV- people with BD.

RESULTS

The prevalence of HIV co-morbidity in the BD population was around 1%. 76% of HIV+ BD men identified as men who have sex with men (MSM). 65% of the HIV+ BD group were diagnosed with BD before becoming HIV+. The HIV+ BD group experienced significantly higher rates of stimulant, GBL/GHB and psychedelic use compared to the HIV- BD group. 85% of the HIV+ BD group were recorded as taking antiretroviral medications.

LIMITATIONS

Retrospective and cross-sectional study design, and a relatively small sample size CONCLUSIONS: The prevalence of HIV comorbidity in BD was comparable to the local general population. HIV infection in BD is associated with MSM status and stimulant, GHB/GBL and psychedelics use suggesting that HIV prevention strategies should particularly target these groups. Lower use of antiretroviral medications by people with BD underlines the importance of engaging HIV+ BD people in HIV services.

Depressive Disorders in HIV/AIDS: A Clinically Focused Narrative Review

After participating in this activity, learners should be better able to:• Assess strategies for diagnosing depressive disorders in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)• Identify factors that contribute to the development of depressive disorders in HIV/AIDS• Evaluate strategies for managing depressive disorders in HIV/AIDS ABSTRACT: Depressive disorders and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) are associated with major socioeconomic burdens. The negative impact of depressive disorders on HIV/AIDS is well known, including on treatment outcomes. Unfortunately, depressive disorders are underdiagnosed and undertreated in seropositive persons. This review summarizes clinically useful information on depressive disorders in HIV/AIDS. More specifically, we address assessment, differential diagnosis, contributing factors, management, and common challenges in the treatment of depressive disorders in seropositive individuals. Assessment and diagnosis of depression may be challenging in seropositive persons because of several biopsychosocial particularities associated with HIV/AIDS. One of the difficulties is the overlap between depression and HIV/AIDS symptoms, particularly in individuals with advanced AIDS, requiring consideration of a broad differential diagnosis. Several factors related to HIV/AIDS status contribute to the higher rates of depressive disorders, including infectious-immunological, psychosocial, and exogenous factors. The treatment of depressive disorders in HIV/AIDS involves three groups of interventions: (1) pharmacological interventions, (2) psychotherapeutic interventions, and (3) management of other contributing factors. Challenges in management include poor adherence to treatment and the risk of suicide. We provide evidence-based recommendations to improve assessment and management of depressive disorders in seropositive persons.

Prevalence and predictors of medication non-adherence among people living with multimorbidity: a systematic review and meta-analysis

OBJECTIVES

This systematic review aimed to describe medication non-adherence among people living with multimorbidity according to the current literature, and synthesise predictors of non-adherence in this population.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. PubMed, EMBASE, CINAHL and PsycINFO were searched for relevant articles published in English language between January 2009 and April 2019. Quantitative studies reporting medication non-adherence and/or predictors of non-adherence among people with two or more chronic conditions were included in the review. A meta-analysis was conducted with a subgroup of studies that used an inclusive definition of multimorbidity to recruit participants, rather than seeking people with specific conditions. Remaining studies reporting prevalence and predictors of non-adherence were narratively synthesised.

RESULTS

The database search produced 10 998 records and a further 75 were identified through other sources. Following full-text screening, 178 studies were included in the review. The range of reported non-adherence differed by measurement method, at 76.5% for self-report, 69.4% for pharmacy data, and 44.1% for electronic monitoring. A meta-analysis was conducted with eight studies (n=8949) that used an inclusive definition of multimorbidity to recruit participants. The pooled prevalence of non-adherence was 42.6% (95% CI: 34.0 - 51.3%, k=8, I²=97%, p<0.01). The overall range of non-adherence was 7.0%-83.5%. Frequently reported correlates of non-adherence included previous non-adherence and treatment-related beliefs.

CONCLUSIONS

The review identified a heterogeneous literature in terms of conditions studied, and definitions and measures of non-adherence used. Results suggest that future attempts to improve adherence among people with multimorbidity should determine for which conditions individuals require most support. The variable levels of medication non-adherence highlight the need for more attention to be paid by healthcare providers to the impact of multimorbidity on chronic disease self-management.

PROSPERO REGISTRATION NUMBER

CRD42019133849.

