Utilization of mental health and substance abuse care for people living with HIV/AIDS, chronic mental illness, and substance abuse disorders

People who living with HIV/AIDS also have a high prevalence of anxiety disorders: a systematic review and meta-analysis

Background

An estimated 301 million people worldwide suffer from anxiety disorders. People living with HIV/AIDS (PLWHA) are particularly prone to anxiety disorders that could interfere with the important developmental process in an individual's development and ultimately result in a wide range of negative mental, physical, and psychosocial consequences, as well as poor quality of life in those population groups. Early intervention for anxiety disorders can reverse some of the physical damage caused by anxiety. However, based on systematic reviews and meta-analyses, the specific prevalence of anxiety disorders in PLWHA remains unknown.

Method

We conducted a literature search on PubMed, Embase, and Web of Science up to 22 October 2022. A random-effects meta-analysis was used to pool prevalence rates from the included studies. Sensitivity and subgroup analyses were performed to identify the possible sources of heterogeneity and to compare the prevalence estimates across groups. The Joanna Briggs Institute's Quality Assessment Checklist was used to assess the quality of the included studies. Cochran's Q and I2 tests were used to assess the between-study heterogeneity.

Results

Ten studies with a total of 238,570 cases were included for the final analysis. Results showed that 15.5% of HIV/AIDS patients had anxiety disorders. The prevalence was higher in females (20.8%) than males (20.7%). The mean age of PLWHA with anxiety disorders was 46.58 ± 11.15 years in these included studies. The subgroup analyses showed significant higher prevalence in non-heterosexual (32.1%).

Conclusion

We attempted to quantify literature that could allow for stronger inferences to be made regarding the significantly higher prevalence of anxiety disorders in PLWHA, a finding that suggests the imperativeness of intervention strategies to alleviate suffering and reduce the probable negative ramifications.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023442219, identifier CRD42023442219.

Co-Utilization of HIV, Substance Use, Mental Health Services Among Women With Current Substance Use: Opportunities for Integrated Care?

BACKGROUND

The syndemic of HIV, substance use (SU), and mental illness has serious implications for HIV disease progression among women. We described co-utilization of HIV care, SU treatment, and mental health treatment among women with or at risk for HIV.

METHODS

We included data from women with or at risk for HIV (n = 2559) enrolled in all 10 sites of the Women's Interagency HIV Study (WIHS) from 2013 to 2020. Current SU was defined as self-reported, non-medical use of drugs in the past year, excluding use of only marijuana. Tobacco and alcohol were assessed separately. We described co-utilization of SU treatment, tobacco and alcohol use treatment, HIV care, and mental health care in the past year among women who were eligible for each service. We compared service utilization by those who did/did not utilize SU treatment using Wald Chi-square tests.

RESULTS

Among women with current SU (n = 358), 42% reported utilizing SU treatment. Among those with current SU+HIV (n = 224), 84% saw their HIV provider, and 34% saw a mental health provider. Among women with current SU+heavy alcohol use (n = 95), 18% utilized alcohol use treatment; among current SU+tobacco use (n = 276), 8% utilized tobacco use treatment. Women who utilized SU treatment had higher utilization of alcohol use treatment (59% vs. 5%; P < .001) and tobacco use treatment (12% vs. 5%; P = .028). HIV care engagement was high regardless of SU treatment.

CONCLUSIONS

We found high engagement in SU and HIV care, but low engagement in alcohol and tobacco use treatment. Integrated SU treatment services for women, including tobacco/alcohol treatment and harm reduction, are needed to optimize treatment engagement and HIV care continuum outcomes.

Brief interventions for alcohol misuse among people living with HIV: a meta-analysis

Background: One-third of people living with HIV (PLHIV) have alcohol misuse or alcohol use disorders which negatively affect course and outcome of HIV.Objectives: The meta-analysis sought to evaluate the effectiveness of brief interventions (BI) on alcohol and HIV outcomes in PLHIV with alcohol misuse.Methods: We included clinical trials published between 1990 and September 2022 on adults with harmful/hazardous alcohol use; only randomized clinical trials (RCTs) were included in the meta-analysis. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Clinical Trials.Gov, and the World Health Organization's International Clinical Trials Registry Platform databases. Cochrane's risk-of-bias assessment was used.Results: Eighteen studies were included in the narrative synthesis, and a meta-analysis could be performed on 13 studies. Among the included RCTs, seven showed a low risk and two showed a high risk of bias; others showed some concerns. There was no evidence of publication bias. Compared to the control, BI significantly reduces the drinks per drinking day (N = 5, Hedge's g= -0.45, 95%CI = -0.58, -0.32) and the number of heavy drinking days (N = 4, Hedge'sg = -0.81, 95% CI= -0.94, -0.67) between 3-6 months post-intervention. BI also reduces the odds of mortality by 42% (N = 7, OR = 0.58, 95% CI = 0.34, 0.99) in 6-12 months. BI does not change the alcohol risk scores and transition to harmful alcohol use; it does not improve adherence to Anti-Retroviral Therapy and increase viral suppression.Conclusion: Policymakers must introduce and scale up integrated screening and brief intervention services within HIV clinics and primary care.

Syndemic trajectories of heavy drinking, smoking, and depressive symptoms are associated with mortality in women living with HIV in the United States from 1994 to 2017

BACKGROUND

Heavy drinking, smoking, and depression are common among people with HIV. Little is known about the co-occurring, synergistic effect of having two or more of these conditions long-term -a sustained syndemic - on mortality among women with HIV (WWH).

METHODS

Data from 3282 WWH of the Women's Interagency HIV Study from 1994 to 2017 were utilized. National Death Index review identified cause of death (n=616). Sustained syndemic phenotypes were based on membership in high-risk groups defined by group-based trajectory models of repeated self-reported alcohol use, smoking, and depressive symptoms and their co-occurrence. Cox proportional hazard models estimated associations of sustained syndemic phenotypes with all-cause, non-AIDS, and non-overdose mortality, adjusting for age, race/ethnicity, education, enrollment wave, illicit drug use, and time-varying HIV viral load and CD4+ T-cell count.

RESULTS

WWH were 58% Black and 26% Hispanic, with a mean baseline age of 36.7 years. Syndemic phenotypes included zero (45%, n=1463), heavy drinking only (1%, n=35), smoking only (28%, n=928), depressive symptoms only (9%, n=282), and 2+ trajectories (17%, n=574). Compared to zero trajectories, having 2+ trajectories was associated with 3.93 times greater all-cause mortality risk (95% CI 3.07, 5.04) after controlling for confounders and each high-risk trajectory alone. These findings persisted in sensitivity analyses, removing AIDS- and overdose-related mortalities.

CONCLUSIONS

Clustering of 2+ conditions of heavy drinking, smoking, and depression affected nearly one in five WWH and was associated with higher mortality than zero or one condition. Our findings underscore the need for coordinated screening and parsimonious treatment strategies for these co-occurring conditions.

Psychosocial impacts of the COVID-19 pandemic from a cross-sectional Survey of people living with HIV in Washington, DC

BACKGROUND

COVID-19 has not only taken a staggering toll in terms of cases and lives lost, but also in its psychosocial effects. We assessed the psychosocial impacts of the COVID-19 pandemic in a large cohort of people with HIV (PWH) in Washington DC and evaluated the association of various demographic and clinical characteristics with psychosocial impacts.

METHODS

From October 2020 to December 2021, DC Cohort participants were invited to complete a survey capturing psychosocial outcomes influenced by the COVID-19 pandemic. Some demographic variables were also collected in the survey, and survey results were matched to additional demographic data and laboratory data from the DC Cohort database. Data analyses included descriptive statistics and multivariable logistic regression models to evaluate the association between demographic and clinical characteristics and psychosocial impacts, assessed individually and in overarching categories (financial/employment, mental health, decreased social connection, and substance use).

