Incident depression symptoms are associated with poorer HAART adherence: a longitudinal analysis from the Nutrition for Healthy Living study

Association of ART regimen and adherence to viral suppression: an observational study of a clinical population of people with HIV

Adherence to antiretroviral therapy (ART) is essential for the effective management of HIV, which includes keeping the HIV viral load undetectable. This study aimed to determine whether certain ART medications are more "forgiving" of poor adherence in achieving viral suppression. We identified subgroups of ART medication usage and determined the extent to which ART adherence is associated with viral suppression across those subgroups. Data came from claims and clinical records (2017-2019) of 3,552 HIV-positive adult members of a Medicaid managed care plan. Pharmacy fill data were examined to characterize ART medications using latent class analysis (LCA), which captures the complexity of real-world ART usage (i.e., multiple medications, ART switching). LCA yielded five ART medication patterns over three years, mostly characterized by recent medications and formulations of ART, though they varied in number of tablets and in medication class. Mixed effects logistic regression models were estimated to determine whether odds of viral suppression differed by ART adherence level. After adjusting for covariates, those with at least 90% adherence (i.e., 90 to < 95%) did not significantly differ from those with 95% adherence or greater in terms of viral suppression, which corroborates existing clinical recommendations. These findings can inform provider-patient communication for people with HIV, especially those who have difficulty maintaining adherence. This includes those experiencing unstable housing, mental health conditions, or substance use.

Systematic review and meta-analysis on the effect of depression on ART adherence among women living with HIV

BACKGROUND

Depression is a very common psychiatric disorder in worldwide. Globally, Human Immunodeficiency Virus (HIV) is highly prevalent among women, and are disproportionately affected by depression. Antiretroviral Therapy (ART) adherence which could highly be affected by depression is yet to be explored effectively. Depression affects overall poor HIV clinical outcomes, socioeconomic and social interactions. However, it is not well understood specifically how depression affects ART adherence in women living with HIV (WLWHIV). Investigating the effects of depression on ART adherence is critical in order to develop nuanced new evidence to address non-adherence in WLWHIV.

OBJECTIVE

To conduct a meta-analysis on the correlation between depression and adherence to antiretroviral therapy among women living with HIV in the globe.

METHOD

Using population, exposed and outcome approach, we searched Scopus, PubMed, EMBASE, Cochrane Library, Psych info, Web of science and google scholar for cohort and cross-sectional studies globally. The search strategy was structured comprising terms associated with antiretroviral therapy and adherence, women living with HIV and depression. We evaluated the paper quality, using the Newcastle-Ottawa Scales (NOS). The fixed effect model was used to analysis the effect of depression on ART adherence.

RESULT

A total of 8 articles comprise 6474 participants were included in this study. There were controversial findings related to the effect of depression to ART adherence. Among three cross-sectional study, one article demonstrating, depression was associated with ART adherence. Of the five cohort studies, four cohort studies reported association. The overall pooled estimated effect of depression on ART adherence was 1.02 [RR = 1.015 with 95% CI (1.004, 1.026)] with a p-value of 0.005.

CONCLUSION AND RECOMMENDATION

Depression was the risk factor for ART adherence among women living with HIV. It is therefore, necessary for clinician to note this and perform screening for ART adherence.

TRIAL REGISTRATION

The review protocol was developed with prospero registration: CRD42023415935.

Depression and associated factors among HIV-positive smokers receiving care at HIV outpatient clinics in Vietnam: a cross-sectional analysis

OBJECTIVES

To assess the prevalence of depressive symptoms and associated factors among people living with HIV (PLWH) who were current cigarette smokers and receiving treatment at HIV outpatient clinics (OPCs) in Vietnam.

DESIGN

A cross-sectional survey of smokers living with HIV.

SETTING

The study was carried out in 13 HIV OPCs located in Ha Noi, Vietnam.

PARTICIPANTS

The study included 527 PLWH aged 18 and above who were smokers and were receiving treatment at HIV OPCs.

OUTCOME MEASURES

The study used the Centre for Epidemiology Scale for Depression to assess depressive symptoms. The associations between depressive symptoms, tobacco dependence and other characteristics were explored using bivariate and Poisson regression analyses.

