The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals

Provocative Findings From a Transdiagnostic Counseling Intervention to Improve Psychiatric Comorbidity and HIV Care Engagement Among People With HIV: A Pilot Randomized Clinical Trial

BACKGROUND

Depression, anxiety, post-traumatic stress, and alcohol/substance use disorders are prevalent among people with HIV (PWH), commonly co-occur, and predict worse HIV care outcomes. Transdiagnostic counseling approaches simultaneously address multiple co-occurring mental health disorders.

METHODS

We conducted a pilot individually randomized trial of the Common Elements Treatment Approach adapted for people with HIV (CETA-PWH), a transdiagnostic counseling intervention, compared with usual care at a large academic medical center in the southern United States. Participants were adults with HIV; at risk for HIV care disengagement; and with elevated symptoms of depression, anxiety, post-traumatic stress, and/or alcohol/substance use. Mental health and HIV care engagement were assessed at 4 and 9 months.

RESULTS

Among participants (n = 60), follow-up was high at 4 (92%) and 9 (85%) months. Intervention engagement was challenging: 93% attended ≥1 session, 43% attended ≥6 sessions in 3 months ("moderate dose"), and 30% completed treatment. Although not powered for effectiveness, mental health outcomes and HIV appointment attendance improved in CETA-PWH relative to usual care in intent-to-treat analyses; those receiving a moderate dose and completers showed progressively greater improvement. Viral load showed small differences between arms. The dose-response pattern was not explained by differences between those who did and did not complete treatment.

CONCLUSIONS

This pilot trial provides preliminary evidence for the potential of CETA-PWH to simultaneously address co-occurring mental health comorbidities and support HIV appointment attendance among PWH. Additional strategies may be an important part of ensuring that clients can engage in the full course of treatment and realize its full benefits.

Understanding healthcare engagement for people who inject drugs

People who inject drugs (PWID) are at an increased risk of multimorbid mental health and chronic diseases, which are frequently underdiagnosed and under-treated due to systemic barriers and ongoing substance use. Healthcare engagement is essential to address these conditions and prevent excess morbidity and mortality. The goal of this study was to understand how PWID engage in care for their chronic health conditions and substance use treatment given the known historic and pervasive barriers. We conducted 24 semistructured qualitative interviews informed by the Behavioral Model for Vulnerable Populations between July-September 2019. Participants were sampled across a range of comorbidities, including co-occurring mental health disorders. Thematic analysis was conducted to explore experiences of healthcare engagement for multimorbid chronic diseases, mental health, and treatment for substance use disorder. Mean age for participants was 58 years; 63% reported male sex and 83% reported Black race. Interviews yielded themes regarding healthcare access and wraparound services, positive patient-provider relationships, service integration for substance use treatment and mental health, healthcare needs alignment, medication of opioid use disorder stigma, and acceptance of healthcare. Taken together, participants described how these themes enabled healthcare engagement. Engagement in care is crucial to support health and recovery. Clinical implications include the importance of strengthening patient-provider relationships, encouraging integration of medical and mental health services, and counseling on substance use treatment options in a non- stigmatizing manner. Additionally, policy to reimburse wrap-around support for substance use recovery can improve care engagement and outcomes related to chronic diseases, mental health, and substance use among PWID. No Patient or Public Contribution: While we acknowledge and thank ALIVE participants for their time for data collection and sharing their perspectives, no ALIVE participants, other people who use drugs, and service users were involved in data collection, analysis or interpretation of data, or in preparation of the manuscript.

Measuring the prevalence of autistic traits in a cohort of adults living with HIV or taking HIV pre-exposure prophylaxis and mapping safer-sex barriers and facilitators: a study protocol

INTRODUCTION

Autistic individuals identify with a wider range of sexual orientations than non-autistic individuals, including higher rates of bisexual orientation in autistic men. Gay, bisexual and other men who have sex with men are at greater risk for HIV. Prevalence data of autistic traits in people living with HIV or using Pre-Exposure Prophylaxis (PrEP) for HIV are lacking so far. Such data, combined with insights in barriers and facilitators for safer sex in autistic people living with HIV or using PrEP, are a first step to improve health support for autistic people in HIV clinics. This support is crucial since autistic individuals have worse physical and mental health outcomes. The objective of this research is to determine the prevalence of autistic traits within the group of people living with HIV or using PrEP in Belgium and to describe specific facilitators and barriers for sexual safer behaviour in people living with HIV and PrEP users with autistic traits.

METHODS AND ANALYSIS

The research is a cross-sectional, observational and multicentre study with recruitment of individual participants. The research consists of two phases. In phase 1, adults coming for HIV/AIDS care or HIV PrEP in participating Belgian HIV Reference Centres will be invited to fill in the validated Autism Spectrum Quotient questionnaire. In phase 2, participants with a score above the predefined cut-off for autistic traits (>26), who agreed to be informed about this score, will be invited to complete an additional survey, inquiring facilitators and barriers for sexual safer behaviour.

ETHICS AND DISSEMINATION OF RESULTS

Institutional Review Board Institute of Tropical Medicine Antwerp, 25 July 2022, REF 1601/22 and University Hospital of Antwerp, 12 September 2022, Project ID 3679: BUN B3002022000111. Study results will be published in peer-reviewed journals and presented to Belgian HIV Reference Centres and at conferences.

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.

What affects timely linkage to HIV Care for Young Men of Color who have sex with Men? Young Men's Experiences Accessing HIV Care after Seroconverting

The HIV care continuum provides intervention points that should be addressed to optimally identify, engage, and retain populations in HIV care. This study addressed the lack of research into barriers and facilitators of linkage to care for HIV-positive young men who have sex with men (YMSM) of color. Data were collected using a qualitative timeline follow-back interview approach with YMSM who had seroconverted in the last 6 months. Interviews were conducted with 15 YMSM from April 2017 to April 2018. This study provides important information about what can delay linkage to care for YMSM of color. These delays include fractured referrals to care providers via mobile HIV testing vans, adapting to an HIV diagnosis and integrating it into their lives, and finding caring and competent providers that offer wraparound services, specifically mental health services, as soon as possible after an HIV diagnosis. Addressing these issues is imperative to optimize YMSM's engagement in the HIV care continuum and work toward ending the epidemic.

Risk factors for late linkage to care and delayed antiretroviral therapy initiation amongst HIV infected adults in sub-Saharan Africa: a systematic review and meta-analyses

BACKGROUND

Late treatment initiation threatens the clinical and public health benefits of antiretroviral therapy (ART). Quantitative synthesises of the existing evidence related to this is lacking in sub-Saharan Africa (SSA), which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesise the available literature on factors affecting linkage to care and ART initiation amongst HIV-infected adults in SSA.

METHODS

Systematic searches were undertaken on four databases to identify observational studies investigating factors affecting both HIV care outcomes amongst adults (age ≥19 years) in SSA, and were published between January 1, 2015 and June 1, 2021. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with 95% confidence interval and <0.05 level of significance.

RESULTS

Forty-six studies were included in the systematic review, of which 18 fulfilled requirements for meta-analysis. In both narrative review and meta-analyses, factors related to health care delivery, individual perception and sociodemographic circumstances were associated with late linkage to care and delays in ART initiation.

CONCLUSION

This review identified a range of risk factors for late linkage to care and delayed ART initiation amongst HIV-infected adults in SSA. We recommend implementation of patient-centred intervention approaches to alleviate these barriers.