RESULTS

Of 891 participants, the median age was 46 years old, 65% were male, and 76% were of non-Hispanic Black race/ethnicity. The most commonly reported psychosocial impact categories were mental health (78% of sample) and financial/employment (56% of sample). In our sample, older age was protective against all adverse psychosocial impacts. Additionally, those who were more educated reported fewer financial impacts but more mental health impacts, decreased social connection, and increased substance use. Males reported increased substance use compared with females.

CONCLUSIONS

The COVID-19 pandemic has had substantial psychosocial impacts on PWH, and resiliency may have helped shield older adults from some of these effects. As the pandemic continues, measures to aid groups vulnerable to these psychosocial impacts are critical to help ensure continued success towards healthy living with HIV.

Health Insurance Coverage, Clinical Outcomes, and Health-Related Quality of Life Among Youth Born to Women Living With HIV

BACKGROUND

Although sustained access to health care is essential, little is known about the relationship between insurance coverage and health among people born to women living with HIV (WLHIV).

SETTING

Prospective cohort studies of youth and young adults born to WLHIV from 2007 to 2019.

METHODS

We used adjusted generalized estimating equation models to estimate mean differences in, and relative risks (RRs) of, health-related quality of life (HR-QoL) and HIV disease measures over time by insurance status. HR-QoL scales with limited variability were dichotomized. Modified Poisson models were used to estimate RRs.

RESULTS

Six hundred sixty-nine Adolescent Master Protocol (AMP) youth [66% living with perinatally-acquired HIV (PHIV), 72% Black] and 939 AMP Up/AMP Up Lite young adults (89% PHIV, 68% Black) reported insurance. Most were publicly insured (87% youth, 67% young adults). Privately insured young adults living with PHIV had lower risk of antiretroviral therapy nonadherence [adjusted RR (aRR): 0.82, 95% CI: 0.70 to 0.97] than those with public insurance. There was a lower risk of suboptimal role functioning for young adults with private insurance (aRR: 0.58, 95% CI: 0.35 to 0.97) and those unaware of their coverage (aRR: 0.41, 95% CI: 0.21 to 0.78). Young adults with private insurance had higher health perception scores than those with public insurance (adjusted mean difference: 3.87, 95% CI: 0.37 to 7.38). For youth, we observed no differences in HR-QOL and HIV disease measures by insurance.

CONCLUSION

These findings suggest meaningful differences in antiretroviral therapy adherence and some HR-QoL outcomes by health insurance coverage among young adults born to WLHIV.

Depression and HIV viral nonsuppression among people engaged in HIV care in an urban clinic, 2014-2019

OBJECTIVE

The aim of this study was to describe the risk of viral nonsuppression across the depression care cascade.

DESIGN

A clinical cohort study.

METHODS

We used depressive symptoms (PHQ-8 ≥ 10) self-reported on computer-assisted surveys, clinical diagnoses of depression in the medical record in the prior year and pharmacologic (any prescription for an antidepressant) and psychologic treatments for depression (attendance at at least two mental health visits in the prior year) to classify patients into groups: no history of depression; prior depression diagnosis; current indication for depression treatment (symptoms or clinical diagnosis); and treated depression (stratified by presence of persistent symptoms). We associated position in the depression care cascade with viral nonsuppression (>200 copies/ml) 7 days before to 6 months after the index self-report of depressive symptoms.

RESULTS

History of depression [adjusted risk difference (aRD) relative to no history = 5.9%, 95% confidence interval (95% CI): 1.5-10.3] and current depression (symptoms or diagnosis) in the absence of treatment (aRD relative to no current depression or depression treatment = 4.8%, 95% CI: 1.8-7.8) were associated with a higher risk of viral nonsuppression than no history of depression. Depression treatment mitigated this association (aRD = -0.4%, 95% CI: -2.5 to 1.7).

CONCLUSION

The relationship between depression care cascade and viral suppression is complex. Untreated depression and clinically unrecognized depressive symptoms were both related to viral nonsuppression. Treated depression was not associated with viral nonsuppression; however, a high proportion of treated patients still had depressive symptoms. Depression treatment should be titrated if patients' symptoms are not responsive and patients with a history of depression should be monitored for ART adherence.

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.

Association of Syndemic Unhealthy Alcohol Use, Smoking, and Depressive Symptoms on Incident Cardiovascular Disease among Veterans With and Without HIV-Infection

Unhealthy alcohol use, smoking, and depressive symptoms are risk factors for cardiovascular disease (CVD). Little is known about their co-occurrence - termed a syndemic, defined as the synergistic effect of two or more conditions-on CVD risk in people with HIV (PWH). We used data from 5621 CVD-free participants (51% PWH) in the Veteran's Aging Cohort Study-8, a prospective, observational study of veterans followed from 2002 to 2014 to assess the association between this syndemic and incident CVD by HIV status. Diagnostic codes identified cases of CVD (acute myocardial infarction, stroke, heart failure, peripheral artery disease, and coronary revascularization). Validated measures of alcohol use, smoking, and depressive symptoms were used. Baseline number of syndemic conditions was categorized (0, 1, ≥ 2 conditions). Multivariable Cox Proportional Hazards regressions estimated risk of the syndemic (≥ 2 conditions) on incident CVD by HIV-status. There were 1149 cases of incident CVD (52% PWH) during the follow-up (median 10.1 years). Of the total sample, 64% met our syndemic definition. The syndemic was associated with greater risk for incident CVD among PWH (Hazard Ratio [HR] 1.87 [1.47-2.38], p < 0.001) and HIV-negative veterans (HR 1.70 [1.35-2.13], p < 0.001), compared to HIV-negative with zero conditions. Among those with the syndemic, CVD risk was not statistically significantly higher among PWH vs. HIV-negative (HR 1.10 [0.89, 1.37], p = .38). Given the high prevalence of this syndemic combined with excess risk of CVD, these findings support linked-screening and treatment efforts.

African American/Black and Latino Adults with Detectable HIV Viral Load Evidence Substantial Risk for Polysubstance Substance Use and Co-occurring Problems: A Latent Class Analysis

Substance use problems are highly prevalent among persons living with (PLWH) in the United States and serve as serious barriers to engagement in HIV care. Yet, in contrast to studies of single substances, little is known about patterns of polysubstance use in this population. Moreover, other risk factors (e.g., financial hardship, incarceration, homelessness, and mental health distress) are also prevalent and complicate HIV management. The present study drew on a cross-sectional survey with African American/Black and Latino (AABL) adult PLWH from low socioeconomic status backgrounds in New York City who were insufficiently engaged in HIV care and evidenced detectable HIV viral load (N = 512). We used latent class analysis (LCA) to explore patterns of polysubstance use and their relationships to financial hardship, incarceration, homelessness, and mental health. LCA yielded three substance use classes: Class 1, a high polysubstance use/high-risk substance use class (9%); Class 2, a polysubstance use/moderate substance use risk class (18%); and Class 3, a moderate polysubstance use/moderate-to-low-risk substance use class (74%). Mental health symptoms were prevalent in all classes, but Class 1 had greater mental health distress than the other two classes. Current homelessness was more prevalent in Classes 1 and 2. We cannot end the HIV epidemic without engaging and treating AABL PLWH who have serious barriers to engagement along the HIV care continuum, and who evidence polysubstance use along with co-occurring risk factors. Clinical settings can develop outreach and engagement approaches to bring this subpopulation of PLWH into care settings, and further, specialized services are needed to successfully screen, treat, and retain them.

Health System-Based Unhealthy Alcohol Use Screening and Treatment Comparing Demographically Matched Participants With and Without HIV

BACKGROUND

Unhealthy alcohol use among persons living with HIV (PLWH) is linked to significant morbidity, and use of alcohol services may differ by HIV status. Our objective was to compare unhealthy alcohol use screening and treatment by HIV status in primary care.

