Impact of depression on HIV outcomes in the HAART era

Clinical presentation of first episode psychosis in people with and without HIV in KwaZulu-Natal, South Africa

AIM

Mental disorders and HIV are the main contributors to the increase in years lived with disability rates per person in sub-Saharan Africa. A complex inter-relationship exists between HIV and mental illness, especially in a region with a high HIV prevalence. We examined the duration of untreated psychosis (DUP), and the nature of psychotic and cognitive symptoms in people with first episode psychosis (FEP) living with and without HIV.

METHODS

Adults aged between 18 and 45 years were assessed using a clinical interview, physical examination and several psychiatric tools. These included the Mini International Neuro-psychiatric Interview to confirm psychosis, Positive and Negative Syndrome Scale, International HIV Dementia Scale and other scales to measure symptom variables. HIV ELISA was used for HIV serology testing, with measures being carried out within 6 weeks of the first presentation.

RESULTS

Of the 172 people presenting with FEP, 36 (21%) had comorbid HIV, those with both being older and more likely to be female (p < .001). Clinically, participants with FEP and HIV scored lower on the positive subscale (p = .008). There were no statistically significant differences for DUP or cognitive screening. Of those living with HIV and FEP (n = 36) comorbidity, nine were newly diagnosed with HIV at the time of the study.

CONCLUSION

Individuals presenting with FEP and comorbid HIV were older, female and reported more mood symptoms. The identification of nine new HIV infections also reflects the ongoing need to test for HIV in people presenting with severe mental illness.

Causes and risk factors of death among people who inject drugs in Indonesia, Ukraine and Vietnam: findings from HPTN 074 randomized trial

INTRODUCTION

The HIV Prevention Trials Network (HPTN) 074 study demonstrated a positive effect of an integrated systems navigation and psychosocial counseling intervention on HIV treatment initiation, viral suppression, medication assisted treatment (MAT) enrollment, and risk of death among people who inject drugs (PWID). In this sub-study, we analyzed the incidence, causes, and predictors of death among HIV-infected and uninfected participants.

METHODS

The HPTN 074 randomized clinical trial was conducted in Indonesia, Ukraine, and Vietnam. HIV-infected PWID with unsuppressed viral load (indexes) were recruited together with at least one of their HIV-negative injection partners. Indexes were randomized in a 1:3 ratio to the intervention or standard of care.

RESULTS

The trial enrolled 502 index and 806 partner participants. Overall, 13% (66/502) of indexes and 3% (19/806) of partners died during follow-up (crude mortality rates 10.4 [95% CI 8.1-13.3] and 2.1 [1.3-3.3], respectively). These mortality rates were for indexes nearly 30 times and for partners 6 times higher than expected in a population of the same country, age, and gender (standardized mortality ratios 30.7 [23.7-39.0] and 5.8 [3.5-9.1], respectively). HIV-related causes, including a recent CD4 < 200 cells/μL, accounted for 50% of deaths among indexes. Among partners, medical conditions were the most common cause of death (47%). In the multivariable Cox model, the mortality among indexes was associated with sex (male versus female aHR = 4.2 [1.5-17.9]), CD4 count (≥ 200 versus < 200 cells/μL aHR = 0.3 [0.2-0.5]), depression (moderate-to-severe versus no/mild aHR = 2.6 [1.2-5.0]) and study arm (intervention versus control aHR = 0.4 [0.2-0.9]). Among partners, the study arm of the index remained the only significant predictor (intervention versus control aHR = 0.2 [0.0-0.9]) while controlling for the effect of MAT (never versus ever receiving MAT aHR = 2.4 [0.9-7.4]).

CONCLUSIONS

The results confirm that both HIV-infected and uninfected PWID remain at a starkly elevated risk of death compared to general population. Mortality related to HIV and other causes can be significantly reduced by scaling-up ART and MAT. Access to these life-saving treatments can be effectively improved by flexible integrated interventions, such as the one developed and tested in HPTN 074.

Association between recent methamphetamine use, antiretroviral therapy and HIV viral load; a mediation analysis from a cohort of HIV positive persons who inject drugs in Hai Phong, Vietnam

BACKGROUND

There has been a significant increase in methamphetamine use among persons who use drugs in Vietnam in the last 5-10 years. We examined the degree to which adherence to antiretroviral therapy (ART) mediates the relationship between recent methamphetamine use and unsuppressed HIV viral load among people who inject drugs (PWID) in Hai Phong, Vietnam.

METHODS

We recruited PWID from October 2016-October 2018 and enrolled HIV positive PWID into a cohort, with up to three years of total follow-up. We assessed relationships among recent methamphetamine use frequency, ART adherence and unsuppressed HIV viral load. Mediation analysis was used to estimate the total and natural direct effects of recent methamphetamine use on unsuppressed HIV viral load and the indirect effect proportion.

RESULTS

We enrolled 792 HIV seropositive PWID into the cohort; approximately 75.9% reported high/perfect ART adherence at baseline and 81.3% were virally suppressed. In mediation analysis, the total effect for the association between methamphetamine use and unsuppressed HIV viral load (1000 copies/mL) was 3.94 (95% CI: 1.95, 7.96); the natural direct effect was 2.14 (95% CI: 1.29, 3.55); the proportion mediated by self-reported ART adherence was 0.444. Similar results were found when examining lower unsuppressed HIV viral load cutpoints of 250 copies/mL and 500 copies/mL.

CONCLUSIONS

Methamphetamine use is associated with unsuppressed HIV viral load among PWID despite high levels of ART adherence. Further research is needed to better understand these relationships, with emphasis on potential biological pathways that may interact with ART.

A Qualitative Exploration of Causes of Depression among Persons Living with HIV Receiving Antiretroviral Therapy in Uganda: Implications for Policy

Introduction

Depression is the fourth leading cause of the global disease burden and worsens the outcome of comorbidities including HIV/AIDS. Depression is particularly problematic among persons living with HIV in sub-Saharan Africa where scarcity of cost-effective interventions is compounded by inadequate understanding of the disease. We examine risk factors for depression among persons living with HIV undergoing antiretroviral treatment in Uganda and discuss policy implications.

Methods

A qualitative study using a narrative approach was conducted, the formative phase of a large study to develop a model for integrating depression management into routine HIV care in Uganda. Participants were purposively sampled at four public health facilities in Mpigi District. In-depth interviews were conducted with four clinicians, three supervisors, and 11 persons living with HIV and suffering from depression, as were three focus group discussions with lay health workers. Exit interviews were conducted with 17 persons living with HIV who completed/interrupted depression treatment but had not been interviewed. Only data collected from persons living with HIV and lay health workers were analysed for the purpose of this paper. A narrative thematic approach was used in data analysis. Findings. There were several pathways through which lack of family social support reportedly led to depression: worries about disclosure in discordant relationships, false perceptions of social support, stigmatisation and discrimination, and domestic violence. Economic/poverty and other causes were identified, but their role was less significant or moderated by family social support.

Conclusion

Family social support plays a dominant role-both directly and indirectly-in influencing depression risk. We propose the mainstreaming of formal psychosocial support and a shift from individual to family-focused counselling that targets both persons living with HIV and their family.

Alexithymia Among People Living with HIV: A Scoping Review

The present scoping review aimed to identify studies that investigated alexithymia, defined as a difficulty in identifying and describing one's own emotions, in people living with HIV (PLWH).A literature search, in line with the guidelines of PRISMA-ScR, was conducted in the following bibliographic databases: PubMed, PsycINFO, and Web of Science. The databases were queried using the following strings (using Boolean operators): ("alexithymia" OR "alexithymic") AND ("HIV" OR "Human Immunodeficiency Virus"). In line with the eligibility criteria, fourteen articles were found.Ten studies showed the involvement of alexithymia in disease severity (e.g., viral load levels), and adherence to antiretroviral therapy. Three studies revealed an association between alexithymia and cardiovascular disease, and three studies highlighted the implication of alexithymia in cognitive impairment.This review revealed the complex role of alexithymia in HIV disease. A careful clinical assessment of the emotional regulation process of PLWH can provide useful prognostic information.