S-Equol mitigates motivational deficits and dysregulation associated with HIV-1

Motivational deficits (e.g., apathy) and dysregulation (e.g., addiction) in HIV-1 seropositive individuals, despite treatment with combination antiretroviral therapy, necessitates the development of innovative adjunctive therapeutics. S-Equol (SE), a selective estrogen receptor β agonist, has been implicated as a neuroprotective and/or neurorestorative therapeutic for HIV-1 associated neurocognitive disorders (HAND); its therapeutic utility for motivational alterations, however, has yet to be systematically evaluated. Thus, HIV-1 transgenic (Tg) and control animals were treated with either a daily oral dose of SE (0.2 mg) or vehicle and assessed in a series of tasks to evaluate goal-directed and drug-seeking behavior. First, at the genotypic level, motivational deficits in HIV-1 Tg rats treated with vehicle were characterized by a diminished reinforcing efficacy of, and sensitivity to, sucrose. Motivational dysregulation was evidenced by enhanced drug-seeking for cocaine relative to control animals treated with vehicle. Second, treatment with SE ameliorated both motivational deficits and dysregulation in HIV-1 Tg rats. Following a history of cocaine self-administration, HIV-1 Tg animals treated with vehicle exhibited lower levels of dendritic branching and a shift towards longer dendritic spines with decreased head diameter. Treatment with SE, however, led to long-term enhancements in dendritic spine morphology in HIV-1 Tg animals supporting a potential underlying basis by which SE exerts its therapeutic effects. Taken together, SE restored motivated behavior in the HIV-1 Tg rat, expanding the potential clinical utility of SE to include both neurocognitive and affective alterations.

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.

Mortality rate trends in patients diagnosed with schizophrenia or bipolar disorder: a nationwide study with 20 years of follow-up

Background

Patients with severe mental illness (SMI) have a reduced life expectancy of one to two decades as compared to the general population, with most years of life lost due to somatic diseases. Most previous studies on disorders constituting SMI, e.g. schizophrenia and bipolar disorder, have investigated the disorders separately and hence not compared the disorders in terms of mortality rates relative to the background population.

Methods

A register-based cohort study including the entire Danish population comparing mortality rates relative to the background population, controlling for age and sex, i.e. standardized mortality ratios (SMRs) in patients diagnosed with schizophrenia with those in patients diagnosed with bipolar disorder, during the study period from 1995 to 2014.

Results

The SMR of patients with SMI was significantly higher than one for each calendar year in the study period with an overall SMR of 4.58, 95% CI (4.48–4.69) in patients diagnosed with schizophrenia (n = 38,500) and of 2.57 (95% CI 2.49–2.65) in patients diagnosed with bipolar disorder (n = 23,092). When investigating time trends in SMR for schizophrenia and for bipolar disorder, respectively, an increase in SMR over time was shown with a mean increase of 0.03 per year for schizophrenia and 0.02 for bipolar disorder (p < 0.01 for both disorders). The ratio between SMR for schizophrenia and SMR for bipolar disorder for each calendar year over the study period was constant (p = 0.756).

Conclusions

Increasing SMRs over the last 20 years were found for both patients diagnosed with bipolar disorder and patients diagnosed with schizophrenia. Despite clear differences between the two disorders regarding SMRs, the increases in SMR over time were similar, which could suggest similar underlying factors influencing mortality rates in both disorders.

Bipolar spectrum disorders and associated factors among adults attending an antiretroviral therapy clinic in Gedeo zone health centers, southern Ethiopia

BACKGROUND

Bipolar spectrum disorders (BPSDs) are more common among HIV-positive individuals than the general population. Although BPSDs have very diverse and devastating consequences (immune suppression, cognitive impairment and poor medication adherence), little is known about BPSDs among HIV-positive individuals in Ethiopia. Therefore, this study was aimed to assess the prevalence and associated factors of BPSDs among adults attending antiretroviral therapy (ART) clinics in Gedeo zone health centers, southern Ethiopia.

PATIENTS AND METHODS

An institutional-based cross-sectional study was conducted by screening 412 randomly selected HIV-positive individuals using Mood Disorder Questionnaire. SPSS version 20 was used for data analysis. Bivariable and multivariable logistic regression models were fitted to identify factors associated with BPSDs. Adjusted OR (AOR) with corresponding 95% CI was computed to determine the association.

RESULTS

Of the total 412 participants, 11.2% were screened positive for BPSDs. Lower CD4 count (AOR =2.97; 95% CI: 1.11, 7.90), past history of mental health problem (AOR =3.35; 95% CI: 1.576, 7.144), poor social support (AOR =2.6; 95% CI: 1.06, 6.63) and poor ART drug adherence (AOR =3.59; 95% CI: 1.78, 7.21) had a positive association with BPSDs.

CONCLUSION

In this study, the prevalence of BPSDs was high among adult patients attending ART clinics in Gedeo zone health centers. Poor social support, poor ART drug adherence, lower CD4 level and history of mental illness had statistically significant association with BPSDs. This demonstrates a need for the integration of Mental Health and Psycho Social Support with HIV/AIDS care services. Moreover, establishing good social support and controlling ART adherence were found to be very crucial too.