METHODS

Cohort study of adult (≥18 years) PLWH and HIV-uninfected participants frequency matched 20:1 to PLWH by age, sex, and race/ethnicity who were enrolled in a large integrated healthcare system in the United States, with information ascertained from an electronic health record. Outcomes included unhealthy alcohol screening, prevalence, provider-delivered brief interventions, and addiction specialty care visits. Other predictors included age, sex, race/ethnicity, neighborhood deprivation index, depression, smoking, substance use disorders, Charlson comorbidity index, prior outpatient visits, insurance type, and medical facility. Cox proportional hazards models were used to compute hazard ratios (HR) for the outcomes of time to unhealthy alcohol use screening and time to first addiction specialty visit. Poisson regression with robust standard errors was used to compute prevalence ratios (PR) for other outcomes.

RESULTS

11,235 PLWH and 227,320 HIV-uninfected participants were included. By 4.5 years after baseline, most participants were screened for unhealthy alcohol use (85% of PLWH and 93% of HIV-uninfected), but with a lower rate among PLWH (adjusted HR 0.84, 95% CI 0.82 to 0.85). PLWH were less likely, compared with HIV-uninfected participants, to report unhealthy drinking among those screened (adjusted PR 0.74, 95% CI 0.69 to 0.79), and among those who screened positive, less likely to receive brief interventions (adjusted PR 0.82, 95% CI 0.75 to 0.90), but more likely (adjusted HR 1.7, 95% CI 1.2 to 2.4) to have an addiction specialty visit within 1 year.

CONCLUSIONS

Unhealthy alcohol use was lower in PLWH, but the treatment approach by HIV status differed. PLWH reporting unhealthy alcohol use received less brief interventions and more addiction specialty care than HIV-uninfected participants.

Depressive symptoms and substance use: Changes overtime among a cohort of HIV-positive and HIV-negative MSM

BACKGROUND

The objective of this study was to examine depressive symptoms overtime and quantify the variance in symptoms attributable to substance use among a cohort of HIV-positive and HIV-negative men.

METHODS

Participants were enrolled in an NIH/NIDA funded cohort, with 534 men resulting in 1,888 visits between August 2014 and June 2018. Participants were between 18 and 45 years, and half were HIV-positive. At baseline and semi-annual visits, information was collected on depressive symptoms, sexual behaviors, and substance use. Changes overtime in symptom scores were evaluated using individual growth curve modeling.

RESULTS

The average CES-D₂₀ score was 19.5 (SD = 12.7). Depressive symptoms were highest among daily/weekly methamphetamine users (56% vs. 39% occasional users and 27% non-users; p value<.01). Factors independently associated with depressive symptoms included methamphetamine use (adjusted OR = 1.5; 95% CI 1.1-2.3) and transactional sex (adjusted OR = 1.8; 95% CI 1.4-2.5). Based on growth curve modeling, methamphetamine was the most influential predictor of depressive symptoms, accounting for 10% of individual variance (p value<.01). Declines in depressive symptoms were noted for heavy users of a number of drugs, except for methamphetamine. For instance, those reporting daily/weekly heroin had a 3.38 point decline in CESD₂₀ scores overtime (p value = 0.01). However, heavy methamphetamine users had much higher CESD₂₀ scores and their scores remained high overtime (p value for change = 0.91).

CONCLUSIONS

The prevalence of depressive symptoms among this cohort of HIV-negative and HIV-positive MSM was high, especially among frequent methamphetamine users. These findings suggest that reducing methamphetamine use may have the potential to reduce depressive symptoms.

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

OBJECTIVE

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and drug treatment initiation and engagement among people living with the human immunodeficiency virus (HIV) and patients without an HIV diagnosis

Background:

Problematic use of alcohol and other drugs (AOD) is highly prevalent among people living with the human immunodeficiency virus (PLWH), and untreated AOD use disorders have particularly detrimental effects on human immunodeficiency virus (HIV) outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) measures of treatment initiation and engagement are important benchmarks for access to AOD use disorder treatment. To inform improved patient care, we compared HEDIS measures of AOD use disorder treatment initiation and engagement and health care utilization among PLWH and patients without an HIV diagnosis.

Methods:

Patients with a new AOD use disorder diagnosis documented between October 1, 2014, and August 15, 2015, were identified using electronic health records (EHR) and insurance claims data from 7 health care systems in the United States. Demographic characteristics, clinical diagnoses, and health care utilization data were also obtained. AOD use disorder treatment initiation and engagement rates were calculated using HEDIS measure criteria. Factors associated with treatment initiation and engagement were examined using multivariable logistic regression models.

Results:

There were 469 PLWH (93% male) and 86,096 patients without an HIV diagnosis (60% male) in the study cohort. AOD use disorder treatment initiation was similar in PLWH and patients without an HIV diagnosis (10% vs. 11%, respectively). Among those who initiated treatment, few engaged in treatment in both groups (9% PLWH vs. 12% patients without an HIV diagnosis). In multivariable analysis, HIV status was not significantly associated with either AOD use disorder treatment initiation or engagement.

Conclusions:

AOD use disorder treatment initiation and engagement rates were low in both PLWH and patients without an HIV diagnosis. Future studies need to focus on developing strategies to efficiently integrate AOD use disorder treatment with medical care for HIV.

Factors associated with hazardous alcohol use and motivation to reduce drinking among HIV primary care patients: Baseline findings from the Health & Motivation study

BACKGROUND

Limited primary care-based research has examined hazardous drinking risk factors and motivation to reduce use in persons with HIV (PWH).

METHODS

We computed prevalence ratios (PR) for factors associated with recent (<30 days) hazardous alcohol use (i.e., 4+/5+ drinks in a single day for women/men), elevated Alcohol Use Disorders Identification Test (AUDIT) scores, and importance and confidence (1-10 Likert scales) to reduce drinking among PWH in primary care.

RESULTS

Of 614 participants, 48% reported recent hazardous drinking and 12% reported high alcohol use severity (i.e., AUDIT zone 3 or higher). Factors associated with greater alcohol severity included moderate/severe anxiety (PR: 2.07; 95% CI: 1.18, 3.63), tobacco use (PR: 1.79; 1.11, 2.88), and other substance use (PR: 1.72; 1.04, 2.83). Factors associated with lower alcohol severity included age 50-59 years (PR: 0.46; 0.22, 2.00) compared with age 20-39 years, and having some college/college degree (PR: 0.61; 0.38, 0.97) compared with ≤high school. Factors associated with greater importance to reduce drinking (scores >5) included: moderate/severe depression (PR: 1.43; 1.03, 2.00) and other substance use (PR: 1.49; 1.11, 2.01). Lower importance was associated with incomes above $50,000 (PR: 0.65; 0.46, 0.91) and marijuana use (PR: 0.65; 0.49, 0.87). HIV-specific factors (e.g., CD4 and HIV RNA levels) were not associated with alcohol outcomes.

CONCLUSIONS

This study identified modifiable participant characteristics associated with alcohol outcomes in PWH, including anxiety and depression severity, tobacco use, and other substance use.

Outcomes Among Persons with HIV Following a Mental Health Admission: A Population-Based Study

To compare outcomes following psychiatric hospitalization between people with and without HIV. Population-based study of people with (n = 1,089) and without (n = 280,888) HIV who were hospitalized for psychiatric illness between January 1, 2006 and December 31, 2014. Overall, 9 (0.8%) people with HIV died within 30 days of discharge, compared with 3,710 (1.3%) HIV-negative individuals. Following multivariable adjustment, there was no difference in the risk of readmission or emergency department (ED) visits for psychiatric illness in the 90 days following discharge. Conversely, people with HIV were at higher risk of ED visits for substance use disorders and less likely to receive psychiatry follow-up during this period. HIV is associated with ED use for substance use disorders and less psychiatry follow-up within 90 days of hospital discharge for psychiatric illness. Interventions facilitating continuity of care following discharge are warranted.

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.

Impact of depression and recreational drug use on emergency department encounters and hospital admissions among people living with HIV in Ontario: A secondary analysis using the OHTN cohort study

Introduction

Nearly half of HIV-positive patients experience mental health and substance use problems, but many do not receive adequate or ongoing mental health or addiction care. This lack of ongoing care can result in the use of costly acute care services. Prospective evaluations of the relationship between psychiatric and substance use disorders and acute care services use are lacking, and this information is needed to understand unmet needs and improve access to appropriate services.