Neuroinflammation in HIV-associated depression: evidence and future perspectives

People living with HIV face a high risk of mental illness, especially depression. We do not yet know the precise neurobiological mechanisms underlying HIV-associated depression. Depression severity in the general population has been linked to acute and chronic markers of systemic inflammation. Given the associations between depression and peripheral inflammation, and since HIV infection in the brain elicits a neuroinflammatory response, it is possible that neuroinflammation contributes to the high prevalence of depression amongst people living with HIV. The purpose of this review was to synthesise existing evidence for associations between inflammation, depression, and HIV. While there is strong evidence for independent associations between these three conditions, few preclinical or clinical studies have attempted to characterise their interrelationship, representing a major gap in the literature. This review identifies key areas of debate in the field and offers perspectives for future investigations of the pathophysiology of HIV-associated depression. Reproducing findings across diverse populations will be crucial in obtaining robust and generalisable results to elucidate the precise role of neuroinflammation in this pathophysiology.

Screening PLHIV for depression using PHQs: A RCT comparing non-selective with selective screening strategy within a primary health care facility in Uganda

BACKGROUND

Depression is rarely screened for among People Living with Human Immunodeficiency Virus (PLHIV) although it is 2 to 3 times more prevalent among PLHIV than in the general population. In instances where depression is screened for using screening tools, it usually follows noticing depression risk factors. This practice of selectively screening for depression could be leaving some cases of depression unattended to. On the other hand, subjecting every client to screening tools (non-selective screening) offers every patient an opportunity to be managed for depression. However, this could require additional resources as compared to selective screening. We present and discuss results on whether non-selective and selective screening strategies differ in depression case detection, and in addition, we also present perceptions of the stake holders on the two screening strategies.

METHODS

The study was conducted in Princess Diana Memorial Health Centre IV HIV clinic using a randomized controlled trial with a qualitative component. To determine whether there was a difference in depression case detection, consecutively sampled participants were randomly allocated to either non-selective or selective screening strategy. Participants allocated to selective screening were screened for depression using the patient health questionnaire (s) (PHQs) if they were at "crisis points". While those allocated to non-selective screening were screened regardless of whether the "crisis points" were noticed or not. The PHQ-2 and PHQ-9 were used in sequence. 326 PLHIV participated in the study. Outcomes of the MINI evaluation were analyzed for those with PHQ-9 scores of 10 or more to confirm major depressive disorder (MDD). Data was analyzed using the two sample Z-test for proportions with Stata 2013 software. To explore the perceptions of the stake holders, key informant interviews were performed with six stakeholders that experienced the study.

RESULTS

Cases of depression (PHQ-9 score ≥ 5) were more likely to be detected by the non-selective screening strategy 30.2% (49/162) compared to the selective screening strategy 19.5% (32/164) (difference in proportions 0.107, 95% confidence interval 0.014-0.200, Cohen's h = 0.25, P = 0.03). The stake holders thought it was important to screen for depression among PLHIV with preference to non-selective screening strategy.

CONCLUSION

Evidence from this data suggests that more cases of depression (PHQ-9 score ≥ 5) are likely to be detected with non-selective screening as opposed to selective screening.

TRIAL REGISTRATION

PACTR201802003141213 (name: comparison of routine versus selective screening for depression strategies among PLHIV attending Princess Diana Memorial Health Centre iv Soroti).

Prevalence of depression among HIV-positive pregnant women and its association with adherence to antiretroviral therapy in Addis Ababa, Ethiopia

Background

Vertical transmission of HIV remains one of the most common transmission modes. Antiretroviral therapy (ART) decreases the risk of transmission to less than 2%, but maintaining adherence to treatment remains a challenge. Some of the commonly reported barriers to adherence to ART include stress (physical and emotional), depression, and alcohol and drug abuse. Integrating screening and treatment for psychological problem such as depression was reported to improve adherence. In this study, we sought to determine the prevalence of depression and its association with adherence to ART among HIV-positive pregnant women attending antenatal care (ANC) clinics in Addis Ababa, Ethiopia.

Methods

We conducted a cross-sectional survey from March through November 2018. Participants were conveniently sampled from 12 health institutions offering ANC services. We used the Patient Health Questionnaire-9 (PHQ-9) to screen for depression and the Center for Adherence Support Evaluation (CASE) Adherence index to evaluate adherence to ART. Descriptive statistics was used to estimate the prevalence of depression during third-trimester pregnancy and nonadherence to ART. A bivariate logistic regression analysis was used to get significant predictors for each of the two outcome measures. The final multivariable logistic regression analysis included variables with a P<0.25 in the bivariate logistic regression model; statistical significance was evaluated at P<0.05.

Results

We approached 397 eligible individuals, of whom 368 (92.7%) participated and were included in the analysis. Of the total participants, 175(47.6%) had depression. The participants’ overall level of adherence to ART was 82%. Pregnant women with low income were twice more likely to have depression (AOR = 2.10, 95%CI = 1.31–3.36). Women with WHO clinical Stage 1 disease were less likely to have depression than women with more advanced disease (AOR = 0.16, 95%CI = 0.05–0.48). There was a statistically significant association between depression and nonadherence to ART (P = 0.020); nonadherence was nearly two times higher among participants with depression (AOR = 1.88, 95%CI = 1.08–3.27).

Conclusion

We found a high prevalence of depression among HIV-positive pregnant women in the selected health facilities in Addis Ababa, and what was more concerning was its association with higher rates of nonadherence to ART adversely affecting the outcome of their HIV care. We recommend integrating screening for depression in routine ANC services.

The Global Landscape of the Burden of Depressive Symptoms/Major Depression in Individuals Living With HIV/AIDs and Its Effect on Antiretroviral Medication Adherence: An Umbrella Review

BACKGROUND

People living with HIV/AIDS have a higher rate of depression/depressive symptoms and this highly affects antiretroviral medication adherence. Therefore, much stronger evidence weighing the burden of depressive symptoms/major depression is warranted.

METHODS

We investigated PubMed, Scopus, Psych-Info, and Embase databases for systematic review studies. A PRISMA flow diagram was used to show the search process. We also used the Assessment of Multiple Systematic Reviews (AMSTAR) checklist scores. A narrative review and statistical pooling were accompanied to compute the pooled effect size of outcome variables.

RESULTS

Overall, 8 systematic review studies addressing 265 primary studies, 4 systematic review studies addressing 48 primary studies, and six systematic review studies addressing 442 primary studies were included for depressive symptoms, major depression, and their effect on medication non-adherence, respectively. Globally, the average depressive symptoms prevalence using the random effect model was 34.17% (24.97, 43.37). In addition, the average prevalence of major depressive disorder was obtained to be 13.42% (10.53, 16.31). All of the 6 included systematic review studies reported a negative association between depressive symptoms and antiretroviral medication non-adherence. The pooled odds ratio of antiretroviral medication adherence among patients with depressive symptoms was 0.54 (0.36, 0.72) (I ² = 0.0%, p = 0.487).

CONCLUSION

Globally, the prevalence of depressive symptoms and major depression is high. There existed a high degree of association between depressive symptoms and antiretroviral medication non-adherence. So, focused intervention modalities should be developed and implemented.

Incidence and Predictors of Viral Load Suppression After Enhanced Adherence Counseling Among HIV-Positive Adults in West Gojjam Zone, Amhara Region, Ethiopia

Background

Methods

Results

Conclusion

Study of Treatment and Reproductive Outcomes Among Reproductive-Age Women With HIV Infection in the Southern United States: Protocol for a Longitudinal Cohort Study

BACKGROUND

Nearly a quarter of the 1.1 million individuals with HIV in the United States are women. Racial and ethnic minority women in the Southern United States are disproportionately impacted. Reproductive-age women with HIV are prone to poor HIV outcomes but remain underrepresented in HIV research. We will answer contemporary questions related to the health outcomes in this population by enrolling a prospective cohort of reproductive-age women with and without HIV in the Southern United States.

OBJECTIVE

The Study of Treatment and Reproductive Outcomes (STAR) will enroll and retain 2000 reproductive-age women with and without HIV. The STAR will leverage the infrastructure of the US-based Multicenter AIDS Cohort Study (MACS)/Women's Interagency HIV Study (WIHS) Combined Cohort Study, comprising the WIHS (a cohort of women with and at risk for HIV, which began in 1993), and the MACS (a cohort of gay and bisexual men with and at risk for HIV, which began in 1984). Although the advancing age of the participants enrolled in the MACS/WIHS Combined Cohort Study provides an opportunity to address the questions related to HIV and aging, the research questions pertinent to the reproductive years must also be addressed. The STAR will conduct high-priority scientific research in key areas with the overall aim of addressing the unique needs of reproductive-age women with HIV.