Association Between ART Adherence and Mental Health: Results from a National HIV Sero-Behavioural Survey in South Africa

This paper assesses the levels of antiretroviral treatment (ART) adherence and mental health distress among study participants in a national behavioural HIV-sero prevalence study South Africa. The study was a cross-sectional population-based multi-stage stratified cluster random survey, (SABSSM V, 2017). Structured questionnaires were used to collect information on socio-demographics, HIV knowledge, perceptions, HIV testing and HIV treatment history. Study participants were tested for HIV infection, antiretroviral use, viral suppression, and ART drug resistance. A total of 2155 PLHIV aged 15 years or older who were on ART were included in the study. Incidence of either moderate or severe mental health distress was 19.7%. Self-reported ART adherence among study participants with no, mild, moderate, or severe mental distress was 82%, 83%, 86% and 78%, respectively. The adjusted odds ratio for ART non-adherence was 0.58 (95% CI 0.24; 1.40) for mild mental distress, 0.82 (95% CI 0.35; 1.91) for moderate mental distress and 2.19 (95% CI 1.14; 4.19) for severe mental distress groups compared to the no mental health distress group. The other factors that were associated with ART non-adherence in adjusted models included education level, alcohol use and province/region of residence. The study revealed that mental health remains a challenge to ART adherence in South Africa. To improve ART adherence, HIV continuum of care programs should include screening for mental health among people living with HIV.

The Lived Experience of Managing HIV and Chronic Pain: Qualitative Interviews with Patients and Healthcare Providers

People living with HIV (PLWH) experience higher rates of comorbid chronic pain conditions compared to the general population. Managing HIV and chronic pain, two stigmatized health conditions, can exacerbate physical and psychological suffering. The current qualitative study was designed to increase our understanding of the experience of living with HIV and chronic pain. Twenty participants were recruited from a hospital-based immunology center to participate in individual in-depth qualitative interviews. The interviews focused on the experience of living with (or managing) chronic pain for PLWH. All interviews were audio recorded, transcribed and double-coded. Several themes emerged from our applied thematic analysis of the transcripts. The primary theme was that pain remained poorly managed among PLWH. Patients engaged in a variety of pain management strategies and described benefits from both traditional pain management interventions (e.g., pharmacology, physical therapy) as well as non-traditional approaches (e.g., medical marijuana, cannabidiol products, and spirituality). Other themes that emerged included barriers related to health insurance and the need to validate the patient pain experience. PLWH and chronic pain described compounding effects of managing two chronic health conditions, including perceived immune system over-activation, heightened awareness of illness, and negative mindset. More research is needed to improve care for those managing these often co-occurring health conditions.

Mental health and initiation of antiretroviral treatment at enrolment into HIV care in Cameroon under a national "treat all" policy: a cross-sectional analysis

Introduction

Rapid antiretroviral treatment (ART) initiation reduces time from HIV infection to viral suppression, decreasing HIV transmission risk. Mental health symptoms may influence timing of ART initiation. This study estimated the prevalence of ART initiation at enrolment into HIV care and the relationship between mental health and ART initiation at enrolment into HIV care.

Methods

We conducted interviews with 426 individuals initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the association between mental health and timing of ART initiation. Depression (Patient Health Questionnaire‐9; cut‐point 10), anxiety (Generalized Anxiety Disorder‐7; cut‐point 10), post‐traumatic stress disorder (PTSD) (PTSD Checklist for DSM‐5; cut‐point 31) and harmful alcohol use (Alcohol Use Disorders Identification Test; cut‐point 16) were dichotomized to represent those with and without each exposure at first HIV care appointment. Date of ART initiation (date ART prescribed) was ascertained from medical records. Separate multivariable log‐binomial regression models were used to estimate the association between mental health exposures and ART initiation at enrolment into care.

Results and discussion

Overall, 87% initiated ART at enrolment into HIV care. Approximately 20% reported depressive symptoms, 15% reported PTSD symptoms, 12% reported anxiety symptoms and 13% reported harmful alcohol use. In multivariable analyses, individuals with moderate to severe depressive symptoms had 1.7 (95% confidence interval [CI] 1.1, 2.7) times the prevalence of not initiating ART at enrolment into HIV care compared to those with no or mild depressive symptoms. Those with symptoms of PTSD, compared to those without, had 1.9 (95% CI 1.2, 2.9) times the prevalence of not initiating ART at enrolment into HIV care. Symptoms of anxiety or harmful drinking were not associated with ART initiation at enrolment into HIV care in multivariable models.

Conclusions

Symptoms of depression and PTSD were associated with lower prevalence of ART initiation at enrolment into HIV care among this sample of individuals initiating HIV care in Cameroon under a “treat all” policy. Research should examine barriers to timely ART initiation, whether incorporating mental health services into HIV care improves timely ART initiation, and whether untreated symptoms of depression and PTSD drive suboptimal HIV care outcomes.

Readiness for Hospital Discharge and Its Correlates Among People Living With HIV in Hunan, China: A Cross-sectional Study

ABSTRACT

We aimed to (a) describe the readiness for hospital discharge in people living with HIV and (b) explore factors associated with readiness for hospital discharge. A cross-sectional survey was conducted at two infectious disease hospitals in Hunan, China, from May to November 2017. The readiness for hospital discharge scale (RHDS) was used to assess discharge readiness. The average item mean for the RHDS ranges from 0 to 10, and higher scores represent a higher level of readiness for hospital discharge. The mean score of the RHDS was 7.78 (95% confidence interval 7.586-7.968), and 27.6% of participants (n = 56/203) felt unready for discharge (RHDS <7). We found that older age, lack of medical insurance, lower self-rated health status, poorer quality of discharge teaching, and more severe depressive symptoms were significantly associated with a lower level of readiness for hospital discharge. Interventions are needed to improve readiness of people living with HIV for hospital discharge in Hunan, China, especially for those of advanced age, without medical insurance, with worse self-rated health status, and those with higher levels of depressive symptoms.

The Patient Reported Outcomes as a Clinical Tool (PROACT) Pilot Study: What Can be Gained by Sharing Computerized Patient-Reported Mental Health and Substance Use Symptoms with Providers in HIV Care?

Substance use and mental health (SU/MH) disorders are insufficiently recognized in HIV care. We examined whether conveying SU/MH screening results to patients and providers increased SU/MH discussions and action plans. Intervention participants completed a computerized patient-reported questionnaire before their HIV visit; screened positive on ≥ 1 measure: depression, anxiety, PTSD symptoms, at-risk alcohol use, or drug use; and reviewed screening results to decide which to prioritize with their provider. Screening results and clinical recommendations were conveyed to providers via medical record. A historic control included patients with positive screens but no conveyance to patient or provider. The patient-provider encounter was audio-recorded, transcribed, and coded. For the overall sample (n = 70; 38 control, 32 intervention), mean age (SD) was 51.8 (10.3), 61.4% were male, and 82.9% were Black. Overall, 93.8% raised SU/MH in the intervention compared to 50.0% in the control (p < 0.001). Action plans were made for 40.0% of intervention and 10.5% of control encounters (p = 0.049). Conveying screening results with clinical recommendations increased SU/MH action plans, warranting further research on this intervention to address SU/MH needs.

Substance use and HIV stage at entry into care among people with HIV

BACKGROUND

Information regarding the impact of substance use on the timing of entry into HIV care is lacking. Better understanding of this relationship can help guide approaches and policies to improve HIV testing and linkage.

METHODS

We examined the effect of specific substances on stage of HIV disease at entry into care in over 5000 persons with HIV (PWH) newly enrolling in care. Substance use was obtained from the AUDIT-C and ASSIST instruments. We examined the association between early entry into care and substance use (high-risk alcohol, methamphetamine, cocaine/crack, illicit opioids, marijuana) using logistic and relative risk regression models adjusting for demographic factors, mental health symptoms and diagnoses, and clinical site.