Methods

We conducted a secondary data analysis from a multicenter, longitudinal, prospective cohort study (n = 3,482 adults) between October 1, 2007 and March 31, 2013. We used explanatory extended Cox proportional hazard regression models to examine the impact of current depression and recreational drug use on acute care services use, and to explore whether current depression and recreational drug use were associated with potentially avoidable acute care services use.

Results

Over our 5.5 year study period, HIV-positive participants with current depression-only (aHR [95% CI]:1.2[1.1–1.4]), recreational drug use-only (1.3[1.1–1.6]), or co-occurring depression and recreational drug use (1.4[1.2–1.7]) were associated with elevated hazard of emergency department (ED) encounters compared to participants without these conditions. Over half of ED encounters were potentially avoidable. Participants with current depression-only (1.3[1.1–1.5];1.3[1.03–1.6]), recreational drug use-only (1.3[1.04–1.6];1.5[1.1–1.9]), or co-occurring depression and recreational drug use (1.3[1.04–1.7];1.4[1.06–1.9]) were associated with elevated hazard of low-acuity or repeated ED encounters respectively.

Conclusions

We found a significant increase in ED services use and potentially avoidable ED encounters (including low-acuity or repeated ED encounters), particularly among those with either current depression or recreational drug use. These findings emphasize the challenges in managing HIV and mental health/addiction co-morbidities in the current HIV care model. Future research should evaluate integrated and collaborative care programs for improving the coordination of care and effectively treat mental health and addiction problems among HIV-positive patients in Ontario.

Alcohol and substance use diagnoses among HIV-positive patients receiving care in NYC clinic settings

BACKGROUND

Substance use among HIV-positive persons exacerbates health problems. This study sought to estimate the prevalence of alcohol and drug-use diagnoses and examined hypothesized predictors associated with alcohol and drug-use diagnoses among HIV-positive patients in New York City (NYC).

METHODS

This cohort study reviewed electronic medical records (EMRs) of 4965 HIV-positive patients based on diagnostic codes. These patients attended a comprehensive care clinic in NYC in 2012. Multinomial logistic regression was used to predict the odds of classification into substance use diagnosis grouping.

RESULTS

Of the full sample, only 12.7% of patients had an alcohol use diagnosis documented in their EMR compared with more than one-quarter (26.4%) of patients having a recorded drug use diagnosis (p<0.001). Compared with the No Alcohol or Drugs group, the regression model showed that older age and having a recent inpatient hospital stay independently predicted being in the Alcohol Only group; years living with HIV, having an unsuppressed viral load, and having a recent inpatient hospital stay were associated with higher odds of being in the Drugs Only and Alcohol and Drugs groups; and being women and men who have sex with men (MSM) were associated with decreased odds of being in the Drugs Only and Alcohol and Drugs groups.

CONCLUSIONS

Substance use diagnosis was associated with viremia and low CD4 counts and hospital stays. This implies that providers should screen for substance use in HIV-positive patients with poor health. Further examination of the extent of such comorbidity is instrumental for intervention efforts.

Implementation and Operational Research: Affordable Care Act Implementation in a California Health Care System Leads to Growth in HIV-Positive Patient Enrollment and Changes in Patient Characteristics

OBJECTIVES

This study examined implementation of the Affordable Care Act (ACA) in relation to HIV-positive patient enrollment in an integrated health care system; as well as changes in new enrollee characteristics, benefit structure, and health care utilization after key ACA provisions went into effect in 2014.

METHODS

This mixed-methods study was set in Kaiser Permanente Northern California (KPNC). Qualitative interviews with 29 KPNC leaders explored planning for ACA implementation. Quantitative analyses compared newly enrolled HIV-positive patients in KPNC between January and December 2012 ("pre-ACA," N = 661) with newly enrolled HIV-positive patients between January and December 2014 ("post-ACA," N = 880) on demographics; medical, psychiatric, and substance use disorder diagnoses; HIV clinical indicators; and type of health care utilization.

RESULTS

Interviews found that ACA preparation focused on enrollment growth, staffing, competition among health plans, concern about cost sharing, and HIV pre-exposure prophylaxis (PrEP) services. Quantitative analyses found that post-ACA HIV-positive patient enrollment grew. New enrollees in 2014 were more likely than 2012 enrollees to be enrolled in high-deductible plans (P < 0.01) or through Medicaid (P < 0.01), and marginally more likely to have better HIV viral control (P < 0.10). They also were more likely to be diagnosed with asthma (P < 0.01) or substance use disorders (P < 0.05) and to have used primary care health services in the 6 months postenrollment (P < 0.05) than the pre-ACA cohort.

CONCLUSIONS

As anticipated by KPNC interviewees, ACA implementation was followed by HIV-positive patient enrollment growth and changing benefit structures and patient characteristics. Although HIV viral control improved, comorbid diagnosis findings reinforced the importance of coordinated health care.

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.

Mind the Gap: Gaps in Antidepressant Treatment, Treatment Adjustments, and Outcomes among Patients in Routine HIV Care in a Multisite U.S. Clinical Cohort

BACKGROUND

Depression affects 20-30% of HIV-infected patients and is associated with worse HIV outcomes. Although effective depression treatment is available, depression is largely untreated or undertreated in this population.

METHODS

We quantified gaps in antidepressant treatment, treatment adjustments, and outcomes among US patients in routine HIV care in the nationally distributed CNICS observational clinical cohort. This cohort combines detailed clinical data with regular, self-reported depressive severity assessments (Patient Health Questionnaire-9, PHQ-9). We considered whether participants with likely depression received antidepressants, whether participants on antidepressants with persistently high depressive symptoms received timely dose adjustments, and whether participants achieved depression remission. We considered a cross-sectional analysis (6,219 participants in care in 2011-2012) and a prospective analysis (2,936 participants newly initiating CNICS care when PHQ-9 screening was active).

RESULTS

The cross-sectional sample was 87% male, 53% Caucasian, 25% African American, and 18% Hispanic; the prospective sample was similar. In both samples, 39-44% had likely depression, with 44-60% of those receiving antidepressants. Of participants receiving antidepressants, 20-26% experienced persistently high depressive symptoms; only a small minority of those received antidepressant dose adjustments. Overall, 35-40% of participants on antidepressants achieved full depression remission. Remission among participants with persistently high depressive symptoms was rare regardless of dose adjustments.

CONCLUSIONS

In this large, diverse cohort of US patients engaged in routine HIV care, we observed large gaps in antidepressant treatment, timely dose adjustment to address persistently high depressive symptoms, and antidepressant treatment outcomes. These results highlight the importance of more effective pharmacologic depression treatment models for HIV-infected patients.

Prevalence, Recurrence, and Incidence of Current Depressive Symptoms among People Living with HIV in Ontario, Canada: Results from the Ontario HIV Treatment Network Cohort Study

Introduction

Current studies of depression among people living with HIV focus on describing its point prevalence. Given the fluctuating nature of depression and its profound impacts on clinical and quality-of-life outcomes, this study aimed to examine the prevalence, recurrence and incidence of current depressive symptoms and its underlying catalysts longitudinally and systematically among these individuals.

Methods

We conducted a prospective cohort study between October 1, 2007 and December 31, 2012 using longitudinal linked data sources. Current depressive symptoms was identified using the Centre for Epidemiologic Studies Depression Scale or the Kessler Psychological Distress Scale, first at baseline and again during follow-up interviews. Multivariable regressions were used to characterize the three outcomes.

Results

Of the 3,816 HIV-positive participants, the point prevalence of depressive symptoms was estimated at 28%. Of the 957 participants who were identified with depressive symptoms at baseline and who had at least two years of follow-up, 43% had a recurrent episode. The cumulative incidence among 1,745 previously depressive symptoms free participants (at or prior to baseline) was 14%. During the five-year follow-up, our multivariable models showed that participants with greater risk of recurrent cases were more likely to feel worried about their housing situation. Participants at risk of developing incident cases were also likely to be younger, gay or bisexual, and unable to afford housing-related expenses.