METHODS

The STAR is a prospective, observational cohort study that will be conducted at 6 sites in the United States-Atlanta, Georgia; Birmingham, Alabama; Jackson, Mississippi; Chapel Hill, North Carolina; Miami, Florida; and Washington, District of Columbia. Visits will occur semiannually for 2 years, with additional visits for up to 5 years. At each visit, the participating women will complete a structured interview for collecting key demographic, psychosocial, and clinical variables, and undergo biospecimen collection for laboratory testing and repositing (blood, urine, hair, vaginal, anal, and oral specimens). Pregnant women and infants will undergo additional study assessments. The initial scientific focus of the STAR is to understand the roles of key social determinants of health, depression, reproductive health, and oral health on HIV and pregnancy outcomes across the reproductive life span.

RESULTS

Enrollment in the STAR commenced in February 2021 and is ongoing.

CONCLUSIONS

Through in-depth, longitudinal data and biospecimen collection, the newly initiated STAR cohort will create a platform to answer scientific questions regarding reproductive-age women with and without HIV. STAR will be uniquely positioned to enable investigators to conduct high-impact research relevant to this population. Building on the legacy of the MACS and WIHS cohorts, the STAR is designed to foster multidisciplinary collaborations to galvanize scientific discoveries to improve the health of reproductive-age women with HIV and ameliorate the effects of the HIV epidemic in this population in the United States.

The relationship between intimate partner violence and HIV outcomes among pregnant women living with HIV in Malawi

Background

Intimate partner violence (IPV) is a global public health concern particularly in pregnancy where IPV can have negative health implications for the mother and child. Data suggest IPV disproportionately affects pregnant women living with HIV (PWLWH) compared to those without HIV. HIV-related outcomes are worse among women experiencing IPV. Despite this knowledge, there is paucity of data concerning PWLWH and IPV in Malawi, where there is a high HIV prevalence (10.6%).

Objectives

We aim to characterize IPV amongst PWLWH in Malawi and describe its relationship to demographic characteristics, psychosocial factors, and HIV-related outcomes.

Methods

This analysis used data from the VITAL Start pilot study, which is a video-based intervention targeting retention and ART adherence amongst PWLWH in Malawi. PWLWH not on ART were recruited at antenatal clinic and given study questionnaires to assess demographics, IPV, and psychosocial factors. Questionnaires were also administered at one-month follow-up to assess outcomes related to HIV. Descriptive statistics and logistic regression models were used to explore the risk factors associated with IPV.

Results

Thirty-nine percent of participants reported ever experiencing IPV from their current partner. The majority (53%) reporting IPV experienced more than one type of violence. IPV was associated with being married (p=0.04) and depression (p<0.0001) in the univariable analysis. For women retained at one-month, IPV was associated with reporting a missed ART dose in the past month but not with adherence measured by pill count.

Conclusions

A large proportion of PWLWH experienced IPV from their current partner and IPV was associated with worse self-reported ART adherence at one-month follow-up. Further evidence is needed to understand how IPV impacts PWLWH throughout postpartum and beyond. Given the detrimental impact on health outcomes among PWLWH in Malawi, additional focus on IPV is essential to identify mechanisms to prevent, screen, and manage IPV among this population.

Association between depression and HIV treatment outcomes in a US military population with HIV infection

Background

Depression is common among HIV-infected individuals and may contribute to suboptimal adherence to antiretroviral therapy (ART) and subsequent inability to attain viral load (VL) suppression. We evaluated associations between depression, self-reported adherence, and longitudinal HIV treatment outcomes in US Military HIV Natural History Study (NHS) participants with and without depression.

Methods

Male NHS participants with available ICD-9 data for mental health diagnoses, Center for Epidemiological Studies Depression (CES-D) measures, and self-reported adherence (SRA) were included. ART use was defined as ART initiation between 2006 and 2010, with follow-up through 2015. SRA was defined as taking 95% of ART doses and continuous ART was defined as longitudinal ART use with gaps  < 30 days. Continuous VL suppression was defined as maintaining VLs  < 200 c/mL on ART. To analyse the association between depression and HIV treatment outcomes, latent class analysis was used to create classes of depression trajectories: low depression (LD), recent onset depression (ROD) and high Depression (HD).

Results

Participants had a mean age of 32 (± 8.3) years at HIV diagnosis, and similar proportions were Caucasian (44.3%) or African American (40.8%). Overall, older participants at HIV diagnosis had greater odds of having 95% self-reported adherence (OR 1.06, 95% CI 1.02–1.12), and African Americans had lower odds (OR 0.41, 95% CI 0.22–0.76) compared to Caucasians (OR 1.49, 95% CI 0.52–4.28). However, there was no difference in SRA by depression trajectory. Participants with HD had an increased odds of taking ART continuously (OR 1.75, 95% CI 0.99–3.09), and those with ROD had significantly higher odds of virologic failure (OR 0.58, 95% CI 0.38–0.91).

Conclusions

Although there was no observed association between depression and SRA, participants with ROD had lower odds of attaining the HIV treatment goal of VL suppression. Continued efforts to identify and aggressively manage mental health disorders is important to success along the HIV care continuum.

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.

Depressive symptoms and their determinants in patients who are on antiretroviral therapy in the case of a low-income country, Ethiopia: a systematic review and meta-analysis

Background

The presence of depression in people living with HIV/AIDS could lead to non-adherence to antiretroviral medications. It also leads to further comorbid and opportunistic illness and then lowering the patient's quality of life. The objective of this study was therefore to determine the pooled prevalence of depression and its related factors in HIV patients.

Methods

Relevant articles in PubMed, Scopus, and EMBASE were investigated. The Meta-XL version 5.3 was used to extract data and STATA-11 Meta-prop packages with the Random effect model was used to quantify depression and its related factors. Sensitivity and subgroup analysis were performed to explore sources of heterogeneity. The Cochran’s Q-statistic and the Higgs I² test were also done. Besides, the Eggers test and symmetry in the funnel plot were used to detect the presence/absence of publication bias.

Result

In this meta-analysis, we included 21 articles that assessed 10,090 participants. The average prevalence of depression among people with HIV/AIDS was 35.8% (95% CI 28.29, 43.25). The average estimated prevalence of depressive symptoms was 59.4% in the Oromia region and 29.25% in southern Ethiopia. Besides, the average prevalence of depression was 45.6% and 26.2% as measured with Beck’s depression inventory and Hospital anxiety and depression scale respectively. Moreover, the prevalence of depression was 47.7% in studies that used a sample size ≤ of 400 participants and 28.5% in studies that used a sample size of > 400 participants. The pooled adjusted odds ratio (AOR) of perceived HIV stigma was 3.75 (95% CI 2.34, 5.16) and that of poor social support was 6.22 (95% CI 2.96, 9.47). Moreover, the average odds ratio of poor medication adherence, opportunistic infection, and advanced stages of AIDS were 3.03 (95% CI 1.00, 5.05), 5.5 (95% CI 1.97, 10.03), and 5.43 (95% CI 1.60, 9.28) respectively.

Conclusion

The pooled prevalence of depression among individuals living with HIV/AIDS was high. Factors such as perceived HIV stigma, poor social support, opportunistic infection, advanced AIDS stage, and poor medication adherence were related to it. Routine screening and management of depression and its related factors should be given due consideration.

Major depressive disorder and its association with adherence to antiretroviral therapy and quality of life: cross-sectional survey of people living with HIV/AIDS in Northwest Ethiopia

BACKGROUND

Major depression is believed to affect treatment adherence and overall quality of life (QoL) of people living with HIV/AIDS (PLWHA). Comorbid major depression contributes to a two-fold higher risk of mortality among PLWHA. Understanding the relationships of major depression, adherence to antiretroviral therapy (ART) and QoL is important to identify areas for intervention. The aim of this study is to examine relationship of major depressive disorder (MDD) and adherence to ART with QoL, and to investigate socio-demographic and clinical factors associated with MDD, adherence and QoL among PLWHA in Northwest Ethiopia.

METHOD

A cross-sectional study was conducted in the ART clinic of Felege-Hiwot referral hospital in Northwest Ethiopia from July to October 2019. Adult PLWHA were selected using a systematic random sampling technique. Data were collected using interview administered questionnaires and chart reviews. Mini International Neuropsychiatric Interview and WHOQOL-HIV-BREF-Eth instruments were used to measure MDD and QoL respectively. Adherence to ART was assessed using pill count data from patients' adherence monitoring chart. Univariate and multivariate Poisson regressions were used to assess associations of socio-demographic and clinical factors with MDD and adherence to ART. A multivariate linear regression was used to examine the associations of both MDD and adherence with overall QoL.