RESULTS

The prevalence of depressive symptoms among smokers living with HIV was 38.3%. HIV-positive smokers who were female (prevalence ratio, PR 1.51, 95% CI 1.02 to 2.22), unmarried (PR 2.06, 95% CI 1.54 to 2.76), had a higher level of tobacco dependence (PR 1.06, 95% CI 1.01 to 1.11) and reported their health as fair or poor (PR 1.66, 95% CI 1.22 to 2.26) were more likely to have depression symptoms compared with HIV-positive smokers who were male, married, had a lower level of tobacco dependence and self-reported their health as good, very good or excellent.

CONCLUSION

The prevalence of depressive symptoms among smokers receiving HIV care at HIV OPCs was high. Both depression and tobacco use screening and treatment should be included as part of ongoing care treatment plans at HIV OPCs.

Cognitive Performance, as well as Depression, Alcohol Use, and Gender, predict Anti-Retroviral Therapy Adherence in a South African Cohort of People with HIV and Comorbid Major Depressive Disorder

Depression and cognitive impairment, which commonly coexist in people with HIV (PWH), have been identified as potential barriers to optimal antiretroviral therapy (ART) adherence. We investigated associations between cognitive performance, depression (as well as other sociodemographic, psychosocial and psychiatric variables) and ART adherence in a South African cohort of PWH with comorbid major depressive disorder (MDD). Cognitive performance and ART adherence were assessed at two time points 8 months apart (Nbaseline = 105, Nfollow-up = 81). Adherence was indicated by self-report, objective measures (Wisepill usage and plasma tenofovir-diphosphate levels), and HIV viral suppression. Mixed-effects regression models examined associations across both time points. Univariate models detected no significant associations between cognitive performance (globally and within-domain) and ART adherence. Multivariate modelling showed increased depression severity (β = - 0.54, p < 0.001) and problematic alcohol use (β = 0.73, p = 0.015) were associated with worse adherence as measured subjectively. Being female (OR 0.27, p = 0.048) and having better global cognitive performance (OR 1.83, p = 0.043) were associated with better adherence as indicated by viral suppression. This study identifies poor global cognitive performance, as well as depression and problematic alcohol use, as potential barriers to optimal ART adherence in PWH and comorbid MDD. Hence, clinicians could consider assessing for cognitive deficits, depression, and problematic alcohol use, and should endeavour to provide the appropriate support so as to improve adherence.

Cerebrospinal fluid levels of 5-HIAA and dopamine in people with HIV and depression

Depression is a common illness in people with HIV (PWH) and is associated with substantial morbidity and mortality. The mechanisms that underpin depression in PWH remain incompletely elucidated, and more research is therefore needed to develop effective treatments. One hypothesis is that neurotransmitter levels may be altered. These levels could be influenced by the chronic inflammation and viral persistence that occurs in PWH. We examined a panel of cerebrospinal fluid (CSF) neurotransmitters in PWH on suppressive antiretroviral therapy (ART), many of whom had a current depression diagnosis. CSF monoamine neurotransmitters and their metabolites were measured from participants in studies at the Emory Center for AIDS Research (CFAR). Only participants on stable ART with suppressed HIV RNA from both plasma and CSF were analyzed. Neurotransmitter levels were measured with high-performance liquid chromatography (HPLC). Neurotransmitters and their metabolites included dopamine (DA), homovanillic acid (HVA, a major metabolite of dopamine), serotonin (5-HT), 5-hydroxyindole-3-acetic acid (5-HIAA, a major metabolite of serotonin), and 4-hydroxy-3-methoxyphenylglycol (MHPG, a major metabolite of norepinephrine). Multivariable logistic regression was used to evaluate factors associated with depression. There were 79 PWH with plasma and CSF HIV RNA levels < 200 copies/mL at the time of the visit, and 25 (31.6%) carried a current diagnosis of depression. Participants with depression were significantly older (median age 53 years versus 47 years, P = 0.014) and were significantly less likely to be African American (48.0% versus 77.8%, P = 0.008). Participants with depression had significantly lower dopamine levels (median 0.49 ng/mL versus 0.62 ng/mL, P = 0.03) and significantly lower 5-HIAA levels (median 12.57 ng/mL versus 15.41 ng/mL, P = 0.015). Dopamine and 5-HIAA were highly correlated. In the multivariable logistic regression models, lower 5-HIAA was significantly associated with the depression diagnosis when accounting for other significant demographic factors. The associations between lower 5-HIAA, lower dopamine, and depression in PWH suggest that altered neurotransmission may contribute to these comorbid conditions. However, the effects of antidepressants on neurotransmitters cannot be ruled out as a factor in the 5-HIAA results.