Conclusions

Depressive symptoms are prevalent and likely to recur among people living with HIV. Our results support the direction of Ontario’s HIV/AIDS Strategy to 2026, which addresses medical concerns associated with HIV (such as depression) and the social drivers of health in order to enhance the overall well-being of people living with or at risk of HIV. Our findings reinforce the importance of providing effective mental health care and demonstrate the need for long-term support and routine management of depression, particularly for individuals at high risk.

Harder-to-reach people living with HIV experiencing high prevalence of all-type mental health disorder diagnosis

People living with HIV/AIDS (PHA) often concurrently cope with mental health disorders that may greatly influence HIV and other health-related outcomes. The objective of this study was to examine the prevalence and correlates of self-reported mental health disorder diagnosis among a cohort of harder-to-reach HIV-positive individuals in British Columbia, Canada. Between 2007 and 2010, 1000 PHA who had initiated ART were enrolled in the Longitudinal Investigation into Supportive and Ancillary health services (LISA) study. Socio-demographic, behavioral, health-care utilization and psychosocial information was collected through interviewer-led questionnaires and linked to longitudinal clinical variables through the provincial Drug Treatment Program at the BC Centre for Excellence in HIV/AIDS. We identified the prevalence of all-type and specific mental health disorders among this population. Of the 916 participants included in this analysis, 494 (54%) reported ever having a mental health disorder diagnosis. Mood (85%) and anxiety (65%) disorders were the two most frequently reported mental health conditions. Self-reported all-type mental health disorder was independently associated with decreased overall functioning (adjusted odds ratio [AOR] = 0.90, 95% confidence interval [CI] = 0.83-0.98) and life satisfaction (AOR = 0.81, 95% CI = 0.74-0.89), and having higher stigma score (AOR = 1.11, 95%CI = 1.02-1.21). Participants reporting any mental health disorder were more likely to report a history of sexual assault (AOR = 2.45, 95% CI = 1.75-3.43) and to have used case management services (AOR = 1.63, 95%CI = 1.17-2.27). Our findings uncovered a high burden of mental health disorders among harder-to-reach PHA and suggest that PHA with at least one mental health disorder diagnosis are disproportionately impacted by sexual violence and stigma.

Adequacy of Mental Health Services for HIV-Positive Patients with Depression: Ontario HIV Treatment Network Cohort Study

Background

Major depression can profoundly impact clinical and quality-of-life outcomes of people living with HIV, and this disease is underdiagnosed and undertreated in many HIV-positive individuals. Here, we describe the prevalence of publicly funded primary and secondary mental health service use and antidepressant use, as well as mental health care for depression in accordance with existing Canadian guidelines for HIV-positive patients with depression in Ontario, Canada.

Methods

We conducted a prospective cohort study linking data from the Ontario HIV Treatment Network Cohort Study with administrative health databases in the province of Ontario, Canada. Current depression was assessed using the Center for Epidemiologic Depression Scale or the Kessler Psychological Distress Scale. Multivariable regressions were used to characterize prevalence outcomes.

Results

Of 990 HIV-positive patients with depression, 493 (50%) patients used mental health services; 182 (18%) used primary services (general practitioners); 176 (18%) used secondary services (psychiatrists); and 135 (14%) used both. Antidepressants were used by 407 (39%) patients. Patients who identified as gay, lesbian, or bisexual, as having low income or educational attainment, or as non-native English speakers or immigrants to Canada were less likely to obtain care. Of 493 patients using mental health services, 250 (51%) received mental health care for depression in accordance with existing Canadian guidelines.

Conclusions

Our results showed gaps in delivering publicly funded mental health services to depressed HIV-positive patients and identified unequal access to these services, particularly among vulnerable groups. More effective mental health policies and better access to mental health services are required to address HIV-positive patient needs and reduce depression’s impact on their lives.

A Spanish Study on Psychological Predictors of Quality of Life in People with HIV

In Spain little research has focused on assessment of health indicators, both physical and psychological, in people living with HIV. The aim of this study is to evaluate a set of different indicators that allow us to identify psychological factors that may be influencing the quality of life of these people. The sample consist of 744 people infected with HIV aged between from 18 to 82 years (M = 43.04; SD = 9.43). Results show that factors such as self-esteem and leading a healthy lifestyle act as protectors in both, physical and mental health. On the other hand, financial problems, body disfigurement, and depressive mood could have harmful effects on both, physical and mental health. The structural model reveals depressed mood as the factor with greatest influence upon mental health, which in turn can be largely explained by factors such as the stress generated by HIV and personal autonomy. This work has allowed us to identify the vulnerability and protective factors that play a significant role in the physical and mental HRQOL of persons with HIV, providing guidelines for design and implementation of psychological intervention programs aimed to improve HRQOL in this population.

Heterogeneity of Mental Health Service Utilization and High Mental Health Service Use Among Women Eight Years After Initiating Substance Use Disorder Treatment

OBJECTIVE

The aim of this study was to determine mental health service utilization patterns among women treated for substance use disorders (SUD) and identify factors associated with patterns of high mental health service use.

METHODS

Data were provided by 4447 women treated for SUD in California during 2000-2002 for whom mental health services utilization records were acquired. A latent class model was fitted to women's high use of services (>6 services/year over 8 years). Multinomial logistic regression was used to identify predisposing, enabling, and need factors associated with utilization patterns.

RESULTS

In 8 years after initiating SUD treatment, 50% of women utilized mental health services. High use probability was consistently low for most women (76.9%); for others, however, it decreased immediately following SUD treatment and then increased over time (8.7%), increased immediately following SUD treatment and then decreased (9.3%), or remained consistently high (5.1%). Consistently high services use was negatively associated with marriage (OR 0.60, p<0.05) and employment (OR 0.53, p<0.05) and positively associated with older age (OR 1.04, p<0.001), homelessness (OR 1.68, p<0.05), public assistance (OR 1.76, p<0.01), outpatient SUD treatment (OR 3.69, p<0.01), longer SUD treatment retention (OR 1.00, p<0.01), treatment desire (ORs 1.46, p<0.001), and co-occurring disorder diagnosis (ORs 2.89-44.93, p<0.001). Up to 29% of women with co-occurring mental health disorders at SUD treatment entry did not receive any mental health treatment in the subsequent 8 years.

CONCLUSIONS

Mental health services utilization patterns among women treated for SUD are heterogeneous and dynamic. Understanding factors related to women's utilization patterns may aid efforts to optimize care and ensure appropriate use of mental health services.

Undertreatment of human immunodeficiency virus in psychiatric inpatients: a cross-sectional study of seroprevalence and associated factors

BACKGROUND

The aims of this study were to evaluate the prevalence of HIV and its associated demographic and clinical factors among psychiatric inpatients of a general hospital.

METHODS

This was a single-center, observational, cross-sectional study that included patients consecutively admitted to our unit aged 16 years or older and with no relevant cognitive problems. The patients were evaluated using a semistructured interview and an appropriate test for HIV infection.

RESULTS

Of the 637 patients who were screened, 546 (86%) who consented to participate were included in the analyses. Twenty-five (4.6%, 95% confidence interval [CI] 3.0-6.8) patients were HIV-positive. The prevalence was higher among patients with substance misuse (17.4%, 95% CI 9.7-28.8). All except one of the 25 patients knew of their seropositive condition prior to participation in the study. Only 14 (56%) of the 25 seropositive patients had previously received pharmacological treatment for their infection. According to the multiple logistic regression analysis, the likelihood of HIV infection was lower in patients with higher levels of education and higher among patients who were single, had history of intravenous drug use, and had an HIV-positive partner, particularly if they did not use condoms. Among the patients with HIV infection, 18 (72%) had a history of suicide attempts compared with 181 (34.7%) of the patients without HIV infection (relative risk 2.1, 95% CI 1.6-2.7; P<0.001).