RESULT

Of the total of 393 invited participants, 391 (99.5%) completed the interviews. MDD was negatively associated with overall QoL: participants with MDD had a lower QoL score of 0.17 points compared to those with no MDD. MDD was associated with reduced adherence to ART when functional disability was controlled (RR = 1.43; 95%CI = 1.05, 1.96; p = 0.025). However, there was no statistical association between adherence to ART and overall QoL. Functional disability was associated with both MDD (RR = 5.07; 95%CI = 3.27,7.86; p < 0.001) and overall QoL (β = 0.29; 95%CI = 0.21,0.36; p < 0.001).

CONCLUSION

The relationship between MDD and QoL indicates the need for feasible, acceptable and evidence-based mental health interventions to reduce depression and improve overall QoL of PLWHA. We recommend future studies investigate causal relationships of MDD, adherence to ART and QoL of PLWHA to better understand priority areas for intervention.

Patterns of alcohol use and associated characteristics and HIV-related outcomes among a sample of African-American women living with HIV

BACKGROUND

Alcohol use is common among people living with HIV and negatively impacts care and outcomes. African-American women living with HIV are subject to vulnerabilities that may increase risk for alcohol use and associated HIV-related outcomes.

METHODS

We used baseline data from a randomized controlled trial of an HIV-related stigma-reduction intervention among African-American women living with HIV in Chicago and Birmingham (2013-2015). Patterns of alcohol use [any use, unhealthy alcohol use (UAU), heavy episodic drinking (HED)] were measured using the AUDIT-C. We assessed demographic, social, and clinical characteristics which may influence alcohol use and HIV-related outcomes which may be influenced by patterns of alcohol use in bivariate and multivariable analyses.

RESULTS

Among 220 African-American women living with HIV, 54 % reported any alcohol use, 24 % reported UAU, and 27 % reported HED. In bivariate analysis, greater depressive symptoms, lower religiosity, lower social support, marijuana, and crack/cocaine use were associated with patterns of alcohol use (p < 0.05). Marijuana and cocaine/crack use were associated with patterns of alcohol use in adjusted analysis (p < 0.05). In adjusted analysis, any alcohol use and HED were associated with lower likelihood of ART adherence (ARR = 0.72, 95 % CI: 0.53-0.97 and ARR = 0.65, 95 % CI: 0.44-0.96, respectively), and UAU was associated with lack of viral suppression (ARR = 0.78, 95 % CI: 0.63-0.96).

CONCLUSIONS

Findings suggest any and unhealthy alcohol use is common and associated with poor HIV-related outcomes in this population. Regular alcohol screening and intervention should be offered, potentially targeted to subgroups (e.g., those with other substance use).

Depression and anxiety among pregnant women living with HIV in Kilimanjaro region, Tanzania

INTRODUCTION

Mental health disorders in pregnant women living with HIV are associated with poor maternal and child outcomes, and undermine the global goals of prevention of mother-to-child transmission of HIV (PMTCT). This study aimed to determine prevalence of depression and anxiety and identify factors associated with these common mental health disorders among HIV-infeced pregnant women in Tanzania.

METHODS

We enrolled 200 pregnant women living with HIV from antenatal care clinics in the Kilimanjaro region. Women were eligible if they were in the second or third trimester of pregnancy and had been in PMTCT care for a minimum of one month. Data were collected via interviewer administered surveys. Participants self reported depression symptoms (Edinburgh Postnatal Depression Scale, EPDS) and anxiety symptoms (Brief Symptom Index, BSI). Multivariate logistic regression models examined factors associated with depression, anxiety, and comorbid depression and anxiety.

RESULTS

25.0% of women met screening criteria for depression (EPDS ≥10). Depression was significantly associated with being single (aOR = 4.2, 95% CI = 1.1-15.5), food insecurity (aOR = 2.4, 95% CI = 1.0-6.4), and HIV shame (aOR = 1.2, 95% CI = 1.1-1.3). 23.5% of participants met screening criteria for anxiety (BSI ≥1.01). Anxiety was associated with being single (aOR = 3.6, 95%CI = 1.1-11.1), HIV shame (aOR = 1.1, 95% CI = 1.1-1.2) and lifetime experience of violence (aOR = 2.3, 95% CI = 1.0-5.1). 17.8% of the sample met screening criteria for both depression and anxiety. Comorbid depression and anxiety was associated with being single (aOR = 4.5, 95%CI = 1.0-19.1), HIV shame (aOR = 1.2, 95%CI = 1.1-1.3) and lifetime experience of violence (aOR = 3.4, 95% CI = 1.2-9.6).

CONCLUSION

Depression and anxiety symptomatology was common in this sample of pregnant women living with HIV, with a sizable number screening positive for comorbid depression and anxiety. In order to successfully engage women in PMTCT care and support their well-being, strategies to screen for mental health disorders and support women with mental illnesses are needed.

Dopaminergic impact of cART and anti-depressants on HIV neuropathogenesis in older adults

The success of combination antiretroviral therapy (cART) has transformed HIV infection into a chronic condition, resulting in an increase in the number of older, cART-treated adults living with HIV. This has increased the incidence of age-related, non-AIDS comorbidities in this population. One of the most common comorbidities is depression, which is also associated with cognitive impairment and a number of neuropathologies. In older people living with HIV, treating these overlapping disorders is complex, often creating pill burden or adverse drug-drug interactions that can exacerbate these neurologic disorders. Depression, NeuroHIV and many of the neuropsychiatric therapeutics used to treat them impact the dopaminergic system, suggesting that dopaminergic dysfunction may be a common factor in the development of these disorders. Further, changes in dopamine can influence the development of inflammation and the regulation of immune function, which are also implicated in the progression of NeuroHIV and depression. Little is known about the optimal clinical management of drug-drug interactions between cART drugs and antidepressants, particularly in regard to dopamine in older people living with HIV. This review will discuss those interactions, first examining the etiology of NeuroHIV and depression in older adults, then discussing the interrelated effects of dopamine and inflammation on these disorders, and finally reviewing the activity and interactions of cART drugs and antidepressants on each of these factors. Developing better strategies to manage these comorbidities is critical to the health of the aging, HIV-infected population, as the older population may be particularly vulnerable to drug-drug interactions affecting dopamine.

The relationship between depression and sexual health service utilization among men who have sex with men (MSM) in Côte d'Ivoire, West Africa

BACKGROUND

In Cote D'Ivoire, there has been limited coverage of evidence-based sexual health services specifically supporting men who have sex with men (MSM). To date, there has been limited study of the determinants of engagement in these services including multiple intersecting stigmas and depression.

METHODS

1301 MSM aged 18 years and older, were recruited using respondent-driven sampling in Abidjan, Yamoussoukro, Gagnoa and Bouake, Cote d'Ivoire from January 2015 to October 2015. Inclusion criteria included anal sex with another man in the past 12 months were to complete a structured questionnaire including the Patient Health Questionnaire (PHQ)-9 to screen for depression. Chi-Square tests were used to test difference in healthcare utilization across variables, and multiple logistic regression was used to test the association between depression and health care utilization represented by HIV and sexually transmittable infection testing and treatment.

RESULTS

Depression (aOR:1.40, 95% CI: 1.07-1.84), being aged 25-29 years (aOR:1.84, 95% CI: 1.11-3.03),unemployed (aOR:0.64, 95% CI: 0.42-0.98), being a student (aOR:0.67, 95% CI: 0.48-0.96), being identified as male (aOR:0.44, 95% CI: 0.29-0.67), and identifying as homosexual (aOR:0.74, 95% CI:0.56-0.99) were significantly associated with utilization of sexual health care services in the final multivariable model. Healthcare enacted stigma (aOR: 1.55, 95% CI: 1.03-2.33) was associated with utilizing sexual health care services, but perceived healthcare stigma, social stigma and family stigma were not.

CONCLUSION

Given higher levels of depressive symptomatology among those engaging in sexual health care services, this engagement represents an opportunity for service integration which may have synergistic benefits for both sexual and mental health. Moreover, MSM in Cote D'Ivoire who had engaged in sexual health services were more likely to report having experienced health-care enacted stigma. Taken together, these results reinforce the need for stigma mitigation interventions to support sustained engagement in HIV prevention, treatment and care services as a means of reducing health disparities among MSM in Cote d'Ivoire.