RESULTS

We found that current methamphetamine use, past and current cocaine and marijuana use was associated with earlier entry into care compared with individuals who reported no use of these substances.

CONCLUSION

Early entry into care among those with substance use suggests that HIV testing may be differentially offered to people with known HIV risk factors, and that individuals with substances use disorders may be more likely to be tested and linked to care due to increased interactions with the healthcare system.

Drug Use is Associated with Delayed Advancement Along the HIV Care Continuum Among Transgender Women of Color

Transgender women are impacted by elevated rates of HIV infection and drug use. This study investigated effects of drug use on HIV care outcomes among transgender women of color living with HIV who enrolled in a combined peer health navigation (PHN) and contingency management intervention (N = 129). At baseline, 71.3% reported any drug use in the past 6 months. Linkage to HIV care was delayed for users of any stimulant compared to non-users of stimulants, and for methamphetamine users compared to non-users of methamphetamine. Any drug use, relative to no drug use, was associated with fewer HIV care visits (IRR 0.50, 95% CI [0.30, 0.85]), but did not significantly impact ART adherence, or attaining an undetectable viral load. PHN sessions were positively related to the number of HIV care visits (IRR 1.20, 95% CI [1.07, 1.34]), especially for users of any stimulant and for methamphetamine users, to ART adherence (OR 2.54, 95% CI [1.67, 3.86]), and to virological suppression (OR 7.57, 95% CI [1.64, 34.94]). These findings demonstrate the value of assessing drug use as a possible barrier to HIV care.

Antiretroviral treatment adherence and mental disorders: observational case-control study in people living with HIV in Spain

Mental disorders hamper immunological control of HIV infection by exerting a negative influence on antiretroviral therapy (ART) adherence. We sought to address the possible relationship between non-adherence to antiretroviral treatment (ART), mental disorders and substance use in people living with HIV/AIDS (PLWHA) in Spain, which presents a high prevalence of intravenously transmitted HIV infection. We assessed 125 PLWHA attending regular outpatient follow-up. The main adherence measure was pill collection from the Hospital Pharmacy. We included sociodemographic variables, mental disorders diagnosis, and substance use in the 12 months prior to the assessment. Harmful alcohol consumption (OR: 6.834; 95% CI: 2.008-23.257; p = 0.002), suffering from depression (OR: 5.851; 95% CI: 1.470-23.283; p = 0.012) and being at risk of suicide (OR: 3.495; 95% CI: 1.136-10.757; p = 0.029) increased the likelihood of non-adherence. 29.6% of the sample had been infected via blood contact. HCV co-infection was present in 46.4% of the study sample, increasing the likelihood of non-adherence (OR: 3.223; 95% CI: 1.119-9.286; p = 0.030). Harmful alcohol use and some serious mental disorders (especially depression and suicide risk) are consistently associated with non-adherence to ART. HCV co-infection could be an important risk marker of non-adherence among PLWHA with a high prevalence of intravenous drug use.

Correlates of missed HIV appointments in low-resource settings: a study from Uganda

Aims: Alarming reports of antiretroviral treatment failure have recently emerged in sub-Saharan Africa. The onset of virologic failure has multiple causes but suboptimal treatment adherence is one of the leading causes. This study aimed to explore correlates of adherence to HIV appointments in community care patients living with HIV/AIDS in Uganda.Methods: Two hundred and ninety-five people living with HIV (median age 37.0 years; interquartile range 16.0; female 67.8% [n = 200]) reported whether they had missed any of their four-weekly appointments during the past 24 weeks. They also completed the Internalized AIDS-Related Stigma Scale, Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, the Alcohol-Use Disorders Identification Test, and the Physical Activity Vital Sign.Results: Thirty-three (11.2%) patients missed at least one of their six scheduled appointments in the 24-week period. The adjusted odds ratio for missing at least one of six appointments was 3.03 (95% CI: 1.21-8.43, p = 0.01) for those who were physically inactive, and 2.29 (95% CI: 0.93-5.63, p = 0.046) for those with depression.Conclusions: Targeting future rehabilitation studies for PLHIV around feelings of depression and around physical inactivity could be important in achieving optimal HIV treatment adherence.

Natural Language Processing of Clinical Notes to Identify Mental Illness and Substance Use Among People Living with HIV: Retrospective Cohort Study

Background

Mental illness and substance use are prevalent among people living with HIV and often lead to poor health outcomes. Electronic medical record (EMR) data are increasingly being utilized for HIV-related clinical research and care, but mental illness and substance use are often underdocumented in structured EMR fields. Natural language processing (NLP) of unstructured text of clinical notes in the EMR may more accurately identify mental illness and substance use among people living with HIV than structured EMR fields alone.

Objective

The aim of this study was to utilize NLP of clinical notes to detect mental illness and substance use among people living with HIV and to determine how often these factors are documented in structured EMR fields.

Methods

We collected both structured EMR data (diagnosis codes, social history, Problem List) as well as the unstructured text of clinical HIV care notes for adults living with HIV. We developed NLP algorithms to identify words and phrases associated with mental illness and substance use in the clinical notes. The algorithms were validated based on chart review. We compared numbers of patients with documentation of mental illness or substance use identified by structured EMR fields with those identified by the NLP algorithms.

Results

The NLP algorithm for detecting mental illness had a positive predictive value (PPV) of 98% and a negative predictive value (NPV) of 98%. The NLP algorithm for detecting substance use had a PPV of 92% and an NPV of 98%. The NLP algorithm for mental illness identified 54.0% (420/778) of patients as having documentation of mental illness in the text of clinical notes. Among the patients with mental illness detected by NLP, 58.6% (246/420) had documentation of mental illness in at least one structured EMR field. Sixty-three patients had documentation of mental illness in structured EMR fields that was not detected by NLP of clinical notes. The NLP algorithm for substance use detected substance use in the text of clinical notes in 18.1% (141/778) of patients. Among patients with substance use detected by NLP, 73.8% (104/141) had documentation of substance use in at least one structured EMR field. Seventy-six patients had documentation of substance use in structured EMR fields that was not detected by NLP of clinical notes.

Conclusions

Among patients in an urban HIV care clinic, NLP of clinical notes identified high rates of mental illness and substance use that were often not documented in structured EMR fields. This finding has important implications for epidemiologic research and clinical care for people living with HIV.

Depressive symptoms and use of HIV care and medication-assisted treatment among people with HIV who inject drugs

OBJECTIVE

Vietnam, Indonesia, and Ukraine have major burdens of IDU and HIV. We estimated the prevalence of depressive symptoms at baseline among people living with HIV who inject drugs, evaluated associations between depression at baseline and 12-month HIV care outcomes and medication-assisted treatment (MAT), and evaluated the study intervention effect by baseline depression subgroups.

DESIGN

HPTN 074 was a randomized study. The study intervention included psychosocial counseling, systems navigation, and antiretroviral treatment (ART) at any CD4+ cell count.

METHODS

Moderate-to-severe depression was defined as a Patient Health Questionnaire-9 score of 10 or above. ART and MAT were self-reported. Eligibility criteria were: 18-60 years of age, active IDU, and viral load of at least 1000 copies/ml. Adjusted probability differences (aPD) were estimated using inverse-probability weighting.