Closing the gaps in the continuum of depression care for persons with HIV: modeling the impact on viral suppression in the United States

OBJECTIVE

Depression is prevalent among persons with HIV (PWH) and is associated with poorer adherence and lack of viral load suppression (VLS). When treated for depression, PWH are more likely to stay in HIV care and adhere to medications; however, for many PWH, depression is not adequately diagnosed or treated. We adapted Progression and Transmission of HIV (PATH 3.0), a U.S. agent-based dynamic stochastic simulation model, by incorporating a continuum of depression care and estimating the impact on VLS of an enhanced depression diagnosis and care scenario (EDC).

METHODS

We compared EDC - whereby every PWH is assessed for depression, gets treatment if diagnosed, and of those, half achieve remission - to a status quo scenario (SQ) on VLS. Based on published findings, assumptions for SQ were: 34.7% depressed, 45% diagnosed, 55.3% treated and 33% of treated achieving remission. Compared to PWH without depression, we assumed the probability of being non-virally suppressed increased by 1.57 times for PWH with depression (PWH-D), and by 0.95 times for PWH with remitted depression.

RESULTS

There was an average increase of 14.6% (11.5-18.5) in the proportion of PWH-D who achieved VLS in EDC compared to SQ. Among all PWH, there was a 4.7% (3.4-6.0) increase in the proportion who achieved VLS in EDC compared to SQ.

CONCLUSIONS

Fully diagnosing and adequately treating depression would improve health and quality of life for a substantial proportion of PWH-D and result in a nearly 5% increase in expected rates of VLS in the United States, supporting national prevention goals.

The comorbidity of depression and neurocognitive disorder in persons with HIV infection: call for investigation and treatment

Depression and neurocognitive disorder continue to be the major neuropsychiatric disorders affecting persons with HIV (PWH). The prevalence of major depressive disorder is two to fourfold higher among PWH than the general population (∼6.7%). Prevalence estimates of neurocognitive disorder among PWH range from 25 to over 47% - depending upon the definition used (which is currently evolving), the size of the test battery employed, and the demographic and HIV disease characteristics of the participants included, such as age range and sex distribution. Both major depressive disorder and neurocognitive disorder also result in substantial morbidity and premature mortality. However, though anticipated to be relatively common, the comorbidity of these two disorders in PWH has not been formally studied. This is partly due to the clinical overlap of the neurocognitive symptoms of these two disorders. Both also share neurobehavioral aspects - particularly apathy - as well as an increased risk for non-adherence to antiretroviral therapy. Shared pathophysiological mechanisms potentially explain these intersecting phenotypes, including neuroinflammatory, vascular, and microbiomic, as well as neuroendocrine/neurotransmitter dynamic mechanisms. Treatment of either disorder affects the other with respect to symptom reduction as well as medication toxicity. We present a unified model for the comorbidity based upon deficits in dopaminergic transmission that occur in both major depressive disorder and HIV-associated neurocognitive disorder. Specific treatments for the comorbidity that decrease neuroinflammation and/or restore associated deficits in dopaminergic transmission may be indicated and merit study.

Assessing incident depression among older people with and without HIV in U.S

PURPOSE

Despite substantially higher prevalence of depression among people living with HIV/AIDS (PLWHA), few data exist on the incidence and correlates of depression in this population. This study assessed the effect of HIV infection, age, and cohort period on the risk of developing depression by sex among older U.S. Medicare beneficiaries.