Mental health disorders and substance use among people living with HIV in Nepal: their influence on non-adherence to anti-retroviral therapy

People living with HIV often experience mental health disorders and engage in substance use. Evidence, however, is limited about the influence of mental health disorders and substance use on non-adherence to ART. We conducted a cross-sectional study among 682 HIV-positive people on ART in Nepal. We measured their depressive symptoms, anxiety, stress levels, substance use, and non-adherence to ART. We developed logistic regression models to examine the association of mental health disorders and substance use with non-adherence to ART. Experiencing depressive symptoms was positively associated with ART non-adherence among HIV-positive people (men: AOR = 2.77, p = .001; women: AOR = 3.69, p = .001). Additionally, both men and women were more likely to have non-adherence to ART when they had anxiety (men: AOR = 2.19, p = .022; women AOR = 2.83, p = .001) and higher stress scores (men: AOR = 1.11, p = .001; women: AOR = 1.08, p = .001). While substance use was associated with non-adherence only in HIV-positive men (AOR = 3.12, p < .001). Depressive symptoms, anxiety, and high level of stress had negative roles on adherence in HIV-positive men and women. While substance use had a negative role on ART adherence among men only. Results highlight that the HIV-positive people should be screened and provided treatment and psychosocial support while providing ART services to improve their medication adherence.

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.

The Psychosocial and Clinical Well-Being of Women Living with Human Immunodeficiency Virus/AIDS

This study examined factors impacting the psychological well-being of women living with human immunodeficiency virus/AIDS and the impact of depression on clinical outcomes. Nearly two-thirds of participants in this cross-sectional study reported significant depressive symptoms. Compared with women living with human immunodeficiency virus/AIDS without depressive symptoms, those with depression reported significantly poorer health outcomes. Health care providers should regularly screen these women for and adequately treat depression, and must collaborate with mental health providers and pastoral care counselors to address the mental health needs of women living with human immunodeficiency virus/AIDS to optimize their human immunodeficiency virus-related outcomes.

HIV-Related Stigma, Social Support, and Psychological Distress Among Individuals Initiating ART in Ethiopia

Recent World Health Organization HIV treatment guideline expansion may facilitate timely antiretroviral therapy (ART) initiation. However, large-scale success of universal treatment strategies requires a more comprehensive understanding of known barriers to early ART initiation. This work aims to advance a more comprehensive understanding of interrelationships among three known barriers to ART initiation: psychological distress, HIV-related stigma, and low social support. We analyzed cross-sectional interview data on 1175 adults initiating ART at six HIV treatment clinics in Ethiopia. Experience of each form of HIV-related stigma assessed (e.g., anticipatory, internalized, and enacted) was associated with increased odds of psychological distress. However, among those who reported enacted HIV-related stigma, there was no significant association between social support and psychological distress. Interventions to improve mental health among people living with HIV should consider incorporating components to address stigma, focusing on strategies to prevent or reduce the internalization of stigma, given the magnitude of the relationship between high internalized stigma and psychological distress. Interventions to increase social support may be insufficient to improve the mental health of people living with HIV who experienced enacted HIV-related stigma. Future research should examine alternative strategies to manage the mental health consequences of enacted HIV-related stigma, including coping skills training.

A systematic review and meta-analysis of epidemiology of depression in people living with HIV in east Africa

BACKGROUND

Depression is the most prevalent psychiatric disorder among people living with HIV (PLWHIV) and is associated with poor quality of life, additional comorbidities, disability, unemployment, poorer therapeutic outcomes and risky behaviors. The present systematic review and meta-analysis aims to systematically summarize empirical evidence and to formulate recommendations for future research.

METHODS

We searched PubMed, EMBASE, SCOPUS, and relevant literature for possible studies to include. A qualitative and quantitative analysis was undertaken for this systematic review. Subgroup and sensitivity analysis were performed. Cochran's Q- and the I² test were used to assess heterogeneity. The presence of publication bias was evaluated by using Egger's test and visual inspection of the symmetry in funnel plots.

RESULTS

Of 283 titles initially identified, 81 abstracts were eligible for review. Of these, 46 articles qualified for full text review and 19 were retained. In our meta-analysis the pooled prevalence of depression in PLWHIV was 38% (95% CI 29.30-47.54). The pooled prevalence estimates of depression was 49.79% in Ethiopia and 30.88% in Uganda. In addition, the prevalence of depression was 12.40% and 46% as measured by diagnostic and screening instrument respectively. Our qualitative synthesis showed that factors such as having opportunistic infection, perceived stigma, negative life event, WHO clinical staging of disease, hospitalization in the past one month, stressful life events, food insecurity, self-efficacy, missed frequency of clinic visit, frequency of follow-up, older age, low income, urban residence and being government employee were strongly and significantly associated with depression in PLWHIV in east Africa.

CONCLUSION

The pooled prevalence estimates of prevalence of depression in PLWHIV was 38%. The prevalence estimates of depression in PLWHIV in Ethiopia was significantly higher than Uganda. In addition the prevalence of depression was significantly higher in studies conducted by screening than diagnostic instrument. Routine screening and integrated management of depression into the existing HIV care services is warranted. Validation and use of standard instrument to assess depression in PLWHIV is needed. Moreover, longitudinal and community based studies focusing on incidence and determinates of depression in PLWHIV are recommended.

Use of Nonantiretroviral Medications That May Impact Neurocognition: Patterns and Predictors in a Large, Long-Term HIV Cohort Study

BACKGROUND

Neurocognitive impairment is a frequent and often disabling comorbidity of HIV infection. In addition to antiretroviral therapies, individuals with HIV infection may commonly use nonantiretroviral medications that are known to cause neurocognitive adverse effects (NC-AE). The contribution of NC-AE to neurocognitive impairment is rarely considered in the context of HIV and could explain part of the variability in neurocognitive performance among individuals with HIV.

SETTING

Women's Interagency HIV Study, a prospective, multisite, observational study of US women with and without HIV.

METHODS

After a literature review, 79 medications (excluding statins) with NC-AE were identified and reported by Women's Interagency HIV Study participants. We examined factors associated with self-reported use of these medications over a 10-year period. Generalized estimating equations for binary outcomes were used to assess sociodemographic, behavioral, and clinical characteristics associated with NC-AE medication use.

RESULTS

Three thousand three hundred women (71% with HIV) and data from ∼42,000 visits were studied. HIV infection was associated with NC-AE medication use (odds ratio = 1.52; 95% confidence interval: 1.35 to 1.71). After adjustment for HIV infection status, other predictors of NC-AE medication use included having health insurance, elevated depressive symptoms, prior clinical AIDS, noninjection recreational drug use, and an annual household income of <$12,000 (Ps < 0.004). NC-AE medication use was less likely among women who drank 1-7 or 8-12 alcoholic drinks/week (vs. abstaining) (P < 0.04).

CONCLUSIONS

HIV infection was associated with NC-AE medication use, which may influence determinations of HIV-associated neurocognitive impairment. Providers should consider the impact of NC-AE medications when evaluating patients with HIV and concurrent neurocognitive symptoms.

Intersectional health-related stigma in persons living with HIV and chronic pain: implications for depressive symptoms

"Intersectional health-related stigma" (IHRS) refers to stigma that arises at the convergence of multiple health conditions. People living with HIV (PLWH) and chronic pain have two highly stigmatized health conditions, and thus may be at especially high risk for internalizing these stigmas and consequently experiencing depression. This study examined the intersectionality of internalized HIV and chronic pain stigma in relation to depressive symptoms in a sample of PLWH and chronic pain. Sixty participants were recruited from an HIV clinic in the Southeastern United States. Chronic pain was defined as pain that has been present for at least three consecutive months, and that has been an ongoing problem for at least half the days in the past six months. All participants completed the HIV Stigma Mechanisms Scale, Internalized Stigma in Chronic Pain Scale, the Short-Form Brief Pain Inventory, and the Center for Epidemiological Studies - Depression Scale. Clinical data was collected from medical records. An intersectional HIV and chronic pain composite variable was created and participants were categorized as either high (28%), moderate (32%), or low (40%). Results revealed that intersectional HIV and chronic pain stigma was significantly associated with severity of depressive symptoms (p = .023). Pairwise contrasts revealed that participants with high (p = .009) and moderate (p = .033) intersectional stigma reported significantly greater mean depressive symptom severity than those with low intersectional stigma. Participants who reported the highest levels of internalized HIV and chronic pain stigma also reported the greatest severity of depressive symptoms. This suggests that the experience of both HIV and chronic pain stigma (i.e., IHRS) among PLWH and chronic pain may synergistically perpetuate negative mood in a more profound manner than experiencing either one stigma alone.

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.