Mental health and HIV: research priorities related to the implementation and scale up of 'treat all' in sub-Saharan Africa

World Health Organization (WHO) guidelines call for antiretroviral therapy (ART) for all people living with HIV (PLWH) regardless of CD4 cell count, a policy often referred to as 'treat all'. This article seeks to: (1) provide an overview of mental health research among PLWH in sub-Saharan Africa (SSA) and interventions or strategies to address comorbid mental illness among those living with HIV; and (2) describe key mental health-related recommendations to inform the successful implementation and scale up of 'treat all' policies in SSA. An initial set of mental health-related research recommendations was developed by a working group comprising investigators affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Recommendations were shared with those who attended the All-Africa IeDEA Meeting in Kigali, Rwanda in November 2017 and refined following the meeting. Recommendations reflect a need for epidemiological research to examine the prevalence, incidence, and impact of mental health multimorbidities on HIV treatment outcomes, intervention research to examine the extent to which improving the mental health of people living with HIV enhances HIV treatment outcomes, and implementation science research to evaluate promising models of integrated mental health and HIV care. Key research recommendations can advance understanding and treatment of mental illness among those living with HIV in sub-Saharan Africa and beyond.

Effects of HIV Infection, methamphetamine dependence and age on cortical thickness, area and volume

OBJECTIVE

This study examined the effects of HIV infection, methamphetamine dependence and their interaction on cortical thickness, area and volume, as well as the potential interactive effects on cortical morphometry of HIV and methamphetamine with age.

METHOD

T1-weighted structural images were obtained on a 3.0T General Electric MR750 scanner. Freesurfer v5.3.0 was used to derive cortical thickness, area and volume measures in thirty-four regions based on Desikan-Killiany atlas labels.

RESULTS

Following correction for multiple statistical tests, HIV diagnosis was not significantly related to cortical thickness or area in any ROI, although smaller global cortical area and volume were seen in those with lower nadir CD4 count. HIV diagnosis, nevertheless, was associated with smaller mean cortical volumes in rostral middle frontal gyrus and in the inferior and superior parietal lobes. Methamphetamine dependence was significantly associated with thinner cortex especially in posterior cingulate gyrus, but was not associated with cortical area or volume following correction for multiple statistical tests. We found little evidence that methamphetamine dependence moderated differences in cortical area, volume or thickness for any ROI in the HIV seropositive group. Interactions with age revealed that HIV diagnosis attenuated the degree of age-related cortical thinning seen in non-infected individuals; intercepts indicated that young HIV seropositive individuals had thinner cortex than non-infected peers.

CONCLUSIONS

Methamphetamine dependence does not appear to potentiate a reduction of cortical area, volume or thickness in HIV seropositive individuals. The finding of thinner cortex in young HIV seropositive individuals and the association between CD4 nadir and global cortical area and volume argue for prioritizing early antiretroviral treatment.

The Impact of co-morbid severe mental illness and HIV upon mental and physical health and social outcomes: a systematic review

Our aim was to review the evidence related to the impact of co-morbid severe mental illness SMI (schizophrenia, schizoaffective and bipolar disorder) and HIV upon mental health, physical health and social outcomes. We carried out a systematic review of scientific evidence, searching online databases (MEDLINE, PsychInfo, EMBASE, Global Health and Scopus) for studies between 1983 and 2017 using search terms for SMI and HIV. Studies were included if they compared health or social outcomes between people living with co-morbid SMI and HIV and people living with either: a) HIV only; or b) SMI only. Outcomes of interest were: mortality, health service use, HIV/SMI-related, co-morbidities, and social outcomes. We identified 20 studies which met our inclusion criteria. Although studies were generally high quality, there was heterogeneity in both selection of outcomes and choice of measure. It was therefore difficult to draw strong conclusions regarding the impact of co-morbid SMI and HIV across any outcome. We found little evidence that co-morbid SMI and HIV were associated with lower levels of treatment, care or poorer clinical outcomes compared to people living with SMI or HIV alone. However, mortality appeared to be higher among the co-morbid group in three out of four analyses identified. Physical and mental co-morbidities and social outcomes were rarely measured. Limited data mean that the impact of co-morbid SMI and HIV is uncertain. In order to develop evidence-based guidelines, there is an urgent need for further research. This may be realized by exploring opportunities for using data from existing cohort studies, routinely collected data and data linkage to investigate important questions relating to this neglected but potentially important area.

Does Diagnosis Make a Difference? Estimating the Impact of an HIV Medication Adherence Intervention for Persons with Serious Mental Illness

The heightened risk of persons with serious mental illness to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Here we evaluate the interaction between psychiatric diagnosis and response to a community based-intervention targeted at treatment adherence in 236 HIV+ persons with co-occurring mental illness. To examine differential effectiveness of the intervention for categories of patient diagnosis, we reanalyzed the data after stratifying participants into two diagnostic groups: (1) participants with depressive disorders without psychosis and (2) participants with a psychotic or bipolar disorder. Outcomes included viral load and mental health quality of life (SF-12 Mental Health). We found that HIV+ persons with non-psychotic depressive disorders demonstrated a larger decrease in HIV viral load and more improvement in measures of mental health quality of life when compared to HIV+ persons with psychotic and bipolar disorders. We suggest that successful adherence interventions should be informed by psychiatric symptomatology.

TRIAL REGISTRATION

clinicaltrials.gov 29 identifier NCT00264823.