RESULTS

A total of 502 participants enrolled from April 2015 to June 2016. Median age was 35 years; 85% identified as men. Prevalence of baseline moderate-to-severe depression was 14% in Vietnam, 14% in Indonesia, and 56% in Ukraine. No evident associations were detected between baseline depression and ART, viral suppression, or MAT at 12-month follow-up. The study intervention improved the proportions of people who inject drugs achieving 12-month viral suppression in both the depressed [intervention 44%; standard of care 24%; estimated aPD = 25% (95% confidence interval: 4.0%, 45%)] and nondepressed subgroups [intervention 38%; standard of care 24%; aPD = 13% (95% confidence interval: 2.0%, 25%)].

CONCLUSION

High levels of depressive symptoms were common among people living with HIV who inject drugs in Ukraine but were less common in Vietnam and Indonesia. The study intervention was effective among participants with or without baseline depression symptoms.

Improvements in Retention in Care and HIV Viral Suppression Among Persons with HIV and Comorbid Mental Health Conditions: Patient-Centered HIV Care Model

The Patient-centered HIV Care Model (PCHCM) integrated community-based pharmacists with medical providers and required sharing of patient clinical information and collaborative therapy-related action planning. We determined the proportions of participants with HIV and mental health conditions who were retained in care and the proportion virally suppressed, pre- and post-implementation. Overall, we found a relative 13% improvement in both retention [60% to 68% (p = 0.009)] and viral suppression [79% to 90% (p < 0.001)]. Notable improvements were seen among persons triply diagnosed with HIV, mental illness and substance use [+ 36% (50% to 68%, p = 0.036) and + 32% (66% to 86%, p = 0.001) in retention and viral suppression, respectively]. There were no differences in the proportions of persons adherent to psychiatric medications, pre- to post-implementation, nor were there differences in the proportions of persons retained in care or virally suppressed by psychiatric medication adherence, post-implementation. PCHCM demonstrated that collaborations between community-based pharmacists and medical providers can improve HIV care continuum outcomes among persons with mental health conditions.

Drug Use Among Adolescents and Young Adults with Unsuppressed HIV Who Use Alcohol: Identifying Patterns of Comorbid Drug Use and Associations with Mental Health

Youth living with HIV (YLWH; aged 16-24) are at elevated risk of alcohol and drug use. Studies in older populations have identified patterns or profiles of multiple substance use differentially associated with mental health and anti-retroviral therapy (ART) adherence. No studies of YLWH have yet examined such patterns. A sample of 179 YLWH, reporting ART non-adherence and alcohol use, were recruited at five Adolescent Trials Network clinics in urban areas of the US between November 2014 and August 2017. Participants completed the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) to assess substance use involvement scores, and the Brief Symptom Inventory. Latent Profile Analysis identified three substance use patterns: minimal illicit drug use (15.1%), cannabis only (56.4%), and global polysubstance use (28.5%). Global polysubstance users experienced more mental health problems compared to the minimal illicit drug use group. The co-occurrence of drug use with alcohol was common among these YLWH-all of whom reported ART adherence problems-indicating the importance of interventions capable of addressing multiple substance use rather than alcohol alone.

The Role of Mental Health Conditions in the Diagnosis of Neurocognitive Impairment in People Living with HIV

The aims of the present study were to evaluate the prevalence of undiagnosed mental health conditions (UMHC) in people living with HIV (PLWHIV) on antiretroviral treatment and with long-term suppressed HIV viremia, and its association with neurocognitive impairment (NCI). A cross-sectional observational study on HIV subjects, ≥18 years old, on stable antiretroviral treatment and with HIV viral load <50 copies/mL was carried out. Patients with known comorbidities, substances abuse, anxiety or depression were excluded. UMHC were evaluated by the Millon Clinical Multiaxial Inventory-III and NCI by Frascati criteria. The association between NCI and sociodemographic, clinical HIV variables and mental health conditions was analyzed. Further, the relationship between mental health conditions scores and NCI diagnosis was evaluated. Eighty patients were included, 37.5% had at least one undiagnosed mental health condition, and 26.3% had NCI. The most frequent mental health conditions were: anxiety (21.3%); bipolar disorder (11.3%); and substance dependence (8.8%). Only longer time since HIV diagnosis (p = 0.030) and at least one mental health condition diagnosis (p = 0.002) showed an association with NCI. Participants with NCI presented higher scores in anxiety, alcohol dependence and post-traumatic stress. Undiagnosed mental health conditions are frequent in PLWHIV. These disorders cannot be identified by HIV clinicians or basic screening questionnaires, and they are not usually self-reported by patients. UMHC could act as confounders in the evaluation of NCI.

Psychiatric Comorbidity of Unipolar Mood, Anxiety, and Trauma Disorders Prior to HIV Testing and the Effect on Linkage to Care Among HIV-Infected Adults in South Africa

Psychiatric comorbidity, the presence of two or more psychiatric disorders, leads to worse HIV outcomes in the United States; this relationship has not been studied in sub-Saharan Africa. We conducted a preliminary study to describe the prevalence of psychiatric comorbidity (unipolar mood, anxiety, and trauma disorders) among 363 adults prior to HIV testing at Witkoppen Health and Welfare Centre, a primary care clinic in Johannesburg, South Africa. We also examined whether psychiatric comorbidity predicted subsequent linkage to HIV care 3 months later. Prevalence of psychiatric comorbidity prior to HIV testing was approximately 5.5%. In the final HIV-positive subsample (n = 76), psychiatric comorbidity of unipolar mood, anxiety, and trauma disorders did not predict linkage to care [adjusted relative risk = 1.01 (0.59, 1.71)] or number of follow-up appointments (adjusted relative risk = 0.86 (0.40, 1.82)]. A similar psychiatric profile emerged for HIV-positive and HIV-negative individuals before becoming aware of their HIV status. The psychiatric burden typically seen in HIV-positive individuals may manifest over time.

Brief Report: Reduced Use of Illicit Substances, Even Without Abstinence, Is Associated With Improved Depressive Symptoms Among People Living With HIV

PURPOSE

Substance use is linked with poor outcomes among people living with HIV (PLWH) and is associated with mental health disorders. This analysis examines the impact of decreasing substance use, even without abstinence, on depressive symptoms among PLWH.

METHODS

Data are from PLWH enrolled in the Centers for AIDS Research Network of Integrated Clinical Sites cohort. Participants completed longitudinal assessments of substance use (modified ASSIST) and depressive symptoms (PHQ-9). Changes in substance use frequency were categorized as abstinence, reduced use, and nondecreasing use. Adjusted linear mixed models with time-updated change in substance use frequency and depressive symptom scores were used to examine associations between changes in the use of individual substances and depressive symptoms. Analyses were repeated using joint longitudinal survival models to examine associations with a high (PHQ-9 ≥10) score.

RESULTS

Among 9905 PLWH, 728 used cocaine/crack, 1016 used amphetamine-type substances (ATS), 290 used illicit opiates, and 3277 used marijuana at baseline. Changes in ATS use were associated with the greatest improvements in depressive symptoms: stopping ATS led to a mean decrease of PHQ-9 by 2.2 points (95% CI: 1.8 to 2.7) and a 61% lower odds of PHQ-9 score ≥10 (95% CI: 0.30 to 0.52), and decreasing ATS use led to a mean decrease of 1.7 points (95% CI: 1.2 to 2.3) and a 62% lower odds of PHQ-9 score ≥10 (95% CI: 0.25 to 0.56). Stopping and reducing marijuana and stopping cocaine/crack use were also associated with improvement in depressive symptoms.

CONCLUSIONS

We demonstrated that both substance use reduction and abstinence are associated with improvements in depressive symptoms over time.