Depression and adherence to antiretroviral treatment in HIV-positive men in São Paulo, the largest city in South America: Social and psychological implications

OBJECTIVES

The aim of the present study was to investigate the prevalence of depression and adherence to antiretroviral treatment in two groups of individuals: men who have sex with men (MSM) and men who have sex with women (MSW).

METHODS

Two hundred and sixteen participants (MSM=116; MSW=100) who visited the Clinics Hospital of the School of the Medicine of the University of São Paulo completed two independent surveys (the BECK Depression Inventory and an adherence self-declared questionnaire) to evaluate their depression status and adherence to antiretroviral treatment, respectively.

RESULTS

The study highlighted a positive relationship between depression and low adherence to Highly Active Antiretroviral Therapy in these patients regardless of age and sexual orientation. In addition, MSM subjects were two times more prone than MSW subjects to develop depression symptoms. White or mixed race men showed 7.6 times greater adherence to treatment than black men. The probability of complete adherence to treatment was 3.8 times higher in non-depressed subjects than in depressed subjects regardless of their ethnicity. The chance of developing depression was 4.17 times higher for an individual with non-adherent behavior than for an adherent individual.

CONCLUSIONS

Individuals with low adherence rates have proportionally higher depression rates. Depressed men tend to show less adherence to treatment. Black but not mixed race or white men show less adherence to Highly Active Antiretroviral Therapy and have a greater chance of developing depression, which directly interferes with adherence. The chances of developing depression are four times greater for a patient with non-adherent behavior than for a patient with adherent behavior.

Process Evaluation of a Randomized Controlled Trial of Group Support Psychotherapy for Depression Treatment Among People with HIV/AIDS in Northern Uganda

We describe the process evaluation for a randomized controlled trial that compared group support psychotherapy (GSP) with group HIV education for treatment of depression among people with HIV. Process data were obtained using mixed methods. Variables evaluated were indicators of feasibility and acceptability; causal mediating processes and contextual influences. GSP was feasible and acceptable. Potential mediating variables between GSP and reduction of depression were improved emotional and social support, better coping strategies, and pursuit of livelihoods. Culturally sensitive intervention content facilitated intervention delivery. These data complement the trial outcomes, and may provide a contextualized description of how GSP treats depression.

Prevalence and Predictors of Hospitalizations Among HIV-Infected and At-Risk HIV-Uninfected Women

OBJECTIVES

We evaluated the Veterans Aging Cohort Study (VACS) Index score, an index composed of age, CD4 count, viral load, hemoglobin, Hepatitis C coinfection, Fibrosis Index-4, and estimated glomerular filtration rate, and psychosocial and clinical risk factors for all-cause hospitalization among HIV-infected women on highly active antiretroviral therapy and HIV-uninfected women.

METHODS

Data were collected from 2008 to 2014 from 1585 highly active antiretroviral therapy-experienced HIV infected and 692 uninfected women. Cox proportional hazards regression evaluated predictors of first hospitalization over 2 years.

RESULTS

Among HIV-infected women, VACS Index score (per 5 points) [adjusted hazard ratio (aHR) 1.08; 95% confidence interval (CI): 1.06 to 1.11], Centers for Epidemiologic Studies-Depression (CESD) scores ≥16 (aHR 1.61; 95% CI: 1.30 to 1.99), smoking (aHR 1.26; 95% CI: 1.02 to 1.55), abuse history (aHR 1.52; 95% CI: 1.20 to 1.93), diabetes (aHR 1.63; 95% CI: 1.31 to 2.04), and black race (aHR 1.28; 95% CI: 1.03 to 1.59) increased risk of hospitalization. Among HIV-uninfected women, VACS Index score (aHR 1.08; 95% CI: 1.03 to 1.13), CESD scores ≥16 (aHR 1.38; 95% CI: 1.02 to 1.86), diabetes (aHR 2.15; 95% CI: 1.57 to 2.95), and black race (aHR 1.61; 95% CI: 1.15 to 2.24) predicted subsequent hospitalization.

CONCLUSIONS

Psychosocial and clinical factors were associated with risk of hospitalization independently of the VACS Index score. Additional research on contextual and psychosocial influences on health outcomes among women is needed.

Relationship between ever reporting depressive symptoms and all-cause mortality in a cohort of HIV-infected adults in routine care

OBJECTIVE

The aim of this study was to assess whether ever reporting depressive symptoms affects mortality in the modern HIV treatment era.

DESIGN

A cohort study of HIV-infected adults in routine clinical care at seven sites in the USA.

METHODS

We examined the effect of ever reporting depressive symptoms on all-cause mortality using data from the Centers for AIDS Research Network of Integrated Clinical Systems cohort. We included individuals with at least one depression measure between 2005 and 2014. Depressive symptoms were measured with the Patient Health Questionnaire (PHQ)-9. We used weighted Kaplan-Meier curves and marginal structural Cox models with inverse probability weights to estimate the effect of ever reporting depressive symptoms (PHQ-9 ≥10) on all-cause mortality.

RESULTS

A total of 10 895 individuals were included. Participants were followed for a median of 3.1 years (35 621 total person-years). There were 491 (4.5%) deaths during the follow-up period (crude incidence rate 13.8/1000 person-years). At baseline, 28% of the population reported depressive symptoms. In the weighted analysis, there was no evidence that ever reporting depressive symptoms increased the hazard of all-cause mortality (hazard ratio 0.82, 95% confidence interval 0.55-1.24).

CONCLUSION

In a large cohort of HIV-infected adults in care in the modern treatment era, we observed no evidence that ever reporting depressive symptoms increased the likelihood of all-cause mortality, controlling for a range of time-varying factors. Antiretroviral therapy that is increasingly robust to moderate adherence and improved access to depression treatment may help to explain changes in the relationship between depressive symptoms and mortality in the modern treatment era.

Putting evidence into practice: evidence-based interventions for oral agents for cancer

BACKGROUND

The limited evidence available suggests that adherence to oral agents for cancer is a significant clinical problem and may have a substantial impact on treatment success or failure. Adherence is a difficult issue among patients who are very sick with a life-threatening disease who often must adhere to complex treatment protocols independently at home.

OBJECTIVES

This article aims to identify effective interventions for the promotion, treatment, and management of adherence to oral agents for cancer and to synthesize the literature for use in clinical practice.

METHODS

As part of the Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP) initiative, a comprehensive examination of the current literature was conducted to identify effective interventions for patients prescribed oral agents for cancer. The ONS PEP weight-of-evidence classification schema levels of evidence were used to categorize interventions to assist nurses in identifying strategies that are effective at improving adherence.

FINDINGS

The majority of evidence found was conducted in conditions other than cancer; therefore, research is needed to identify whether these interventions are effective at promoting adherence in patients with cancer.

Prevalence of and factors associated with depression among people living with HIV in France

OBJECTIVES

Depression is common among people living with HIV (PLWHIV) and is associated with poorer therapeutic outcomes and risky behaviours. We sought to estimate the prevalence of major depressive episode (MDE) across PLWHIV groups, to compare this with its prevalence in the general population and to assess factors associated with it.

METHODS

We used data from the Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS)-Vespa2 study, a national study on a representative sample of PLWHIV conducted in France in 2011. The short form of the depression module of the World Health Organization's Composite International Diagnostic Instrument (CIDI-SF) was used to characterize the occurrence of an MDE during the previous year. MDE prevalence was assessed among the various groups of PLWHIV and compared with that in the general population, accounting for the sociodemographic characteristics of the two populations, using multivariate Poisson regression models. The same method was used to assess associated factors.

RESULTS

MDE prevalence was 28.1% among PLWHIV, ranging from 10.9 to 55.7% across groups. Compared with the general population by sex, regardless of sexual orientation and origin, MDE prevalence was 5.1-fold higher in HIV-infected men who have sex with men [95% confidence interval (CI) 3.9-6.6], 3.1-fold higher in non-sub-Saharan African (SSA) heterosexual men (95% CI 2.2-4.4), 1.6-fold higher in SSA migrant men (95% CI 0.9-2.6), 2.6-fold higher in non-SSA heterosexual women (95% CI 2.1-3.3), and 1.9-fold higher in SSA migrant women (95% CI 1.5-2.5). In the HIV-infected population, MDE was positively related to unemployment, material deprivation, disclosure, experience of discrimination, and untreated hepatitis C, and negatively related to age.

CONCLUSIONS

The prevalence of depression varied across the different groups of PLWHIV, with levels much higher than in the general population. Moreover, there was a strong association with socioeconomic status and HIV experience.