HIV and ageing: improving quantity and quality of life

PURPOSE OF REVIEW

Evidence-based strategies are needed to address the growing complexity of care of those ageing with HIV so that as life expectancy is extended, quality of life is also enhanced.

RECENT FINDINGS

Modifiable contributing factors to the quantity and quality of life in adults ageing with HIV include: burden of harmful health behaviours, injury from HIV infection, HIV treatment toxicity and general burden of age-associated comorbidities. In turn, these factors contribute to geriatric syndromes including multimorbidity and polypharmacy, physiologic frailty, falls and fragility fractures and cognitive dysfunction, which further compromise the quality of life long before they lead to mortality.

SUMMARY

Viral suppression of HIV with combination antiviral therapy has led to increasing longevity but has not enabled a complete return to health among ageing HIV-infected individuals (HIV+). As adults age with HIV, the role of HIV itself and associated inflammation, effects of exposure to antiretroviral agents, the high prevalence of modifiable risk factors for age-associated conditions (e.g. smoking), and the effects of other viral coinfections are all influencing the health trajectory of persons ageing with HIV. We must move from the simplistic notion of HIV becoming a 'chronic controllable illness' to understanding the continually evolving 'treated' history of HIV infection with the burden of age-associated conditions and geriatric syndromes in the context of an altered and ageing immune system.

At-Risk Alcohol Use is Associated with Antiretroviral Treatment Nonadherence Among Adults Living with HIV/AIDS

BACKGROUND

Alcohol use is a risk factor for nonadherence to antiretroviral therapy (ART) among people living with HIV/AIDS (PLWHA); however, differences in ART adherence across levels of alcohol use are unclear. This study examined whether "at-risk" alcohol use, defined by National Institute of Alcohol Abuse and Alcoholism guidelines, was associated with ART nonadherence among PLWHA.

METHODS

Participants were 535 HIV-infected adults enrolled in studies at the HIV Neurobehavioral Research Program. ART nonadherence was identified by either self-reported missed dose or plasma viral load detectability (≥50 copies/ml). Potential covariates for multivariable logistic regression included demographics, depression, and substance use disorders.

RESULTS

Using a stepwise model selection procedure, we found that at-risk alcohol use (OR = 0.64; p = 0.032) and low education (OR = 1.09 per 1 year increase in education; p = 0.009) significantly predict lower ART adherence.

CONCLUSIONS

A greater focus on the treatment of at-risk alcohol use may improve ART adherence among HIV-infected persons.

Predictors of primary non-adherence to concomitant chronic treatment in HIV-infected patients with antiretroviral therapy

Objectives

To identify the independent risk factors of primary non-adherence to chronic concomitant treatment in HIV-positive patients, and to measure primary and secondary non-adherence rates to chronic treatments, and secondary non-adherence to antiretroviral therapy and the prevalence of concomitant chronic diseases.

Methods

We conducted a retrospective study that included HIV-infected patients with antiretroviral treatmentwho attended the pharmaceutical care office between January and December 2012. The dependent variable was primary non-adherence to concomitant prescription drugs for chronic diseases. To know the predictors of concomitant primary non-adherence, we performed a univariate analysis and a multivariate binary logistic regression model to identify the independent predictors of primary non-adherence to co-medication.

Results

Out of 598 patients analysed, 333 patients had a new co-medication prescribed during the studied period. The number of comorbidities per patient was 2.3 and the patients were treated with an average of 3.4 drugs. The rates of primary and secondary non-adherence to co-medication were 8.4% and 44.4%, respectively. The co-occurrence of primary and secondary non-adherence was 24.9%. The number of comorbidities (p=0.001) and co-medications (p=0.001) was significantly higher in patients who had primary non-adherence to co-medication. Furthermore, there was a statistically significant relationship between primary non-adherence and patients treated with psychotropic drugs (p=0.03). The multivariate analysis showed the independent predictor of primary non-adherence to co-medication was the number of co-medications (p<0.001).

Conclusion

One-third of new concomitant medications prescribed to HIV-positive patients were never filled from the pharmacy. The number of co-medications was identified as a predictor of primary non-adherence to chronic concomitant treatment in HIV-infected population.

Renal safety of lithium in HIV-infected patients established on tenofovir disoproxil fumarate containing antiretroviral therapy: analysis from a randomized placebo-controlled trial

Background

The prevalence of bipolar disorder in HIV-infected patients is higher than the general population. Lithium is the most effective mood stabiliser, while tenofovir disoproxil fumarate (TDF) is frequently used as part of combination antiretroviral therapy (ART). Both TDF and lithium are associated with renal tubular toxicity, which could be additive, or a pharmacokinetic interaction may occur at renal transporters with a decrease in TDF elimination.

Objective

We report on the change in estimated glomerular filtration rate (eGFR) using the modification of diet in renal disease formula in participants who received ART including TDF and were enrolled in a 24 week randomised trial of lithium versus placebo in patients with HIV-associated neurocognitive impairment.