METHODS

We constructed a retrospective matched cohort using a 5% nationally representative sample of Medicare beneficiaries (1996-2015). People with newly diagnosed (n = 1309) and previously diagnosed (n = 1057) HIV were individually matched with up to three beneficiaries without HIV (n = 6805). Fine-Gray models adjusted for baseline covariates were used to assess the effect of HIV status on developing depression by sex strata.

RESULTS

PLWHA, especially females, had higher risk of developing depression within five years. The relative subdistribution hazards (sHR) for depression among three HIV exposure groups differed between males and females and indicated a marginally significant interaction (p = 0.08). The sHR (95% CI) for newly and previously diagnosed HIV (vs. people without HIV) were 1.6 (1.3, 1.9) and 1.9 (1.5, 2.4) for males, and 1.5 (1.2, 1.8) and 1.2 (0.9, 1.7) for females. The risk of depression increased with age [sHR 1.3 (1.1, 1.5), 80 + vs. 65-69] and cohort period [sHR 1.3 (1.1, 1.5), 2011-2015 vs. 1995-2000].

CONCLUSIONS

HIV infection increased the risk of developing depression within 5 years, especially among people with newly diagnosed HIV and females. This risk increased with older age and in recent HIV epidemic periods, suggesting a need for robust mental health treatment in HIV primary care.

Intimate partner violence and HIV treatment adherence in urban South Africa: Mediating role of perinatal common mental disorders

Background

Antiretroviral therapy (ART) has potential to eliminate perinatal HIV infections, but adherence to ART in late pregnancy and postpartum is often suboptimal. Intimate partner violence (IPV) may influence non-adherence among perinatal women living with HIV (WWH), but few quantitative studies have examined this over time or explored mechanisms for this association.

Methods

We used secondary data from a parent trial in Johannesburg comprising WWH from the control arm (n=63) and WWH ineligible for the trial (n=133). Trained nurse researchers administered questionnaires at first antenatal visit on past-year psychological, physical, and/or sexual IPV (WHO instrument), socio-demographics (age, food security, education), and perinatal common mental symptoms of depression (Hospital Anxiety and Depression Screener-d); anxiety (HADS-a); post-traumatic stress disorder (PTSD; Harvard Trauma Questionnaire). At endline visit 2-4 months postpartum, nurse researchers assessed self-reported ART adherence using a visual analog scale (with ≥95% considered "good"). We fitted structural equation models (SEM) in MPlus to explore direct and indirect effects of IPV on ART adherence.

Results

Of 196 perinatal WWH, 53.1% reported IPV exposure at baseline. The majority of participants (85.7%) had good perinatal ART adherence. In adjusted models, IPV at baseline was associated with halved odds of good adherence (aOR=0.51, 95%CI=0.20-0.96). IPV was associated with higher adjusted odds of probable depression (aOR=4.64), anxiety (aOR=2.85), and PTSD (aOR=3.42). In SEM, IPV had a direct (standardized coef=-0.22) and indirect effect (coef=-0.05) on ART via common mental disorders. The total effect of IPV on perinatal adherence was of moderate size (coef= -0.27) and the model had good fit (CFI=0.972; TLI=0.969; RMSEA=0.045; SRMR=0.076).

Conclusion

IPV was longitudinally associated with perinatal ART non-adherence in part due to its relationship with mental health symptomology. Addressing IPV within clinical care has potential to improve perinatal mental health, maternal HIV outcomes, and HIV-free infant survival.

Higher Soluble CD163 in Blood Is Associated With Significant Depression Symptoms in Men With HIV

BACKGROUND

People with HIV (PWH) are more likely to experience depression, a highly morbid disease. More evidence is needed to better understand mechanisms of depression in PWH. We evaluated a panel of blood biomarkers in relation to depression symptoms in the Multicenter AIDS Cohort Study (MACS).

SETTING

Four sites in the United States.

METHODS

A cross-sectional analysis was performed within the MACS, a prospective study of cisgender men with and without HIV. Depression was assessed with the Center for Epidemiological Studies-Depression Scale, and six blood biomarkers were measured: GlycA, high sensitivity C-reactive protein (CRP), interleukin-6, CCL2, soluble CD14 (sCD14), and soluble CD163 (sCD163). Using univariable and multivariable logistic regression, the biomarkers and other factors were evaluated in relation to significant depression symptoms (SDS) by Center for Epidemiological Studies-Depression score ≥16.