HIV and Elevated Mental Health Problems: Diagnostic, Treatment, and Risk Patterns for Symptoms of Depression, Anxiety, and Stress in a National Community-Based Cohort of Gay Men Living with HIV

People living with HIV (PLHIV) have almost double the risk of depression than the rest of the population, and depression and anxiety among PLHIV have been linked with greater disease progression and other physical health problems. Studies to date, however, have focused almost exclusively on depression or general mental health. Much less research has investigated predictors of anxiety and generalized stress among HIV-positive gay men. This paper reports findings from a national community-based sample of 357 HIV-positive Australians gay men aged 18 years and older. Participants reported elevated rates of depression, anxiety, and generalized stress symptoms. A significant proportion of men with elevated depression and anxiety symptoms were not receiving treatment or had not been diagnosed. Risk factors for elevated mental health concerns included experiences of internalized stigma and discrimination. Anxiety was also associated with lower T-cell CD4 counts. A key protective factor was access to social support. The type of support, in particular emotional support, was found to be more important than the source of support. Our findings suggest that greater emphasis is needed on mental health screening and the provision of emotional support for PLHIV.

Determinants of virological response to antiretroviral therapy: socio-economic status still plays a role in the era of cART. Results from the ANRS-VESPA 2 study, France

BACKGROUND

Disparities in combined antiretroviral therapy (cART) outcomes have been consistently reported among people living with HIV (PLWHIV). The present study aims at investigating the mechanisms underlying those disparities among PLWHIV in France.

METHODS

We used data from the Vespa2 survey, a large national cross-sectional survey, representative of HIV-infected people followed at hospitals in 2011. Among participants diagnosed ≥1996, HIV treatment-naive at the time of cART initiation and on cART for at least 12 months, the frequency of sustained virological suppression (SVS; undetectable viral load [<50 copies/ml] for at least 6 months) at the time of the survey, was assessed and its social determinants were measured through logistic regression, accounting for clinical and biological determinants of response to cART.

RESULTS

Among 1,246 participants, 77.7% had achieved SVS. SVS was less frequent among those unemployed (0.6 [range 0.3-1.0]) and those with the lowest level of education (0.4 [range 0.2-0.9]). The late presenters, diagnosed at a CD4⁺ T-cell count <200/mm³ (0.5 [range 0.3-0.9]) and the late starters, diagnosed at a CD4⁺ T-cell count >200 but initiating cART at CD4⁺ T-cell count <200 (0.3 [range 0.1-0.8]) were less likely than the ideal starters (≥350 CD4⁺ T-cells/mm³ at cART initiation) to achieve SVS, as were those who reported suboptimal adherence versus those reporting optimal adherence (0.4 [range 0.2-0.7]). In bivariate analyses, material deprivation, discrimination and a weak social network were also associated with a poorer treatment response.

CONCLUSIONS

Structural social factors remain strong determinants of treatment response and should be addressed in a broad approach of care, but wider political issues should also be investigated.

Toward a comprehensive care of HIV patients: finding a strategy to detect depression in a Spanish HIV cohort

Depression is a common but frequently undiagnosed feature in individuals with HIV infection. To find a strategy to detect depression in a non-specialized clinical setting, the overall performance of the Hospital Anxiety and Depression Scale (HADS) and the depression identification questions proposed by the European AIDS Clinical Society (EACS) guidelines were assessed in a descriptive cross-sectional study of 113 patients with HIV infection. The clinician asked the two screening questions that were proposed under the EACS guidelines and requested patients to complete the HADS. A psychiatrist or psychologist administered semi-structured clinical interviews to yield psychiatric diagnoses of depression (gold standard). A receiver operating characteristic (ROC) analysis for the HADS-Depression (HADS-D) subscale indicated that the best sensitivity and specificity were obtained between the cut-off points of 5 and 8, and the ROC curve for the HADS-Total (HADS-T) indicated that the best cut-off points were between 12 and 14. There were no statistically significant differences in the correlations of the EACS (considering positive responses to one [A] or both questions [B]), the HADS-D ≥ 8 or the HADS-T ≥ 12 with the gold standard. The study concludes that both approaches (the two EACS questions and the HADS-D subscale) are appropriate depression-screening methods in HIV population. We believe that using the EACS-B and the HADS-D subscale in a two-step approach allows for rapid, assumable and accurate clinical diagnosis in non-psychiatric hospital settings.

Psychometric Limitations of the Center for Epidemiologic Studies-Depression Scale for Assessing Depressive Symptoms among Adults with HIV/AIDS: A Rasch Analysis

The Center for Epidemiological Studies-Depression (CES-D) scale is a widely used measure of depressive symptoms, but its psychometric properties have not been adequately evaluated among adults with HIV/AIDS. This study used an item response theory approach (Rasch analysis) to evaluate the CES-D's validity and reliability in relation to key demographic and clinical variables in adults with HIV/AIDS. A convenience sample of 347 adults with HIV/AIDS (231 males, 93 females, and 23 transgenders; age range 22-77 years) completed the CES-D. A Rasch model application was used to analyze the CES-D's rating scale functioning, internal scale validity, person-response validity, person-separation validity, internal consistency, differential item functioning (DIF), and differential test functioning. CES-D scores were generally high and associated with several demographic and clinical variables. The CES-D distinguished 3 distinct levels of depression and had acceptable internal consistency but lacked unidimensionality, five items demonstrated poor fit to the model, 15% of the respondents demonstrated poor fit, and eight items demonstrated DIF related to gender, race, or AIDS diagnosis. Removal of misfitting items resulted in minimal improvement in the CES-D's substantive and structural validity. CES-D scores should be interpreted with caution in adults with HIV/AIDS, particularly when comparing scores across gender and racial groups.

Differences in clinical and psychiatric outcomes between prevalent HIV-1 molecular subtypes in a multiethnic Southeast Asian sample

OBJECTIVE

In Southeast Asia, subtypes B and CRF01_AE are the prevalent human immunodeficiency virus-1 (HIV-1) subtypes. This study examines the intersubtype differences in clinical indicators and psychiatric symptoms in a multiethnic sample.

METHODS

The study site was a national HIV treatment center. Data were extracted from the Molecular Epidemiology Research study and the HIV-Psychiatry Integrated Mental Health Project, and analyzed according to groups defined by viral subtype.

RESULTS

Of 177 subjects, 54.8% were infected with subtype CRF01_AE; 42.9% screened positive on the Hospital Anxiety and Depression Scale (HADS). The CRF01_AE group was significantly older (mean 38.29 years vs. 34.62 years, P=.031) and had advanced immunosuppression (CD4 <200) just prior to HADS screening (33.0% vs. 13.5%, P=.003). By multivariate logistic regression, homosexual transmission [odds ratio (OR) 0.388, 95% confidence interval (CI) 0.158-0.951, P=.038], subtype CRF01_AE (OR 2.898, 95% CI 1.199-7.001, P=.018) and positive HADS screening (OR 2.859, 95% CI 1.261-8.484, P=.012) were associated with advanced immunosuppression; and only advanced immunosuppression was associated with screening positive on the HADS (OR 3.270, 95% CI 1.299-8.227, P=.012).

CONCLUSION

Subtype CRF01_AE is associated with advanced immunosuppression but not with symptoms of anxiety and depression. The results suggest that psychiatric symptoms are associated with advanced HIV disease regardless of subtype.

Discrepancies between physician's perception of depression in HIV patients and self-reported CES-D-20 assessment: the DHIVA study

Depression in HIV/AIDS patients affects adherence and disease progression and often goes unnoticed. DHIVA is a cross-sectional epidemiologic survey, investigating the prevalence of depression in people living with HIV through use of a validated self-administered scale (CES-D-20), as well and the degree of concordance between the physician's perception and patients' reports. A total of 690 HIV-infected patients attending 24 centers across Italy were enrolled. Concordance was calculated by K statistics. Association between depression and subject characteristics were evaluated through univariate and multivariate logistic models (OR and 95%CI). The prevalence of depressive symptoms was 48.8% from patient's questionnaires and 49.5% from physicians' reports, with a low/fair concordance (K = .38, p < .001). CES-D-20 found severe depression in 22.5% of the patients vs 4% identified by physicians. 135/155 (87%) of the severely depressed patients (according to CES-D-20) were considered as non or mildly/moderately depressed by physicians. Risk of severe depression was associated with unemployment (p < .001), previous depression (p < .001), treatment failure (p = .001), and former smoking status (p = .018). Depression is frequent in HIV-infected patients in the HAART era, with significant discrepancy between physician perception and the self-reported CES-D-20 results. Screening should be mandatory in all HIV patients.