Methods

We included HIV-infected adults with cognitive impairment established on ART for at least 6 months with a suppressed viral load attending public sector ART clinics in Cape Town, South Africa. We excluded participants with an eGFR <60 mL/min and treated with medications predisposing to lithium toxicity. We reviewed participants weekly for the first month for adverse events followed by 4 weekly visits for renal function assessment, adverse event monitoring and adherence. Lithium dose was titrated to achieve the maintenance target plasma concentration of between 0.6 and 1.0 mmol/L. Sham lithium concentrations were generated for participants receiving placebo.

Results

We included 23 participants allocated to the lithium arm and 30 participants allocated to the placebo arm. Baseline characteristics were not statistically different with a mean age of 37.7 and 40.8 years, a median time on ART of 33 and 40 months and an eGFR of 139.3 and 131.0 mL/min in the lithium and placebo arms respectively. There was no statistical significant difference in the reduction in eGFR or increase in potassium between the two arms during the 24 weeks.

Conclusions

We found that 24-week treatment of HIV-infected patients with lithium and TDF did not result in increased nephrotoxicity.

Trial registration The study was registered on the Pan African Clinical Trials Registry (PACTR) with the identifier number PACTR201310000635418. Registered 11 October 2013 before the first participant was enrolled

HIV-infection and psychiatric illnesses - A double edged sword that threatens the vision of a contained epidemic: The Greater Stockholm HIV Cohort Study

CONTEXT

The Greater Stockholm HIV Cohort Study is an initiative to provide longitudinal information regarding the health of people living with HIV.

OBJECTIVE

Our aim was to explore the prevalence of HIV and its association with psychiatric co-morbidities.

DESIGN, SETTING AND PARTICIPANTS

All patients with a recorded diagnosis of HIV (any position of the ICD-10 codes B20-B24) were identified during the period 2007-2014 and related to the total population in Stockholm by January 1, 2015, N = 2.21 million. The age at diagnosis, gender, and first occurrence of an HIV diagnosis was recorded. Analyses were done by age and gender. Prevalence of psychiatric co-morbidities amongst HIV patients were recorded.

MAIN OUTCOME MEASURES

Age-adjusted odds ratios with 95% confidence intervals were calculated with logistic regression for prevalent psychiatric co-morbidities in HIV infected individuals compared to the prevalence in the general population.

RESULTS

The total prevalence of HIV was 0.16%; females 0.10% (n = 1134) and males 0.21% (n = 2448). HIV-infected people were more frequently diagnosed with psychiatric illnesses and drug abuse. In females and males with HIV-diagnosis respectively, drug dependence disorder was 7.5 (7.76% vs 1.04%) and 5.1 (10.17% vs 1.98%) times higher, psychotic disorders were 6.3 (2.65% vs 0.42%) and 2.9 (1.43% vs 0.49%) times higher, bipolar disorder was 2.5 (1.41% vs 0.57%) and 3 (1.02% vs 0.34%) times higher, depression diagnosis was 1.5 (8.47% vs 5.82%) and 3.4 (10.17% vs 2.97%) higher, trauma-related disorder was 1.5 (6.00% vs 4.10%) respectively 2.9 (4.45% vs 1.56%) times higher, anxiety disorder was 1.2 (6.88% vs 5.72%) and 2.2 (6.54% vs 2.93%) times higher than in their non-infected peers.

CONCLUSION

Despite effective ART, many individuals with HIV have an impaired mental health and a history of drug abuse that may threaten the vision of a contained epidemic.

Predictors of psychotropic medication adherence among HIV+ individuals living with bipolar disorder

OBJECTIVE

HIV infection and bipolar disorder are highly comorbid and associated with frontostriatal disruption, emotional dysregulation, and neurocognitive impairment. Psychiatric and cognitive factors have been linked to antiretroviral nonadherence; however, predictors of psychotropic adherence among HIV+ individuals with psychiatric comorbidities have not been explored. We evaluated predictors of psychotropic adherence among individuals with HIV infection and bipolar disorder.

METHOD

Psychiatric medication adherence of 50 participants with HIV infection and bipolar disorder was tracked for 30 days using Medication Event Monitoring Systems. Participants completed neurocognitive, neuromedical, and psychiatric batteries.

RESULTS

Mean psychotropic adherence rate was 78%; 56% of participants achieved ≥90% adherence. Younger age and onset of depressive symptoms, more severe current depressive symptoms, number of previous psychiatric hospitalizations and suicide attempts, poorer neurocognition, and more negative attitudes and self-beliefs toward medications univariably predicted worse psychotropic adherence (p's < .10). A multivariable model demonstrated a combination of current depressive symptoms and more negative attitudes toward medications significantly predicting poorer adherence (R(2 )= 0.27, p < 0.003). Secondary analyses revealed an interaction between neurocognition and mood, such that individuals with HIV infection and bipolar disorder who had greater executive dysfunction and depressive symptoms evidenced the poorest psychotropic adherence (p < 0.001).