CONCLUSION

HIV infection is highly prevalent in patients admitted to a psychiatric unit, especially those with a diagnosis of substance misuse. Seropositive patients show very poor treatment adherence. The risk of suicide seems to be very high in this population. Implementing interventions to reduce the suicide risk and improve adherence to antiretroviral therapy and psychotropic medications seems crucial.

Implementing Behavioral Activation and Life-Steps for Depression and HIV Medication Adherence in a Community Health Center

Antiretroviral therapy to treat HIV/AIDS has substantially improved clinical outcomes among patients living with HIV/AIDS, but only in the presence of very consistent adherence. One of the most prevalent and impactful individual-level predictors of poor adherence is depressive symptoms, even at subthreshold levels. Evidence-based cognitive behavioral interventions exist to address improvements in depressive symptoms and adherence in this population, yet these techniques have largely been designed and tested as individual treatments for delivery in mental health settings. This presents a significant challenge when transporting these techniques to medical settings where other formats for delivery may be more appropriate (i.e., groups, less frequent visits) and few hands-on resources exist to guide this process. As such, primary aims of this study were to adapt and implement evidence-based cognitive behavioral techniques for depression (behavioral activation; BA) and HIV medication adherence (Life-Steps) that have potential for dissemination in an outpatient community health center. The intervention incorporated feedback from health center staff and utilized a modular, group format that did not rely on sequential session attendance. Feasibility was examined over 8 weeks (n = 13). Preliminary effects on depression, health-related quality of life, and medication adherence were examined and exit interviews were conducted with a subset of participants (n = 4) to inform future modifications. Treatment descriptions and recommendations for effective clinical implementation based on patient and clinician feedback are provided along with case material of two individual patients and an example group session. Current efforts are an important next step for disseminating evidence-based techniques for depression and HIV medication adherence to community health center or AIDS service organization settings.

Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis

OBJECTIVE

The aim of this study was to systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic evidence search protocol was applied to 7 bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on the data collected from HIV-positive adults in any African member state of the United Nations. A random-effects meta-analysis was used to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.

RESULTS

Of 1117 records initially identified, I included 13 studies of 5373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach alpha ranged from 0.63 to 0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% [95% confidence interval (CI): 20.5 to 39.4], whereas the pooled prevalence of major depressive disorder was 13.9% (95% CI: 9.7 to 18.6). The Center for Epidemiologic Studies Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI: 0.73 to 0.87) for detecting major depressive disorder.

CONCLUSIONS

Depression-screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.

Improvements in depression and changes in quality of life among HIV-infected adults

Improving quality of life (QOL) for HIV-infected individuals is an important objective of HIV care, given the considerable physical and emotional burden associated with living with HIV. Although worse QOL has been associated with depression, no research has quantified the potential of improvement in depression to prospectively improve QOL among HIV-infected adults. We analyzed data from 115 HIV-infected adults with depression enrolled in a randomized controlled trial to evaluate the effectiveness of improved depression care on antiretroviral drug adherence. Improvement in depression, the exposure of interest, was defined as the relative change in depression at six months compared to baseline and categorized as full response (≥50% improvement), partial response (25-49% improvement), and no response (<25% improvement). Multivariable linear regression was used to investigate the relationship between improvement in depression and four continuous measures of QOL at six months: physical QOL, mental QOL, HIV symptoms, and fatigue intensity. In multivariable analyses, physical QOL was higher among partial responders (mean difference [MD] = 2.51, 95% CI: -1.51, 6.54) and full responders (MD = 3.68, 95% CI: -0.36, 7.72) compared to individuals who did not respond. Mental QOL was an average of 4.01 points higher (95% CI: -1.01, 9.03) among partial responders and 14.34 points higher (95% CI: 9.42, 19.25) among full responders. HIV symptoms were lower for partial responders (MD = -0.69; 95% CI: -1.69, 0.30) and full responders (MD = -1.51; 95% CI: -2.50, -0.53). Fatigue intensity was also lower for partial responders (MD = -0.94; 95% CI: -1.94, 0.07) and full responders (MD = -3.00; 95% CI: -3.98, -2.02). Among HIV-infected adults with depression, improving access to high-quality depression treatment may also improve important QOL outcomes.

Documentation of psychiatric disorders and related factors in a large sample population of HIV-positive patients in California

This retrospective cohort study examined electronic medical records of HIV-positive patients in California (N = 7,834) to find the prevalence of any psychiatric condition and the associations between several factors and the likelihood of these disorders. Approximately 53 % of the patients in this study had a documented psychiatric condition, including 23 % who had a mood disorder, 19 % who had a substance-related disorder, and 16 % who had an anxiety disorder. After controlling for potential confounders, significant positive associations (p < 0.001) were found between female gender and the presence of any mood disorder (adjusted odds ratio [95 % confidence interval, 95 %CI] = 1.58 [1.26-1.99]) or anxiety disorder (AOR = 1.54 [1.18-2.02]) and between homosexual orientation and the presence of any psychiatric condition (AOR = 1.33 [1.15-1.55]), mood disorder (AOR = 1.71 [1.42-2.07]), or anxiety disorder (AOR = 1.41 [1.22-1.88]). There were also significant negative associations between African-American race and the presence of any psychiatric condition (AOR = 0.68 [0.60-0.77]), mood disorder (AOR = 0.74 [0.64-0.86]), anxiety disorder (AOR = 0.43 [0.36-0.52]), or substance-related disorder (AOR = 0.78 [0.67-0.91]) and between state/federal insurance and the presence of any psychiatric condition (AOR = 0.70 [0.62-0.79]), mood disorder (AOR = 0.71 [0.62-0.80]), or anxiety disorder (AOR = 0.77 [0.66-0.89]).

Factors associated with treatment initiation for psychiatric and substance use disorders among persons with HIV

OBJECTIVE

Prior studies of individuals with HIV infection have found that accessing psychiatric and substance abuse treatment when needed can improve health and prolong life, yet little is known about factors associated with treatment initiation.

METHODS

In a retrospective cohort design including individuals with HIV infection (≥14 years old) in an integrated health care system in Northern California, this study included 822 patients with a major psychiatric diagnosis and 1,624 with a substance use disorder diagnosis. Data were extracted from a regional HIV registry and computerized databases.

RESULTS

Twenty-four percent (N=198) of study patients with psychiatric diagnoses and 15% (N=245) with substance abuse or dependence received one or more specialty care visits within 12 months of diagnosis. Among patients with a psychiatric diagnosis, significant predictors of visiting a psychiatry clinic included not having an AIDS diagnosis at baseline or before the study (p=.049), having a diagnosis of major depression (p=.013), having a diagnosis of bipolar disorder (p<.001), and receiving a psychiatric diagnosis in 1996 versus later years of the study (p<.01). Among patients with a substance use disorder, significant predictors of initiating substance abuse treatment included age <30 (p=.015) and being in the HIV transmission risk group of injection drug use (p<.001).

CONCLUSIONS

Clinical, diagnostic, and demographic factors were associated with specialty care treatment initiation in this sample of individuals with HIV infection and substance use or psychiatric disorders. Developing strategies to enhance treatment initiation has the potential to improve outcomes for individuals with HIV infection.

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

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

Invited commentary: Prevailing over acquired immune deficiency syndrome and depressive symptoms

The causal and noncausal associations that account for linkages between depressive symptoms and human immunodeficiency virus (HIV)/acquired immune deficiency syndrome are complex and not completely understood. Depression is a common mental health condition that affects approximately 20%-30% of persons receiving HIV medical care. Those suffering from depressive symptoms may be more apt to abuse alcohol or other substances and to have difficulties with adherence to treatment regimens over long periods of time. Persons living with HIV who are effectively treated for their depression are more likely to adhere to antiretroviral therapy over time and to enjoy better health and improved quality of life. The article by Wada et al. in this issue of the Journal (Am J Epidemiol. 2013;177(2):116-125) provides an important look at the long-term survival experiences of men and women who participated in 2 major epidemiologic studies of HIV and acquired immune deficiency syndrome. Long-term follow-up studies such as that by Wada et al. highlight not only the mortality experience of vulnerable groups of people but also their profound resiliency and ability to prevail over personal challenges, such as poverty and unemployment, and health conditions, such as HIV and depression.