HIV Care for Patients With Complex Needs: A Controlled Evaluation of a Walk-In, Incentivized Care Model

BACKGROUND

New approaches are needed to provide care to persons with HIV who do not engage in conventionally organized HIV clinics. The Max Clinic in Seattle, Washington, is a walk-in, incentivized HIV care model located in a public health STD clinic that provides care in collaboration with a comprehensive HIV primary care clinic (the Madison Clinic).

METHODS

We compared outcomes in the first 50 patients enrolled in Max Clinic and 100 randomly selected matched Madison Clinic control patients; patients in both groups were virally unsuppressed (viral load [VL] >200 copies/mL) at baseline. The primary outcome was any VL indicating viral suppression (≥1 VL <200 copies/mL) during the 12 months postbaseline. Secondary outcomes were continuous viral suppression (≥2 consecutive suppressed VLs ≥60 days apart) and engagement in care (≥2 medical visits ≥60 days apart). We compared outcomes in the 12 months pre- and postbaseline and used generalized estimating equations to compare changes in Max vs control patients, adjusting for unstable housing, substance use, and psychiatric disorders.

RESULTS

Viral suppression improved in both groups pre-to-post (20% to 82% Max patients; P < .001; and 51% to 65% controls; P = .04), with a larger improvement in Max patients (adjusted relative risk ratio [aRRR], 3.2; 95% confidence interval [CI], 1.8-5.9). Continuous viral suppression and engagement in care increased in both groups but did not differ significantly (continuous viral suppression: aRRR, 1.5; 95% CI, 0.5-5.2; engagement: aRRR, 1.3; 95% CI, 0.9-1.9).

CONCLUSIONS

The Max Clinic improved viral suppression among patients with complex medical and social needs.

"I Wasn't in My Right Mind": Qualitative Findings on the Impact of Alcohol on Condom Use in Patients Living with HIV/AIDS in Brazil, Thailand, and Zambia (HPTN 063)

PURPOSE

There have been significant biomedical improvements in the treatment and prevention of HIV over the past few decades. However, new transmissions continue to occur. Alcohol use is a known barrier to medication adherence and consistent condom use and therefore may affect treatment as prevention (TasP) efforts. The purpose of this study was to further explore how alcohol is associated with condom use and sexual transmission behavior in three international cities.

METHOD

HIV Prevention Trials Network 063 was an observational mixed-methods study of HIV-infected patients currently in care in Rio de Janeiro, Brazil; Chiang Mai, Thailand; and Lusaka, Zambia. Across these three global cities, 80 qualitative interviews were conducted from 2010 to 2012. From these interviews, quotes related to substance use, almost all of which were alcohol, were analyzed using thematic analysis to identify how the use was related to sexual transmission behaviors.

RESULTS

Overall, the theme that alcohol impairs cognitive abilities emerged from the data and included the following subthemes: expectancies, impaired decision-making, loss of control, and less concern for others. Themes specific to international settings and risk subgroups were also identified.

CONCLUSION

Our analysis identified how alcohol influences sexual transmission behavior in HIV patients in three international settings. These findings may provide direction for content development for future secondary prevention interventions to effectively implement TasP internationally.

Experienced HIV-Related Stigma and Psychological Distress in Peruvian Sexual and Gender Minorities: A Longitudinal Study to Explore Mediating Roles of Internalized HIV-Related Stigma and Coping Styles

Experiencing HIV-related stigma has important impacts on the mental health of people living with HIV, which has implications for treatment adherence, disease progression, and health outcomes. The impacts of stigma are particularly important to consider among sexual and gender minorities, who often face a disproportionate burden of HIV. To address the implications of stigma in these key populations, we leveraged a longitudinal study conducted among Peruvian sexual and gender minorities to compare the relative effects of multiple mediators affecting the relationship between experienced HIV-related stigma and psychological distress: internalized HIV-related stigma, adaptive coping, and maladaptive coping. HIV-related stigma, coping, and distress were measured, respectively, at 24 weeks, 36 weeks, and 48 weeks post-diagnosis for 145 participants from the Sabes Study. HIV-related maladaptive coping largely mediated the relationship between experienced HIV-related stigma and distress. Our findings suggest interventions targeting maladaptive coping may alleviate the mental health consequences of experiencing HIV-related stigma.

Do Symptoms of Depression Interact with Substance Use to Affect HIV Continuum of Care Outcomes?

Few studies examine how depression and substance use interact to affect HIV control. In 14,380 persons with HIV (PWH), we used logistic regression and generalized estimating equations to evaluate how symptoms of depression interact with alcohol, cocaine, opioid, and methamphetamine use to affect subsequent retention in care, maintaining an active prescription for ART, and consistent virologic suppression. Among PWH with no or mild depressive symptoms, heavy alcohol use had no association with virologic suppression (OR 1.00 [0.95-1.06]); among those with moderate or severe symptoms, it was associated with reduced viral suppression (OR 0.80 [0.74-0.87]). We found no interactions with heavy alcohol use on retention in care or maintaining ART prescription or with other substances for any outcome. These results highlight the importance of treating moderate or severe depression in PWH, especially with comorbid heavy alcohol use, and support multifaceted interventions targeting alcohol use and depression.

Depressive Symptoms at HIV Testing and Two-Year All-Cause Mortality Among Men Who Inject Drugs in Vietnam

People who inject drugs (PWID) with HIV experience an elevated risk of death. A potentially important determinant of survival is the high burden of depression. This study examined the relationship of depressive symptoms at HIV testing with 2-year all-cause mortality among newly diagnosed HIV-positive PWID in Vietnam. At HIV testing, 141 PWID (42%) experienced severe depressive symptoms, and over the 2 years following diagnosis, 82 PWID (24%) died. Controlling for potential confounders, the 2-year risk of death among those with depressive symptoms was 9.7% (95% CI - 1.2, 20.6%) higher than the risk among those without depressive symptoms. This increased risk of mortality for PWID with depressive symptoms was relatively consistent throughout the 2-year period: at 6, 12, and 18 months, the risk difference was 12.6% (5.5-19.7%), 13.9% (4.6-23.2%), and 11.0% (0.9-21.1%), respectively. HIV diagnosis may provide an important opportunity for depression screening and treatment, subsequently improving survival in this key population.Trial registry: ClinicalTrials.gov NCT01689545.

The Depression Treatment Cascade: Disparities by Alcohol Use, Drug Use, and Panic Symptoms Among Patients in Routine HIV Care in the United States

Little is known about disparities in depression prevalence, treatment, and remission by psychiatric comorbidities and substance use among persons living with HIV (PLWH). We conducted a cross-sectional analysis in a large cohort of PLWH in routine care and analyzed conditional probabilities of having an indication for depression treatment, receiving treatment, receiving indicated treatment adjustments, and achieving remission, stratified by alcohol use, illicit drug use, and panic symptoms. Overall, 34.7% (95% CI 33.9-35.5%) of participants had an indication for depression treatment and of these, 55.3% (53.8-56.8%) were receiving antidepressants. Among patients receiving antidepressants, 33.0% (31.1-34.9%) had evidence of remitted depression. In a subsample of sites with antidepressant dosage data, only 8.8% (6.7-11.5%) of patients received an indicated treatment adjustment. Current drug users (45.8%, 95% CI 43.6-48.1%) and patients reporting full symptoms of panic disorder (75.0%, 95% CI 72.9-77.1%) were most likely to have an indication for antidepressant treatment, least likely to receive treatment given an indication (current drug use: 47.6%, 95% CI 44.3-51.0%; full panic symptoms: 50.8%, 95% CI 48.0-53.6%), or have evidence of remitted depression when treated (22.3%, 95% CI 18.5-26.6%; and 7.3%, 95% CI 5.5-9.6%, respectively). In a multivariable model, drug use and panic symptoms were independently associated with poorer outcomes along the depression treatment cascade. Few differences were evident by alcohol use. Current drug users were most likely to have an indication for depression treatment, but were least likely to be receiving treatment or to have remitted depression. These same disparities were even more starkly evident among patients with co-occurring symptoms of panic disorder compared to those without. Achieving improvements in the depression treatment cascade will likely require attention to substance use and psychiatric comorbidities.