CONCLUSIONS

Both psychiatric and neurocognitive factors contribute to poorer psychotropic adherence among HIV+ individuals with serious mental illness. Adherence interventions aimed at remediating these factors may be especially fruitful.

Antiretroviral Therapy Outcomes in Patients with Severe Mental Illness

A retrospective cohort analysis was performed to describe outcomes and retention in care on antiretroviral therapy (ART) of 53 patients with severe mental illness (SMI). Diagnoses were psychosis secondary to HIV (24 patients), psychosis not otherwise specified (12), mania with or without psychosis (9), depression with psychotic features (4), and schizophrenia and bipolar mood disorder (2 each). The median baseline CD4 count was 66/mm(3) and viral load was 5.4 log10 copies/mL. Thirteen (25%) patients were lost to follow-up (10 within 6 months), 3 were transferred out, and 3 died. By week 96, 29 (85%) of 34 (64%) patients still in care had a viral load <400 copies/mL and 26 (76%) a viral load <25 copies/mL. Median CD4 count increased to 307/mm(3). Twenty-seven of 34 patients discontinued antipsychotic medication. Patients with SMI and advanced HIV infection responded well to ART. The first 6 months was important for retention in care.

Individualized texting for adherence building (iTAB): improving antiretroviral dose timing among HIV-infected persons with co-occurring bipolar disorder

HIV+ persons with co-occurring bipolar disorder (HIV+/BD+) have elevated rates of medication nonadherence. We conducted a 30-day randomized controlled trial of a two-way, text messaging system, iTAB (n = 25), compared to an active comparison (CTRL) (n = 25) to improve antiretroviral (ARV) and psychotropic (PSY) adherence and dose timing. Both groups received medication adherence psychoeducation and daily texts assessing mood. The iTAB group additionally received personalized medication reminder texts. Participants responded to over 90 % of the mood and adherence text messages. Mean adherence, as assessed via electronic monitoring caps, was high and comparable between groups for both ARV (iTAB 86.2 % vs. CTRL 84.8 %; p = 0.95, Cliff's d = 0.01) and PSY (iTAB 78.9 % vs. CTRL 77.3 %; p = 0.43, Cliff's d = -0.13) medications. However, iTAB participants took ARVs significantly closer to their intended dosing time than CTRL participants (iTAB: 27.8 vs. CTRL: 77.0 min from target time; p = 0.02, Cliff's d = 0.37). There was no group difference on PSY dose timing. Text messaging interventions may represent a low-burden approach to improving timeliness of medication-taking behaviors among difficult-to-treat populations. The benefits of improved dose timing for long-term medication adherence require additional investigation.

Interactive effects of neurocognitive impairment and substance use on antiretroviral non-adherence in HIV disease

While numerous studies have established the adverse independent effects of clinical conditions including neurocognitive dysfunction, psychiatric illness, and substance abuse/dependence on medication adherence among HIV-infected adults, fewer have studied their interactive effects. The current study examined this issue among 204 HIV-infected participants based upon current neurocognitive functioning and DSM-IV-diagnosed psychiatric illness and current substance abuse or dependence. Results confirmed that participants with any of these risk factors demonstrated poorer adherence than individuals with no risk factors. A neurocognitive status × substance abuse/dependence interaction was also identified such that participants with impaired neurocognition and a co-occurring substance abuse/dependence diagnosis demonstrated the poorest adherence. Results confirm the deleterious impact of these risk factors in isolation and also identify a specific interactive effect for individuals with comorbid neurocognitive impairment and a substance abuse/dependence disorder. Findings highlight the need for interventions that simultaneously address these problems.

HIV testing among adults with mental illness in the United States

Nationally representative data from the 2007 National Health Interview Survey (NHIS) were used to compare HIV testing prevalence among US adults with mental illness (schizophrenia spectrum disorder, bipolar disorder, depression, and/or anxiety) to those without, providing an update of prior work using 1999 and 2002 NHIS data. Logistic regression modeling was used to estimate the probability of ever being tested for HIV by mental illness status, adjusting for age, sex, race/ethnicity, marital status, substance abuse, excessive alcohol or tobacco use, and HIV risk factors. Based on data from 21,785 respondents, 15% of adults had a psychiatric disorder and 37% ever had an HIV test. Persons with schizophrenia (64%), bipolar disorder (63%), and depression and/or anxiety (47%) were more likely to report ever being tested for HIV than those without mental illness (35%). In multivariable models, individuals reporting schizophrenia (adjusted prevalence ratio=1.68, 95% confidence interval=1.33-2.13), bipolar disease (1.58, 1.39-1.81), and depression and/or anxiety (1.31, 1.25-1.38) were more likely to be tested for HIV than persons without these diagnoses. Similar to previous analyses, persons with mental illness were more likely to have been tested than those without mental illness. However, the elevated prevalence of HIV in populations with mental illness suggests that high levels of testing along with other prevention efforts are needed.