In-home mental health treatment for individuals with HIV

Mental health problems are highly prevalent among individuals with HIV and are consistently associated with negative health outcomes. However, mental illness often remains untreated due to significant psychosocial and physical barriers to treatment participation. The Collaborative HIV/AIDS Mental Health Program (CHAMP) assessed the outcomes associated with providing 9 months of in-home mental health counseling for 40 individuals with HIV and a Major Axis I mental disorder. The evidence-based Illness Management and Recovery Model was adapted for use with HIV-positive individuals for the study using a community-based participatory research approach. Study participants were surveyed at baseline, 5 and 9 months to assess for changes in health outcomes. Thirty-five percent of study participants were female, 80% African American, 33% self-identified as MSM and the average participant age was 43. Forty percent of participants were on psychotropic medication at baseline. Participants had an average of 8 counseling visits (median 9). Statistically significant decreases in the global Brief Symptom Inventory (BSI) score and a number of BSI symptoms dimensions including anxiety, depression, obsessive compulsive, phobic anxiety and hostility were detected, indicating a reduction of psychiatric symptoms. Statistically significant improvement was also identified for the SF-12 mental health scale, adaptive coping, overall social support and emotional support. No differences in psychiatric outcomes were identified by gender, race/ethnicity, or sexual preference. Findings from the CHAMP Study suggest that the use of in-home mental health treatment may be beneficial in engaging and treating HIV-positive individuals with comorbid mental health disorders.

Social support networks and primary care use by HIV-infected drug users

HIV-infected current and former drug users utilize primary care and preventive health services at suboptimal rates, but little is known about how social support networks are associated with health services use. We investigated the relationship between social support networks and the use of specific types of health services by HIV-infected drug users receiving methadone maintenance. We found that persons with greater social support, in particular more social network members or more network members aware of their HIV status, were more likely to use primary care services. In contrast, social support networks were not related to emergency room or inpatient hospital use. Interventions that build social support might improve coordinated and continuous health services utilization by HIV-infected persons in outpatient drug treatment.

Determinants of nonmedical use, abuse or dependence on prescription drugs, and use of substance abuse treatment

BACKGROUND

Previous studies have found a negative association between health insurance and nonmedical use of prescription drugs (NMUPD), and abuse or dependence on prescription drugs (ADPD); and mixed associations between health insurance and use of substance abuse treatment (SAT). However, effect of health insurance in the specific subgroups of population is largely unknown.

OBJECTIVE

To estimate the relationship between health insurance and (1) NMUPD, (2) ADPD, and (3) use of SAT services among 12-64 years old, noninstitutionalized individuals and to see if these relationships are different in different subgroups of population.

METHODS

This study used cross-sectional survey data from 2007 National Survey on Drug Use and Health. Bivariate and multiple logistic regression analyses were conducted.

RESULTS

In 2007, self-reported prevalence of NMUPD was approximately 10% (N=15,509,703). In multivariate analysis, NMUPD was negatively associated with health insurance, age, race other than non-Hispanic White, education, marital status, and income ($40,000-$74,999). Past year use of tobacco and alcohol were positively associated with NMUPD. Among those with private health insurance, Hispanics and individuals with family income less than $20,000 and $40,000-$74,999 were more likely prone to NMUPD than others. High school graduates with public health insurance were less likely prone to NMUPD. Approximately, 13% of nonmedical users reported ADPD (N=2,011,229). Health insurance and age were negatively associated with ADPD. However, people who were unmarried, reported fair/poor health, and used tobacco were more likely to report ADPD. Lastly, the use of substance abuse treatment programs was approximately 73% and 76% between NMUPD and ADPD population, respectively. Health insurance was not associated with use of substance abuse treatment. Individuals with high school education were 2.6 times more likely to use substance abuse treatment than the college graduates. Additionally, no significant interaction effects were found between health insurance, and sociodemographic factors on ADPD and the use of substance abuse treatment.

CONCLUSIONS

Health insurance had a differential impact on NMUPD only. Among privately insured, Hispanics and individuals reporting family income less than $20,000 were more likely to engage in NMUPD. There is a need to better understand and monitor the use of prescription drugs among these groups. This knowledge can help in developing public health programs and policies that discourage NMUPD among these individuals.

Antidepressant treatment and adherence to antiretroviral medications among privately insured persons with HIV/AIDS

In order to examine relationships between depression treatments (antidepressant and/or psychotherapy utilization) and adherence to antiretroviral therapy (ART), we conducted a retrospective analysis of medical and pharmacy insurance claims for privately insured persons living with HIV/AIDS (PLWHA) diagnosed with depression (n = 1,150). Participants were enrolled in 80 insurance plans from all 50 states. Adherence was suboptimal. Depression treatment initiators were significantly more likely to be adherent to ART than the untreated. We did not observe an association between psychotherapy utilization and ART adherence, yet given the limitations of the data (e.g., there is no information on types of psychological treatment and its targets), the lack of association should not be interpreted as lack of efficacy.

Malaise, motivation and motherhood: predictors of engagement in behavioral interventions from a randomized controlled trial for HIV+ women in drug abuse recovery

Drug abuse has serious consequences for the wellbeing of persons with HIV/AIDS but suboptimal rates of client engagement limit the efficacy of interventions. The present study examines and compares client characteristics that predicted engagement (defined as attendance at two or more sessions) in a family intervention (SET) and a group intervention within a randomized trial aimed at preventing relapse and improving medication adherence for 126 predominantly African American HIV+ women in drug abuse recovery. Intervention engagement (60% overall) was not significantly different across the two interventions. Fewer physical and mental symptoms (malaise) (P < 0.05), living independently (P < 0.05), living with children (P < 0.05), and readiness to change (P < 0.05) were associated with engagement across the two interventions. Results from this study can be used to inform outreach and engagement approaches for women dually affected by drug abuse and HIV/AIDS.

HIV, alcohol dependence, and the criminal justice system: a review and call for evidence-based treatment for released prisoners

BACKGROUND

People with both HIV and alcohol use disorders (AUDs) are disproportionately concentrated within the U.S. criminal justice system; approximately one-quarter of all people with HIV cycle through the system each year. HIV-infected prisoners with AUDs face many obstacles as they transition back to the community. Specifically, although they have impressive HIV treatment outcomes during the period of incarceration while they are free from alcohol; upon [corrected] release, however, they face inordinate challenges including relapse to alcohol use resulting in significant morbidity and mortality.

OBJECTIVE

To review the existing literature regarding the relationship of HIV and treatment for AUDs within the criminal justice system in an effort to determine "best practices" that might effectively result in improved treatment of HIV and AUDs for released prisoners.

METHODS

PubMed, PsychInfo and Medline were queried for articles published in English from 1990 to 2009. Selected references from primary articles were also examined.

RESULTS

Randomized controlled trials affirm the role of pharmacotherapy using naltrexone (NTX) as the therapeutic option conferring the best treatment outcome for AUDs in community settings. Absent from these trials were inclusion of released prisoners or HIV-infected individuals. Relapse to alcohol abuse among HIV-infected prisoners is associated with reduced retention in care, poor adherence to antiretroviral therapy with consequential poor HIV treatment outcomes and higher levels of HIV risk behaviors.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Untreated alcohol dependence, particularly for released HIV-infected prisoners, has negative consequences both for the individual and society and requires a concentrated effort and rethinking of our existing approaches for this vulnerable population.

A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization

BACKGROUND

Alcohol use disorders (AUDs) are highly prevalent and associated with non-adherence to antiretroviral therapy, decreased health care utilization and poor HIV treatment outcomes among HIV-infected individuals.