Ancillary service needs among persons new to HIV care and the relationship between needs and late presentation to care

Ancillary service needs likely influence time to diagnosis and presentation for HIV care. The effect of both met and unmet needs on late presentation to HIV care is not well understood. We used baseline data from 348 people with HIV (PWH) with no prior HIV care who enrolled in iENGAGE (a randomized controlled trial (RCT) of an intervention to support retention in care) at one of four HIV clinics in the US. A standardized baseline questionnaire collected information on ancillary service needs, and whether each need was presently unmet. We examined covariates known to be associated with disease stage at presentation to care and their association with needs. We subsequently assessed the relationship of needs with CD4 accounting for those other covariates by estimating prevalence ratios (PR) using inverse probability weights. Most patients enrolling in the RCT were male (79%) and the majority were Black (62%); median age was 34 years. Prevalence of any reported individual need was 69%. One-third of the sample had a baseline CD4 cell count <200, 42% between 200 and 499 and 27% ≥500. There was no statistically significant association between need or unmet need and baseline CD4. In general, psychiatric health and SU issues (depression, anxiety, and drug use) were consistently associated with higher prevalence of need (met and unmet). Additionally, the Black race was associated with higher basic resource needs (housing: PR 1.67, 95%CI 1.08-2.59; transportation: PR 1.65, 95% CI 1.12-2.45). Ancillary service needs (met and unmet) were common among patients new to HIV care and impacted vulnerable subgroups. However, we found no evidence that reporting a specific individual need, whether met or unmet, was associated with a timely presentation to HIV care. The impact of needs on subsequent steps of the HIV care continuum will be examined with longitudinal data.

Prevalence and correlates of "popper" (amyl nitrite inhalant) use among HIV-positive Latinos living in the U.S.-Mexico border region

Poppers (nitrite inhalants) are legal, commonly used by men who have sex with men, and associated with HIV acquisition, yet research is lacking on popper use and associated adverse outcomes. People living with HIV (PLWH) in the U.S.-Mexico border region lead binational lives, including accessing care and having sex and drug use partners on both sides of the border, with broad personal and public health implications. Understanding popper use provides crucial information to guide policy and develop targeted interventions for binational PLWH. We examine prevalence and correlates of popper use among HIV-positive Latinos in the border region, an underserved population at risk for poor health outcomes. This cross-sectional study recruited a convenience sample from agencies in San Diego and Tijuana to complete quantitative surveys. Participants (N = 121) were primarily male (82.6%) and gay/bisexual (62%). Lifetime substance use (excluding cannabis) was reported by 72% of participants, and 25.6% reported lifetime popper use. Individuals recruited in the U.S. were significantly more likely to report use of poppers than were participants recruited in Mexico. Our regression model found that identifying as gay/bisexual and having bought, sold, or traded sex for money, drugs, or other goods were independently associated with popper use. Findings shed light on the profile of individuals who use poppers and lay the foundation for further research to understand the context of popper use as it relates to high-risk behavior among PLWH in this region of high transborder mobility. Binational collaborative approaches are needed to improve regional HIV care outcomes and reduce transmission risk.

Depression and Quality of Life among Patients Living with HIV/AIDS in the Era of Universal Treatment Access in Vietnam

Although antiretroviral treatment (ART) access has been universal in recent years, few studies have examined if this policy contributes to the mental health of the patients. This study assessed depression and its relations with health-related quality of life (HRQOL), which is defined as the status of general well-being, physical, emotional, and psychological, among HIV patients. A cross-sectional study was conducted in 482 patients at five outpatient clinics. Patient Health Questionnaire-9 (PHQ-9) and EuroQol-5 dimensions-5 levels (EQ-5D-5L) were used to assess the severity of depression and HRQOL. About one-fifth of patients reported symptoms of depression. According to the result of a multivariate logistic regression model, patients who had a lower number of CD4 cells at the start of ART, who received ART in the clinic without HIV counseling and testing (HCT) services, who had a physical health problem, and who experienced discrimination were more likely to have depression. Depression was associated with significantly decreased HRQOL. Depression is prevalent and significantly negatively associated with HRQOL of HIV/AIDS patients. We recommend screening for depression and intervening in the lives of depressed individuals with respect to those who start ART late, and we also recommend community-based behavioral change campaigns to reduce HIV discrimination.

Cumulative Burden of Depression and All-Cause Mortality in Women Living With Human Immunodeficiency Virus

Background

Research linking depression to mortality among people living with human immunodeficiency virus (PLWH) has largely focused on binary "always vs never" characterizations of depression. However, depression is chronic and is likely to have cumulative effects on mortality over time. Quantifying depression as a cumulative exposure may provide a better indication of the clinical benefit of enhanced depression treatment protocols delivered in HIV care settings.

Methods

Women living with HIV (WLWH), naive to antiretroviral therapy, from the Women's Interagency HIV Study were followed from their first visit in or after 1998 for up to 10 semiannual visits (5 years). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. An area-under-the-curve approach was used to translate CES-D scores into a time-updated measure of cumulative days with depression (CDWD). We estimated the effect of CDWD on all-cause mortality using marginal structural Cox proportional hazards models.

Results

Overall, 818 women contributed 3292 woman-years over a median of 4.8 years of follow-up, during which the median (interquartile range) CDWD was 366 (97-853). Ninety-four women died during follow-up (2.9 deaths/100 woman-years). A dose-response relationship was observed between CDWD and mortality. Each additional 365 days spent with depression increased mortality risk by 72% (hazard ratio, 1.72; 95% confidence interval, 1.34-2.20).

Conclusions

In this sample of WLWH, increased CDWD elevated mortality rates in a dose-response fashion. More frequent monitoring and enhanced depression treatment protocols designed to reduce CDWD may interrupt the accumulation of mortality risk among WLWH.

Avoidant Coping Mediates the Relationship Between Self-Efficacy for HIV Disclosure and Depression Symptoms Among Men Who Have Sex with Men Newly Diagnosed with HIV

HIV diagnosis presents a critical opportunity to reduce secondary transmission, improve engagement in care, and enhance overall well-being. To develop relevant interventions, research is needed on the psychosocial experiences of newly diagnosed individuals. This study examined avoidant coping, self-efficacy for HIV disclosure decisions, and depression among 92 newly diagnosed men who have sex with men who reported recent sexual risk behavior. It was hypothesized that avoidant coping would mediate the relationship between self-efficacy and depression. Cross-sectional surveys were collected from participants 3 months after HIV diagnosis. To test for mediation, multiple linear regressions were conducted while controlling for HIV disclosure to sexual partners. Self-efficacy for HIV disclosure decisions showed a negative linear relationship to depression symptoms, and 99% of this relationship was mediated by avoidant coping. The index of mediation of self-efficacy on depression indicated a small-to-medium effect. Higher self-efficacy was related to less avoidant coping, and less avoidant coping was related to decreased depression symptoms, all else held constant. These findings highlight the role of avoidant coping in explaining the relationship between self-efficacy for HIV disclosure decisions and depression.

Prevalence, Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV

We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.