Real-world impact of neurocognitive deficits in acute and early HIV infection

The acute and early period of HIV-1 infection (AEH) is characterized by neuroinflammatory and immunopathogenic processes that can alter the integrity of neural systems and neurocognitive functions. However, the extent to which central nervous system changes in AEH confer increased risk of real-world functioning (RWF) problems is not known. In the present study, 34 individuals with AEH and 39 seronegative comparison participants completed standardized neuromedical, psychiatric, and neurocognitive research evaluations, alongside a comprehensive assessment of RWF that included cognitive symptoms in daily life, basic and instrumental activities of daily living, clinician-rated global functioning, and employment. Results showed that AEH was associated with a significantly increased risk of dependence in RWF, which was particularly elevated among AEH persons with global neurocognitive impairment (NCI). Among those with AEH, NCI (i.e., deficits in learning and information processing speed), mood disorders (i.e., Bipolar Disorder), and substance dependence (e.g., methamphetamine dependence) were all independently predictive of RWF dependence. Findings suggest that neurocognitively impaired individuals with AEH are at notably elevated risk of clinically significant challenges in normal daily functioning. Screening for neurocognitive, mood, and substance use disorders in AEH may facilitate identification of individuals at high risk of functional dependence who may benefit from psychological and medical strategies to manage their neuropsychiatric conditions.

Preliminary Evidence for Feasibility, Use, and Acceptability of Individualized Texting for Adherence Building for Antiretroviral Adherence and Substance Use Assessment among HIV-Infected Methamphetamine Users

The feasibility, use, and acceptability of text messages to track methamphetamine use and promote antiretroviral treatment (ART) adherence among HIV-infected methamphetamine users was examined. From an ongoing randomized controlled trial, 30-day text response rates of participants assigned to the intervention (individualized texting for adherence building (iTAB), n = 20) were compared to those in the active comparison condition (n = 9). Both groups received daily texts assessing methamphetamine use, and the iTAB group additionally received personalized daily ART adherence reminder texts. Response rate for methamphetamine use texts was 72.9% with methamphetamine use endorsed 14.7% of the time. Text-derived methamphetamine use data was correlated with data from a structured substance use interview covering the same time period (P < 0.05). The iTAB group responded to 69.0% of adherence reminder texts; among those responses, 81.8% endorsed taking ART medication. Standardized feedback questionnaire responses indicated little difficulty with the texts, satisfaction with the study, and beliefs that future text-based interventions would be helpful. Moreover, most participants believed the intervention reduced methamphetamine use and improved adherence. Qualitative feedback regarding the intervention was positive. Future studies will refine and improve iTAB for optimal acceptability and efficacy. This trial is registered with ClinicalTrials.gov NCT01317277.

Three types of self-efficacy associated with medication adherence in patients with co-occurring HIV and substance use disorders, but only when mood disorders are present

Background

Adherence with medication regimens for human immunodeficiency virus (HIV) is a life-saving behavior for people with HIV infection, yet adherence is challenging for many individuals with co-occurring substance use and/or mood disorders. Medication-taking self-efficacy, which is the confidence that one can take one’s medication as prescribed, is associated with better adherence with HIV medication. However, little is known about the influence that other kinds of self-efficacy have on adherence with HIV medication, especially among HIV-infected individuals with co-occurring substance use and/or mood disorders. We sought to examine the relationship between adherence with HIV medication among substance users and three specific kinds of self-efficacy, ie, one’s confidence that one can communicate with medical providers, get support, and manage one’s mood. We further sought to examine whether symptoms of depression and anxiety moderate these relationships.

Methods

Patients were recruited from three HIV clinics in the southeastern United States as part of an integrated study of treatment for HIV and substance use.

Results

We interviewed 154 patients with HIV and substance use who reported taking HIV medications. Based on symptoms of depression and anxiety using the Patient Health Questionnaire-9 and the Hospital Anxiety and Depression Scale-Anxiety, 63% had probable depression and/or anxiety. Higher levels of self-efficacy in provider communication (β = 3.86, P < 0.01), getting needed support (β = 2.82, P < 0.01), and mood management (β = 2.29, P < 0.05) were related to better self-reported adherence with HIV medication among study participants with probable depression and/or anxiety. The three kinds of self-efficacy were not associated with medication adherence among participants with HIV and substance use only.

Conclusion

In the search for mutable factors to improve medication adherence among individuals triply diagnosed with HIV, substance use, and mood disorders, these findings support previous research indicating the benefit of enhancing self-efficacy, and further point to three specific kinds of self-efficacy that may benefit medication adherence, ie, provider communication, getting support, and mood management.