OBJECTIVES

To systematically review studies assessing the impact of AUDs on: (1) medication adherence, (2) health care utilization and (3) biological treatment outcomes among people living with HIV/AIDS (PLWHA).

DATA SOURCES

Six electronic databases and Google Scholar were queried for articles published in English, French and Spanish from 1988 to 2010. Selected references from primary articles were also examined.

REVIEW METHODS

Selection criteria included: (1) AUD and adherence (N=20); (2) AUD and health services utilization (N=11); or (3) AUD with CD4 count or HIV-1 RNA treatment outcomes (N=10). Reviews, animal studies, non-peer reviewed documents and ongoing studies with unpublished data were excluded. Studies that did not differentiate HIV+ from HIV- status and those that did not distinguish between drug and alcohol use were also excluded. Data were extracted, appraised and summarized.

DATA SYNTHESIS AND CONCLUSIONS

Our findings consistently support an association between AUDs and decreased adherence to antiretroviral therapy and poor HIV treatment outcomes among HIV-infected individuals. Their effect on health care utilization, however, was variable.

A cross-site, comparative effectiveness study of an integrated HIV and substance use treatment program

Co-occurrence of HIV and substance abuse is associated with poor outcomes for HIV-related health and substance use. Integration of substance use and medical care holds promise for HIV patients, yet few integrated treatment models have been reported. Most of the reported models lack data on treatment outcomes in diverse settings. This study examined the substance use outcomes of an integrated treatment model for patients with both HIV and substance use at three different clinics. Sites differed by type and degree of integration, with one integrated academic medical center, one co-located academic medical center, and one co-located community health center. Participants (n=286) received integrated substance use and HIV treatment for 12 months and were interviewed at 6-month intervals. We used linear generalized estimating equation regression analysis to examine changes in Addiction Severity Index (ASI) alcohol and drug severity scores. To test whether our treatment was differentially effective across sites, we compared a full model including site by time point interaction terms to a reduced model including only site fixed effects. Alcohol severity scores decreased significantly at 6 and 12 months. Drug severity scores decreased significantly at 12 months. Once baseline severity variation was incorporated into the model, there was no evidence of variation in alcohol or drug score changes by site. Substance use outcomes did not differ by age, gender, income, or race. This integrated treatment model offers an option for treating diverse patients with HIV and substance use in a variety of clinic settings. Studies with control groups are needed to confirm these findings.

Management of HIV infection in patients with substance use problems

Although highly active antiretroviral therapy (HAART) has greatly reduced overall morbidity and mortality in patients with HIV, patients with substance use issues have been less likely than other patients with HIV to realize these benefits. Social obstacles (eg, lack of housing, minimal social support), and medical comorbidities (eg, mental illness, hepatitis), complicate the management of this group of patients. Not only are drug and alcohol users less likely to access medical care, initiation of HAART may be delayed due to concerns for adherence and the potential development of drug resistance. Ultimately, a multidisciplinary comprehensive approach is needed to both engage and retain this population in care. Through the integration of case management, addiction therapy, and medical treatment of HIV, we may be able to improve outcomes for patients with HIV and addiction.

Costs of care for people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders

To determine healthcare access and costs for triply diagnosed adults, we examined baseline data from the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site cohort study of HIV+ adults with co-occurring mental and substance abuse disorders conducted between 2000 and 2004. Baseline interviews were conducted with 1138 triply diagnosed adults in eight predominantly urban sites nationwide. A modified version of Structured Interview for DSM-IV Axis I Disorders (SCID) was used to assign Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses for the preceding year. Utilization of a broad range of inpatient and outpatient services and medications over the preceding three months was patient-reported in face-to-face interviews. We then applied nationally representative unit costs to impute average monthly expenditures. We measured (poor) access to care during the three-month period by whether the patient had: (a) no outpatient medical visits; (b) at least one emergency room visit without an associated hospitalization; and (c) at least one hospitalization. At baseline, mean expenditures were $3880 per patient per month. This is nearly twice as high as expenditures for HIV/AIDS patients in general. Inpatient care (36%), medications (33%), and outpatient services (31%) each accounted for roughly one-third of expenditures. Expenditures varied by a factor of 2:1 among subgroups of patients, with those on Medicare or Medicaid, not in stable residences, or with poor physical health or high viral loads exhibiting the highest costs. Access to care was worse for women and those with low incomes, unstable residences, same-sex exposure, poor physical or mental health, and high viral loads. We conclude that HIV triply diagnosed adults account for roughly one-fifth of medical spending on HIV patients and that there are large variations in utilization/costs across patient subgroups. Realized access is good for many triply diagnosed patients, but remains suboptimal overall. Deficiencies in HIV care are unevenly distributed, tending to concentrate on already disadvantaged populations.

Race, outpatient mental health service use, and survival after an AIDS diagnosis in the highly active antiretroviral therapy era

We examined the relationships between survival after AIDS diagnosis and outpatient mental health service use among men with history of highly active antiretroviral therapy (HAART). Analysis involved 1913 black and 1684 white men with AIDS who received HIV care in 2003 in the Veterans Affairs health care system. Negative binomial regression was used to assess the association between service use and length of AIDS diagnosis. Patients with longer survival after AIDS had higher rates of outpatient visits for stress and adjustment disorders as well as for mood, anxiety, and sexual disorders. Blacks had more visits for stress and adjustment disorders (7.4 versus 5.1; p < 0.05). Multiple regression analysis showed that prolonged survival after AIDS (incident rate ratios [IRR] = 1.87; 95% confidence interval [CI] = 1.25-2.77), having CD4 cell count less than 200 cells/mm(3) (IRR = 1.91; 95% CI = 1.19-3.04), and mortality (IRR = 3.84; 95% CI = 1.29-11.43) were associated with greater number of visits for mood, anxiety, and sexual disorders. Injection drug users (IRR = 3.52; 95% CI = 1.94-6.38), men who have sex with men (IRR = 2.87; 95% CI = 1.62-5.06), and patients with AIDS-defining illness (IRR = 2.48; 95% CI = 1.47-4.17) had greater rates of visits for stress and adjustment disorders. Survival after AIDS is associated with mental health service use. As more HIV-infected persons survive longer, adequate risk assessment of mental health concerns that considers race and HIV risk factors should be undertaken to effectively address the impact of mental health on treatment outcomes and mortality.

Use of outpatient mental health services and psychotropic medications among HIV-infected patients in a multisite, multistate study

OBJECTIVE

Although co-occurring psychiatric disorders are highly prevalent among those with HIV, little is known about the use of outpatient mental health services (MHS) and psychotropic medication in the highly active antiretroviral therapy (HAART) era.

METHODS

During 2003, 951 patients were interviewed at 14 sites in the HIV Research Network. Patients were questioned about use of MHS and psychotropic medications. Logistic regression was used to identify socio-demographic and clinical factors associated with MHS and psychotropic medication utilization.

RESULTS

The sample characteristics were as follows: 68% male, 52% black, 14% Hispanic, median age 46 years (range 20-85), 69% were on HAART. Approximately 34% reported at least one MHS within 6 months and 37% reported use of psychotropic medication for a mental health condition. In multivariate logistic regression, MHS was greater among disabled patients [adjusted odds ratio 2.39 (95% CI 1.53-3.72)], current [2.26 (1.53-3.35)] and former drug users [1.84 (1.24-2.73)], and those with more than seven primary care visits in the past 6 months. Blacks [0.61 (0.41-0.92)] were significantly less likely to use MHS compared to whites. Similarly, usage of psychotropic medications was greater among disabled patients [1.79 (1.14-2.82)], women [1.66 (1.13-2.43)], )] and those with more than seven primary care visits. Blacks [0.37 (0.24-0.58])] and Hispanics [0.39 (0.22-0.72)] were less likely to use a psychotropic medication. HAART utilization was not associated with MHS or psychiatric medication use.

CONCLUSIONS

In the HAART era, self-reported rates of mental health service and psychotropic medication utilization are high. Blacks continue to report lower use of MHS and psychotropic medication compared to whites.