Incidence and Persistence of Depression Among Women Living with and Without HIV in South Africa: A Longitudinal Study

Depression and trauma are common among women living with HIV. This is the first study to track the longitudinal course of depression and examine the relationship between depression and trauma over time among women in South Africa. HIV-infected and uninfected women (N = 148) were assessed at baseline and one year later. Results of a path analysis show the multi-directional and entwined influence of early life stress, other life-threatening traumas across the lifespan, depression and PTSD over the course of HIV. We also observed higher rates of depressive symptomatology and more persistent cases among infected women compared to uninfected women, as well as a more consistent and enduring relationship between childhood trauma and depression among women living with HIV. The present study is unique in documenting the course of untreated depression and PTSD in women with and without HIV infection with a high prevalence of early childhood trauma.

Association between coping strategies, social support, and depression and anxiety symptoms among rural Ugandan women living with HIV/AIDS

Poor mental health detrimentally affects quality of life among women living with HIV/AIDS. An improved understanding of how coping and social support relate to depression and anxiety in this population can facilitate the design and implementation of appropriate mental health treatment and support services. Secondary analysis was conducted on baseline data from 288 HIV-positive women enrolled in a parenting intervention in Uganda. Depression and anxiety symptoms, social support, and coping were assessed with the Hopkins Symptom Checklist and adapted versions of the Multidimensional Scale for Perceived Social Support and Ways of Coping Questionnaire. General linear regression models were used to estimate associations between coping and mental health. Based on report of elevated symptoms, approximately 10% of women were categorized as having clinically-relevant depression or anxiety. Emotion-focused (EF: p < .001) and problem-focused (PF: p = .01) coping were associated with more depressive symptoms while greater family support (EF: p = .002; PF: p = .003) was associated with fewer depression symptoms. More anxiety symptoms were associated with reporting both coping strategies (EF: p < .001; PF: p = .02) and higher community support (EF&PF: p = .01). The cross-sectional nature of the study limits our ability to rule out the role of reverse causation in the significant relationship between coping and mental health. Findings do suggest that high family support can be protective against depression and anxiety symptoms among women living with HIV.

A qualitative study examining the benefits and challenges of incorporating patient-reported outcome substance use and mental health questionnaires into clinical practice to improve outcomes on the HIV care continuum

Background

Inadequate identification and treatment of substance use (SU) and mental health (MH) disorders hinders retention in HIV care. The objective of this study was to elicit stakeholder input on integration of SU/MH screening using computer-assisted patient-reported outcomes (PROs) into clinical practice.

Methods

We conducted semi-structured interviews with HIV-positive patients who self-reported SU/MH symptoms on a computer-assisted PROs (n = 19) and HIV primary care providers (n = 11) recruited from an urban academic HIV clinic. Interviews were audio-recorded and transcribed. We iteratively developed codes and organized key themes using editing style analysis.

Results

Two themes emerged: (1) Honest Disclosure: Some providers felt PROs might improve SU/MH disclosure; more were concerned that patients would not respond honestly if their provider saw the results. Patients were also divided, stating PROs could help overcome stigma but that it could be harder to disclose SU/MH to a computer versus a live person. (2) Added Value in the Clinical Encounter: Most providers felt PROs would fill a practice gap. Patients had concerns regarding confidentiality but indicated PROs would help providers take better care of them.

Conclusions

Both patients and providers indicated that PROs are potentially useful clinical tools to improve detection of SU/MH. However, patients and providers expressed conflicting viewpoints about disclosure of SU/MH using computerized PROs. Future studies implementing PROs screening interventions must assess concerns over confidentiality and honest disclosure of SU/MH to understand the effectiveness of PROs as a clinical tool. More research is also needed on patient-centered integration of the results of PROs in HIV care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3203-x) contains supplementary material, which is available to authorized users.

An Exploration of Syndemic Factors That Influence Engagement in HIV Care Among Black Men

Syndemic theory seeks to understand the interactions and clustering of disease and social conditions and explain racial disparities in HIV. Traditionally applied to HIV risk, this study characterizes the syndemic challenges of engagement in care among Black men living with HIV and provides insight into potential HIV treatment interventions to retain vulnerable individuals in care. Interviews were conducted with 23 HIV-positive men who were either out-of-care or nonadherent to antiretroviral therapy (ART). Interviews were audio recorded, transcribed verbatim, and coded using MAXQDA qualitative software. Researchers analyzed data using thematic content analysis to identify syndemic factors associated with disengagement in care or suboptimal ART adherence among Black men. Analyses revealed the syndemic nature of four themes: intersectional stigma, depression, substance use, and poverty. Findings from this study offer numerous opportunities for intervention including social and structural-level interventions to address syndemic processes and the influence of stigma and poverty on engagement in care.

Association Between Depression and Antiretroviral Therapy Use Among People Living with HIV: A Meta-analysis

Depression is common among people living with HIV (PLHIV). Studies on the relationship between depression and use of antiretroviral therapy (ART) are inconclusive. A meta-analysis was conducted to summarize the relationship between depression and ART use among PLHIV. Ten electronic databases, conference abstracts, and dissertations were searched. A random effects meta-analysis was performed to pool the odds ratio estimates from eligible studies. Subgroup analyses and meta-regression were conducted for moderator analysis. Sensitivity analysis was performed to find influential studies. A funnel plot, the Egger test, and the trim and fill analysis were used to detect publication bias. The pooled sample size was 7375 PLHIV from nine eligible studies. The pooled prevalence of depression was 41% (95% confidence interval [CI] 29-53%). The pooled ART use rate was 52% (95% CI 37-67%). PLHIV with depression were 14% less likely (pooled odds ratio [OR] = 0.86; 95% CI 0.71-1.05) to use ART than those without depression. Subgroup analyses showed that depression was significantly associated with no ART use (pooled OR 0.84; 95% CI 0.71-0.99) among studies with a prospective study design (11 estimates from nine studies). Moderator analyses did not show any statistically significant effects. The publication bias analyses showed small study effects may not exist. Depression was associated with non-use of ART among PLHIV. Studies are needed to explore this association in other countries with varied populations, as most published studies have been conducted in the United States.

The Max Clinic: Medical Care Designed to Engage the Hardest-to-Reach Persons Living with HIV in Seattle and King County, Washington

The Max Clinic in Seattle, Washington is designed to engage patients who have extensive barriers to HIV care. In this article, we describe the clinic's evolution and outcomes of patients enrolled in the first 2 years. The clinic is a high-intensity, low-threshold, incentivized care model that includes walk-in access to primary care in a Sexually Transmitted Disease Clinic. Patients who have failed to engage in care and achieve viral suppression with lower intensity support are referred by clinicians, case managers, and the health department Data to Care program. The clinic offers food vouchers, cash incentives, no-cost bus passes, and cell phones, as well as intensive case management with cross-agency coordinated care. The primary evaluation outcome was the percentage of patients who achieved viral suppression (HIV RNA <200 copies/mL) at least once after enrollment. Secondary outcomes were continuous viral suppression (≥2 suppressed results in a row ≥60 days apart) and engagement in care (≥2 completed medical visits ≥60 days apart). During January 2015-December 2016, 263 patients were referred; 170 (65%) were eligible, and 95 (56% of eligible) were enrolled. Most patients used illicit drugs or hazardous levels of alcohol (86%) and had diagnosed psychiatric illness (72%) and unstable housing (65%). During the year after enrollment, 90 (95%) patients engaged in care. As of the end of 2016, 76 (80%) had achieved viral suppression, and 54% had continuous viral suppression. The Max Clinic successfully treated HIV in high-need patients and, to date, has been sustainable through a combination of federal, state, and local funding.