Prevalence of bipolar disorder in a HIV-infected outpatient population

This study assesses the prevalence of bipolar disorder (BD) among 196 HIV-infected adult outpatients attending in a specialized unit in Fortaleza, Brazil. Patients were interviewed with the Mood Disorder Questionnaire (MDQ), the Mini International Neuropsychiatric Interview (MINI), the Alcohol Use Disorders Identification Test (AUDIT), and a socio-demographic questionnaire based on WHO's behavioral surveillance surveys. Positive MDQ screening was found in 13.2% (N=26) and the BD diagnosis was confirmed in 8.1% (N=16) of the sample. There is an almost four times higher prevalence of BD among the HIV-infected patients of the sample (8.1%) than in the general population from the USA (2.1%). The prevalence of BD type I in the HIV patients was 5.6% (N=11) which is almost six times higher than the US general population (1%). The odds ratios of sexual behaviors and substance abuse variables correlated with BD were calculated. The variables associated with the diagnoses of BD were sex with commercial partners, sex outside the primary relationship, alcohol use disorders, and illicit drug abuse. The most common psychiatric comorbidity in the BD group was substance abuse (61.5%). A better understanding of psychiatric comorbidities and behavioral aspects of HIV-positive patients may help in improving long-term outcome of these patients.

Prospective memory and antiretroviral medication non-adherence in HIV: an analysis of ongoing task delay length using the memory for intentions screening test

Using multi-process framework by McDaniel and Einstein (2000), the current study examined whether the length of prospective memory (PM) delay intervals as measured by the 2- and 15-min subscales of the Memory for Intentions Screening Test (MIST) have differential predictive value for antiretroviral (ARV) adherence. Participants included 74 HIV-infected individuals whose ARV adherence was tracked with an electronic monitoring system. Participants were classified as "adherent" (n = 49) or "non-adherent" (n = 25) based on recorded pill bottle openings of ≥90% of prescribed doses over 30 days. An adherence group by MIST delay interval interaction was observed, such that non-adherent participants had worse performance on the 15-min, but not 2-min delay PM MIST subscales. The observed MIST 15-min delay effects were significantly more pronounced on time- versus event-cued PM trials. Long-delay time-based PM was predictive of non-adherence independent of demographics, mood state, self-reported adherence, and general cognitive functioning. Findings from this clinical study indicate that ARV non-adherence may be particularly associated with deficits in strategic cue monitoring over longer PM delays, which may inform interventions to improve adherence among persons living with HIV infection.

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.

Bipolar disorder is associated with HIV transmission risk behavior among patients in treatment for HIV

This study examined HIV transmission risk behavior among 63 patients with bipolar disorder (BD), major depressive disorder, and no mood disorder; half had substance use disorders (SUDs). Patients with BD were more likely than others to report unprotected intercourse with HIV-negative partners and <95 % adherence to antiretroviral medications. In multivariate models, BD and SUD were independent predictors of both risk behaviors. Participants with poorer medication adherence were more likely to have detectable HIV viral loads and unprotected intercourse with HIV-negative partners. Patients with BD deserve careful evaluation and HIV prevention services to reduce HIV transmission risk behaviors.

Approaches to identifying appropriate medication adherence assessments for HIV infected individuals with comorbid bipolar disorder

Assessing medication adherence in already difficult-to-treat HIV-infected subpopulations presents a unique challenge. The objective of this study was to compare different approaches to assessing medication adherence: (1) electronic medication monitoring, (2) standardized self-report questionnaire, and (3) self-report visual analogue scale, and to determine whether antiretroviral therapy (ART) adherence measures differed for HIV-infected persons with bipolar disorder (HIV+ /BD+) as compared to HIV-infected persons without bipolar disorder (HIV+ /BD-). ART adherence was assessed for 74 HIV-positive participants using the Medication Event Monitoring System (MEMS), AIDS Clinical Trials Group (ACTG) adherence questionnaire, and visual analogue scale (VAS). Participants were classified as adherent or nonadherent on each measure by previously validated cutscores. Correlations and logistic regressions were used to examine associations between adherence measures and demographic and clinical variables. In the HIV+ /BD- group, significant correlations existed between each self-report measure and the MEMS. Males comprised 81% of the study population. Participants averaged 44 years of age and 13 years of education. No significant correlations were found among adherence measures in the HIV+ /BD+ group. Among participants reporting adherence on either self-report measure but classified as nonadherent based on MEMS, 94% had a diagnosis of bipolar disorder. Bipolar disorder was a significant predictor of adherence classification discordance among self-report measures. Our findings suggest that it remains difficult to assess ART adherence among HIV-positive individuals with bipolar disorder. Combined approaches of self-report and objective measures may be the best way to estimate adherence, and may provide the best basis for interventions designed to improve adherence in difficult-to-treat populations.

Human immunodeficiency virus and acquired immunodeficiency syndrome: recent developments and their implications for pediatric surgeons

Advances in medical management have enhanced both the quality and the quantity of life currently enjoyed by HIV-infected infants and children. Advances in surgical treatment have complemented these advances and contributed to the improving prognosis of HIV disease in the pediatric population. The resultant "aging" of the pediatric HIV population means that pediatric surgeons can expect to encounter HIV-infected patients on an ever-increasing basis. This article reviews the new advances in diagnosis and treatment of pediatric HIV disease most relevant to pediatric surgical practice.