RESULTS

784 men were analyzed; most of whom (63%) were PWH. PWH were more likely to have SDS (32% vs. 21%). In univariable analysis, higher GlycA, CRP, and sCD163 concentrations were associated with SDS. In multivariable analysis, however, only higher sCD163 concentration was associated with SDS (odds ratio = 2.30, 95% CI = 1.11 to 4.76). This relationship was driven by the PWH group (odds ratio = 2.72, 95% CI = 1.12 to 6.58) and remained significant when controlling for antidepressant use. Lack of college education was also associated with SDS.

CONCLUSIONS

Higher sCD163, a marker of macrophage activation, was significantly associated with significant depression symptoms in the MACS. Further research on this biomarker and macrophage activation in general is warranted to better understand and treat depression in PWH.

Incident depression among Medicare beneficiaries with disabilities and HIV

OBJECTIVE

Despite disproportionally high prevalence of HIV and depression in persons with disabilities, no data have been published on the incidence and correlates of depression in Medicare beneficiaries with disabilities. We assessed the effect of HIV infection on developing depression in this population.

DESIGN

We conducted a retrospective matched cohort study using a 5% sample of Medicare beneficiaries who qualified for disability coverage (1996-2015).

METHODS

Beneficiaries with incident ( n  = 2438) and prevalent ( n  = 5758) HIV were individually matched with beneficiaries without HIV (HIV-, n  = 20 778). Fine-Gray models with death as a competing risk were used to assess the effect of HIV status, age, and cohort period on developing depression by sex strata.

RESULTS

Beneficiaries with HIV had a higher risk of developing depression within 5 years ( P  < 0.0001). Sex differences were observed ( P  < 0.0001), with higher subdistribution hazard ratios (sHR) in males with HIV compared with controls. The risk decreased with age ( P  < 0.0001) and increased in recent years ( P  < 0.0001). There were significant age-HIV ( P  = 0.004) and period-HIV ( P  = 0.006) interactions among male individuals, but not female individuals. The sHR was also higher within the first year of follow-up among male individuals, especially those with incident HIV.

CONCLUSION

Medicare enrollees with disabilities and HIV had an increased risk of developing depression compared to those without HIV, especially among males and within the first year of HIV diagnosis. The HIV-depression association varied by sex, age, and cohort period. Our findings may help guide screening and comprehensive management of depression among subgroups in this vulnerable population.

Evaluation of SARS-CoV-2 Antibodies and the Impact of COVID-19 on the HIV Care Continuum, Economic Security, Risky Health Behaviors, and Mental Health Among HIV-Infected Individuals in Vietnam

Coronavirus disease 2019 (COVID-19) and associated social responses may uniquely affect people living with HIV (PLHIV). SARS-CoV-2 antibody testing and a cross-sectional survey on COVID-19's socio-behavioral impacts were conducted among a large PLHIV cohort in Hanoi, Vietnam. We examined anonymous antibody test results for 1243 PLHIV (99.8%) from whom plasma was obtained and completed surveys were collected in June/July 2020, just after the end of the first COVID-19 outbreak and nationwide lockdown. Three participants (0.2%) tested positive for anti-SARS-CoV-2 IgG antibodies. HIV treatment was generally maintained without antiretroviral therapy interruption, but COVID-19 had substantial impacts on economic security and risky health behaviors among PLHIV, which may have amplified psychological stress. These findings highlight the need for continuous monitoring of COVID-19's impacts on PLHIV and for efforts to mitigate these impacts.

Soluble Biomarkers of Cognition and Depression in Adults with HIV Infection in the Combination Therapy Era

PURPOSE OF REVIEW

Cognitive impairment and depression continue to be common among people with HIV (PWH) in the combination antiretroviral therapy (ART) era. A better understanding of the biological mechanisms that may underpin these disorders is needed. The purpose of this review is to describe published findings on soluble biomarkers from blood and cerebrospinal fluid (CSF) that have been associated with either cognition or depression among PWH in the setting of ART.