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.

The ABCs of Trait Anger, Psychological Distress, and Disease Severity in HIV

BACKGROUND

Trait anger consists of affective, behavioral, and cognitive (ABC) dimensions and may increase vulnerability for interpersonal conflict, diminished social support, and greater psychological distress. The concurrent influence of anger and psychosocial dysfunction on Human Immunodeficiency Virus (HIV) disease severity is unknown.

PURPOSE

The purpose of this study was to examine plausible psychosocial avenues (e.g., coping, social support, psychological distress), whereby trait anger may indirectly influence HIV disease status.

METHODS

Three hundred seventy-seven HIV seropositive adults, aged 18-55 years (58% AIDS-defined), completed a battery of psychosocial surveys and provided a fasting blood sample for HIV-1 viral load and T lymphocyte count assay.

RESULTS

A second-order factor model confirmed higher levels of the multidimensional anger trait, which was directly associated with elevated psychological distress and avoidant coping (p<.001) and indirectly associated with greater HIV disease severity (p<.01) (comparative fit index (CFI)=0.90, root-mean-square error of approximation (RMSEA)=0.06, standardized root-mean-square residual (SRMR)=0.06).

CONCLUSION

The model supports a role for the ABC components of anger, which may negatively influence immune function through various psychosocial mechanisms; however, longitudinal study is needed to elucidate these effects.

Neuropathological sequelae of Human Immunodeficiency Virus and apathy: A review of neuropsychological and neuroimaging studies

Apathy remains a common neuropsychiatric disturbance in the Human Immunodeficiency Virus (HIV-1) despite advances in anti-retroviral treatment (ART). The goal of the current review is to recapitulate findings relating apathy to the deleterious biobehavioral effects of HIV-1 in the post-ART era. Available literatures demonstrate that the emergence of apathy with other neurocognitive and neuropsychiatric symptoms may be attributed to neurotoxic effects of viral proliferation, e.g., aggregative effect of Tat and gp120 on apoptosis, transport and other enzymatic reactions amongst dopaminergic neurons and neuroglia. An assortment of neuroimaging modalities converge on the severity of apathy symptoms associated with the propensity of the virus to replicate within frontal-striatal brain circuits that facilitate emotional processing. Burgeoning research into functional brain connectivity also supports the effects of microvascular and neuro-inflammatory injury linked to aging with HIV-1 on the presentation of neuropsychiatric symptoms. Summarizing these findings, we review domains of HIV-associated neurocognitive and neuropsychiatric impairment linked to apathy in HIV. Taken together, these lines of research suggest that loss of affective, cognitive and behavioral inertia is commensurate with the neuropathology of HIV-1.

Brain derived neurotrophic factor and cognitive status: the delicate balance among people living with HIV, with and without alcohol abuse

INTRODUCTION

The advent of combination antiretroviral therapy(cART) has lead to a significant reduction in morbidity and mortality among people living with HIV(PLWH). However, HIV-associated neurocognitive disorders (HAND) still remain a significant problem. One possible mechanism for the persistence of these disorders is through the effect of HIV on brain-derived neurotrophic factor (BDNF). BDNF is influenced by various factors including hazardous alcohol use (HAU), which is prevalent among PLWH. This study attempts to elucidate the relationships between HAU, BDNF and HAND.

METHODS

Cross-sectional analyses were conducted on a sample of 199 hazardous alcohol users and 198 non-HAU living with HIV. Members of each group were matched according to sociodemographic characteristics and CD4 count. Research procedures included validated questionnaires, neuropsychological assessments and a blood sample to obtain BDNF and immune measurements.

RESULTS

Hazardous alcohol users showed either significantly lower or significantly higher BDNF levels compared to the Non-hazardous (OR=1,4; 95% CI: 1-2.1, p = 0.003). Therefore, for additional analyses, subjects were categorized based on BDNF values in: Group 1 < 4000, Group 2: 4001-7,999 (reference group), and Group 3 for those >8,000 pg/mL. Groups 1 and 3 performed significantly worse than those in Group 2 in the domains of processing speed, auditory-verbal and visuospatial learning and memory. Multivariate analyses confirmed that HAU and BDNF are significant contributors of HAND.

CONCLUSION

Our findings offer novel insights into the relationships between BDNF, and alcohol use among PLWH. Our results also lend support to expanding clinical movement to use BDNF as an intervention target for PLWH, in those with evidence of deficiencies, and highlight the importance of including HAUat the inception of clinical trials.

Barriers to antiretroviral treatment initiation in rural KwaZulu-Natal, South Africa

OBJECTIVES

Although antiretroviral therapy (ART) has been freely available since 2004 in South Africa, not all those who are eligible initiate ART. We aimed to investigate individual and household characteristics as barriers to ART initiation in men and women in rural KwaZulu-Natal.

METHODS

Adults ≥ 16 years old living within a sociodemographic surveillance area (DSA) who accessed the local HIV programme between 2007 and 2011 were included in the study. Individual and household factors associated with ART initiation within 3 months of becoming eligible for ART were investigated using multivariable logistic regression stratified by sex and after exclusion of individuals who died before initiating ART.

RESULTS

Of the 797 men and 1598 women initially included, 8% and 5.5%, respectively, died before ART initiation and were excluded from further analysis. Of the remaining 733 men and 1510 women, 68.2% and 60.2%, respectively, initiated ART ≤ 3 months after becoming eligible (P = 0.34 after adjustment for CD4 cell count). In men, factors associated with a higher ART initiation rate were being a member of a household located < 2 km from the nearest HIV clinic and being resident in the DSA at the time of ART eligibility. In women, ART initiation was more likely in those who were not pregnant, in members of a household where at least one person was on ART and in those with a high wealth index.

CONCLUSIONS

In this rural South African setting, barriers to ART initiation differed for men and women. Supportive individual- and household-level interventions should be developed to guarantee rapid ART initiation taking account gender specificities.

Primary care of women aging with HIV

Women are living longer with HIV infection, but their life expectancy remains shorter than for women in the general population. How best to manage the multiple comorbidities and polypharmacy that are common in individuals wtih HIV has not been studied. This article explores areas where the primary care of women with HIV may differ from that of aging women in the general population. We also discuss aspects of care that may not commonly be considered in those under the age of 65, specifically multimorbidity and polypharmacy. Incorporating a gerontologic approach in the care of these women may optimize outcomes until research provides more definitive answers for how best to collaborate with women with HIV in order to provide them with optimal care.

Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis

BACKGROUND

Depression is a risk factor for nonadherence to HIV/AIDS treatment.

PURPOSE

A meta-analysis was conducted to examine whether treatment of depression and psychological distress improves antiretroviral therapy adherence.

METHODS

PubMed and PsycINFO databases were systematically searched for relevant articles. Studies that reported an association between depression treatment (or an intervention with a component addressing mental health) and antiretroviral adherence were included.

RESULTS

Across 29 studies of 12,243 persons living with HIV/AIDS, treatment of depression and psychological distress improved antiretroviral adherence (p < 0.001). The odds of a person adhering were 83 % better if he/she was treated for depression. Greater improvements in adherence were found for samples with lower CD4 counts or more severe depression, for interventions specifically targeting depression (versus addressing mental health as a secondary objective), longer treatments, and observational studies.

CONCLUSIONS

These findings support the need for detection and treatment of depression among persons living with HIV/AIDS.

Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries

People living with HIV (PLWH) experience greater psychological distress than the general population. Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms, quality of life, and HIV care engagement. However, little is known about the effectiveness of mental health interventions for PLWH in low and middle-income countries (LMICs), where the large majority of PLWH reside. This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these settings. A systematic search strategy was undertaken to identify peer-reviewed published papers of intervention trials addressing negative psychological states or disorders (e.g., depression, anxiety) among PLWH in LMIC settings. Search results were assessed against pre-established inclusion and exclusion criteria. Data from papers meeting criteria were extracted for synthesis. Twenty-six papers, published between 2000 and 2014, describing 22 unique interventions were identified. Trials were implemented in sub-Saharan Africa (n=13), Asia (n=7), and the Middle East (n=2), and addressed mental health using a variety of approaches, including cognitive-behavioral (n=18), family-level (n=2), and pharmacological (n=2) treatments. Four randomized controlled trials reported significant intervention effects in mental health outcomes, and eleven preliminary studies demonstrated promising findings. Among the limited mental health intervention trials with PLWH in LMICs, few demonstrated efficacy. Mental health interventions for PLWH in LMICs must be further developed and adapted for resource-limited settings to improve effectiveness.