Association of Increased Chronicity of Depression With HIV Appointment Attendance, Treatment Failure, and Mortality Among HIV-Infected Adults in the United States

IMPORTANCE

Depression commonly affects adults with HIV and complicates the management of HIV. Depression among individuals with HIV tends to be chronic and cyclical, but the association of this chronicity with HIV outcomes (and the related potential for screening and intervention to shorten depressive episodes) has received little attention.

OBJECTIVE

To examine the association between increased chronicity of depression and multiple HIV care continuum indicators (HIV appointment attendance, treatment failure, and mortality).

DESIGN, SETTING, AND PARTICIPANTS

The study comprised an observational clinical cohort of 5927 patients with 2 or more assessments of depressive severity who were receiving HIV primary care at 6 geographically dispersed US academic medical centers from September 22, 2005, to August 6, 2015.

MAIN OUTCOMES AND MEASURES

Missing a scheduled HIV primary care visit, detectable HIV RNA viral load (≥75 copies/mL), and all-cause mortality. Consecutive depressive severity measures were converted into a time-updated measure: percentage of days with depression (PDD), following established methods for determining depression-free days.

RESULTS

During 10 767 person-years of follow-up, the 5927 participants (5000 men, 926 women, and 1 intersex individual; median age, 44 years [range, 35-50 years]) had a median PDD of 14% (interquartile range, 0%-48%). During follow-up, 10 361 of 55 040 scheduled visits (18.8%) were missed, 6191 of 28 455 viral loads (21.8%) were detectable, and the mortality rate was 1.5 deaths per 100 person-years. Percentage of days with depression showed a dose-response relationship with each outcome. Each 25% increase in PDD led to an 8% increase in the risk of missing a scheduled appointment (risk ratio, 1.08; 95% CI, 1.05-1.11), a 5% increase in the risk of a detectable viral load (risk ratio, 1.05; 95% CI, 1.01-1.09), and a 19% increase in the mortality hazard (hazard ratio, 1.19; 95% CI, 1.05-1.36). These estimates imply that, compared with patients who spent no follow-up time with depression (PDD, 0%), those who spent the entire follow-up time with depression (PDD, 100%) faced a 37% increased risk of missing appointments (risk ratio, 1.37; 95% CI, 1.22-1.53), a 23% increased risk of a detectable viral load (risk ratio, 1.23; 95% CI, 1.06-1.43), and a doubled mortality rate (hazard ratio, 2.02; 95% CI, 1.20-3.42).

CONCLUSIONS AND RELEVANCE

Greater chronicity of depression increased the likelihood of failure at multiple points along the HIV care continuum. Even modest increases in the proportion of time spent with depression led to clinically meaningful increases in negative outcomes. Clinic-level trials of protocols to promptly identify and appropriately treat depression among adults living with HIV should be conducted to understand the effect of such protocols on shortening the course and preventing the recurrence of depressive illness and improving clinical outcomes.

Untreated depression among persons living with human immunodeficiency virus in Kazakhstan: A cross-sectional study

Background

In Kazakhstan, scarce official prevalence data exists for mood disorders. This study investigates the occurrence of depressive symptoms among people living with HIV/AIDS (PLWHA), and the relationship between depressive symptoms, HIV treatment initiation and antiretroviral treatment (ART) adherence.

Methods

A cross-sectional study was conducted among patients seen at the Almaty AIDS Center between April and December 2013. Two data sources were used: 1) self-administered survey that included the Patient Health Questionnaire (PHQ-9) to capture depression symptoms and 2) medical record review. Two primary outcomes were evaluated with log-binomial models and Fisher’s exact test: the relationship between depression symptoms and 1) HIV treatment group, and 2) HIV adherence.

Results

Of the 564 participants, 9.9% reported symptoms consistent with a depressive disorder. None had received treatment for depression. Among those not on ART, a relationship between depressive symptoms and low CD4 counts (≤ 350 cells/mm³) was evident (7.1% for CD4 ≤ 350 cells/mm³ vs. 0.9% for CD4 > 350 cells/mm³, p = 0.029). In multivariable analysis, a higher prevalence of depressive symptoms was statistically associated with ART treatment, positive hepatitis C virus (HCV) status, and being unmarried. For those taking ART, treatment adherence was not statistically associated with a lower prevalence of depressive symptoms (12.5% vs 20.0%, p = 0.176); limited power may have impacted statistical significance.

Conclusions

Untreated depression was found among PLWHA suggesting the need to evaluate access to psychiatric treatment. A collaborative strategy may be helpful to optimize HIV treatment outcomes.

Influence of Substance Use Disorders on 2-Year HIV Care Retention in the United States

Substance use disorders (SUDs) are thought to predict care discontinuity, though magnitude and substance-specific variance of effects are unclear. This report of analytic work undertaken with a multi-regional American cohort of 9153 care enrollees addresses these gaps. Care retention was computed from 24-month post-linkage clinic visit documentation, with SUD cases identified from patient-report screening instruments. Two generalized estimating equations tested binary and hierarchial SUD predictors of retention, and potential effect modification by patient age-group, sex, and care site. Findings demonstrate: (1) detrimental SUD effect, equivalent to a nine percentage-point decrease in retention, with independent effects of age-group and care site; (2) substance-specific effect of marijuana UD associated with lower retention; and (3) age-modification of each effect on care discontinuity, with SUDs serving as a risk factor among 18-29 year-olds and protective factor among 60+ year-olds. Collective findings document patient attributes as influences that place particular subgroups at-risk to discontinue care.

Mental Health Disorders and Publicly Funded Service Use by HIV Positive Individuals: A Population-Based Cross-Sectional Study in Ontario, Canada

We compared use of community and hospital-based mental health and addiction (MH&A) services by adults with and without HIV. This population-based study examined the probability and intensity of MH&A service use by individuals with (n = 5095) and without HIV (n = 2,753,091) in Ontario, Canada between 2013 and 2014. Adults with HIV were more likely than HIV-negative adults to use MH&A primary and psychiatric care, and to have MH&A emergency department visits and hospital admissions; they also used more of each service. Use of MH&A hospital services was particularly high for persons in the HIV group compared to the no HIV group.

Mortality under plausible interventions on antiretroviral treatment and depression in HIV-infected women: an application of the parametric g-formula

PURPOSE

Among HIV-infected persons, antiretroviral therapy (ART) and depression are strongly associated with mortality. We estimated reductions in 5-year mortality in Women's Interagency HIV Study participants under plausible hypothetical increases in ART initiation and reductions in depression (CES-D score≥16).

METHODS

We followed 885 ART-naïve Women's Interagency HIV Study participants for 5 years from their first study visit after April 1998 to death or censoring. We used the parametric extended g-formula to estimate cumulative mortality under the natural course (NC) and alternative exposure distributions.

RESULTS

Baseline prevalence of depression was 52% and 62% initiated ART by 5 years. Compared with mortality under NC (13.2%), immediate ART and elimination of 36% or 67% of depressive episodes were associated with risk differences (RDs) of -5.2% (95% CI: -7.7%, -2.6%) and -5.7 (95% CI: -8.7, -2.7). Compared with immediate ART and NC for depression, additionally eliminating 67% of the depressive episodes was associated with RD = -1.6 (95% CI: -3.9, 0.8). Compared with 5-year mortality under NC for ART and elimination of 67% of depression, also initiating ART immediately was associated with RD = -2.6 (95% CI: -5.0, -0.3).

CONCLUSIONS

Increasing ART initiation and reducing depression were associated with moderate reductions in 5-year mortality among HIV-infected women.