RECENT FINDINGS

Several biomarkers, including those that reflect viral persistence, monocyte/macrophage activation, and other processes, are associated with cognition and depressive symptoms. Some but not all results have been consistent across multiple studies. More research has been published on biomarkers of cognition relative to biomarkers of depression (particularly from CSF). More studies are needed that investigate multiple biomarkers to understand the role of distinct but additive pathways in these disorders and to guide the development of new therapies.

Efavirenz Is Not Associated with an Increased Risk of Depressive Disorders in Patients Living with HIV: An 11-Year Population-Based Study in Taiwan

(1) Background: This study aimed to determine the association between the use of efavirenz and depressive disorders among human immunodeficiency virus (HIV)-infected patients. (2) Methods: A retrospective cohort study was conducted using Taiwan's National Health Insurance Database. We identified patients receiving anti-retroviral therapy (ART) between 2000 and 2009; these patients were followed until 2010 for diagnoses of depressive disorders using the Cox proportional hazard model to estimate hazard ratios. (3) Results: After up to 11 years of follow-up, the incidence of depressive disorders for the efavirenz-treated group was estimated at 12.2/1000 person-years (PYs), and the control group was at 12.5/1000 PY (p = 0.822). The independent risk factors for depressive disorders included an insurance premium of less than NTD 17,820 (New Taiwan Dollars-NTD) (adjusted hazard ratio (aHR) 2.59, 95% confidence interval (CI), 1.79-3.76, p < 0.001), and between NTD 17,821 and NTD 26,400 (aHR 1.55, 95% CI, 1.04-2.31, p = 0.030), living in Southern Taiwan (aHR 1.49, 95% CI, 1.21-1.84, p = 0.002), and with a psychiatric history (excluding depressive disorders) (aHR 4.59, 95% CI, 3.51-6.01, p = 0.030). (4) Conclusions: This study concluded that ART-treated patients with a past history of psychiatric disorders, lower insurance premium, and living in Southern Taiwan have an increased risk of depressive disorders, which are not associated with the use of efavirenz.

Intimate partner violence and the HIV care and treatment cascade among adolescent girls and young women in DREAMS, South Africa

Supplemental Digital Content is Available in the Text.

Background:

Intimate partner violence (IPV) may affect the HIV-treatment cascade.

Setting:

Four high HIV-prevalence DREAMS health districts in South Africa.

Methods:

Secondary analysis of cross-sectional data collected March 2017–June 2018, using random household sample of young (12–24 years) girls and women. Face-to-face interviews assessed IPV and HIV-status knowledge, and finger-prick blood draws assessed ART (antiretroviral therapy) uptake and viral suppression. We used logistic regression to estimate crude and adjusted effects of IPV on HIV knowledge, ART uptake, and viral suppression.

Results:

Of 18,230 adolescent girls and young women, 8413 (46%) reported ever having had sex, of whom 1118 (13%) were HIV positive. The 90:90:90 benchmarks were 61% knew their status, 86% had ART present in their blood sample, and 91% were virally suppressed. Among the entire sample of young women living with HIV, 65.6% were virally suppressed. Past year IPV was reported by 15%. In adjusted models, IPV trended toward increasing the odds that a young woman was aware she was living with HIV [adjusted odds ratios (aOR) = 1.40, 2.00–9.98, P = 0.067]. There was no association between IPV and reduced treatment use (aOR = 0.73, 0.41–1.29). IPV was independently associated with reduced viral suppression (aOR = 0.30, 0.13–0.66).

Conclusions:

Addressing the role of IPV in undermining the treatment cascade for adolescent and young women is a critical issue for HIV programming.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42019133849.

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

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

The association between the use of efavirenz and the occurrence of depressive disorders among HIV-treated patients: An application of Bayesian cox regression

OBJECTIVES: Efavirenz therapy plays an important role in controlling the progression of HIV/AIDS. However, efavirenz often causes short-term side effects for the central nervous system, and it remained controversial as to whether efavirenz leads to depression or even suicidal attempt when applied for a longer period of time. The purpose of this study is to determine the association between the use of efavirenz and depressive disorders. METHODS: This study explored the use of efavirenz on HIV-infected patients using National Health Insurance Research Database (NHIRD) in Taiwan by Bayesian survival analysis and investigated whether the use of efavirenz has the risk of depressive disorders. To reduce the dependence of statistical modeling assumptions, this study applied propensity score matching to research data. RESULTS: Based on the result of this study, it can be found that the use of efavirenz (HR = 1.009, 95% CI=–0.505 0.554), gender (HR = 0.324, 95% CI = –2.544 0.381) were not significantly associated with the occurrence of depressive disorders, whereas age of HIV diagnosis (HR = 1.021, 95% CI = 0.011 0.055) was significantly associated with the occurrence of depressive disorders. This study concludes that the use of efavirenz does not in-crease the risk of depressive disorders among HIV-treated patients. CONCLUSIONS: For the care of HIV-infected patients (especially the older ones), the psychological harm from society, such as lack of social support, social stigma or unemployment is higher than the harm of medicine.

Childhood trauma, major depressive disorder, suicidality, and the modifying role of social support among adolescents living with HIV in rural Uganda

BACKGROUND

Childhood trauma is associated with mental health problems among adolescents living with HIV (ALHIV) in sub-Saharan Africa, but little is known about potential moderating factors.

METHODS

We enrolled 224 ALHIV aged 13-17 years and collected information on childhood trauma, major depressive disorder, and suicidality. We used modified multivariable Poisson regression to estimate the association between the mental health outcome variables and childhood trauma, and to assess for effect modification by social support.

RESULTS

Major depressive disorder had a statistically significant association with emotional abuse (adjusted relative risk [ARR] 2.57; 95% CI 1.31-5.04; P=0.006) and physical abuse (ARR 2.16; 95% CI 1.19-3.89; P=0.01). The estimated association between any abuse and major depressive disorder was statistically significant among those with a low level of social support (ARR 4.30; 95% CI 1.64-11.25; P=0.003) but not among those with a high level of social support (ARR 1.30; 95% CI 0.57-2.98; P=0.52). Suicidality also had a statistically significant association with emotional abuse (ARR 2.03; 95% CI 1.05-3.920; P=0.03) and physical abuse (ARR 3.17; 95% CI 1.60-6.25.; P=0.001), but no differences by social support were noted.

LIMITATIONS

Corporal punishment is used widely in schools and homes as a form of discipline in Uganda; this cultural practice could have biased reporting about physical abuse.

CONCLUSIONS

Childhood trauma is associated with poor mental health among ALHIV, but its effects may be moderated by social support. More research is needed to develop social support interventions for ALHIV with adverse childhood experiences for improved mental health outcomes.

Longitudinal association between intimate partner violence and viral suppression during pregnancy and postpartum in South African women

OBJECTIVE

We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum.

DESIGN

Secondary analysis of an HIV-positive cohort enrolled during pregnancy at a South African antenatal clinic.

METHODS

Viral load was assessed at 10 study visits and analyzed continuously as log10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log10 viral load.

RESULTS

Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR = 0.48, 95% CI = 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log10 viral load (standardized coefficient = 0.12, 95% CI = 0.05-0.23).

CONCLUSION

Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.

The Impact of Mental Health Conditions on Public Insurance Costs of Treating HIV/AIDS

Medicare and Medicaid insurance claims data for Californians living with HIV are analyzed in order to determine: (1)The prevalence of treatment for particular mental health diagnoses among people living with HIV (PLWH) with Medicare or Medicaid insurance in 2010; (2)The relationship between individual mental health conditions and total medical care expenditures; (3)The impact of individual mental health diagnoses on the cost of treating non-mental health conditions; and (4)The implications of the cost of mental health diagnoses for setting managed care capitation payments. We find that the prevalence of mental health conditions among PLWH is high (23% among Medicare and 28% among Medicaid enrollees). PLWH with mental health conditions have significantly higher treatment costs for both mental health and non-mental health conditions. Setting managed care capitations that account for these greater expenditures is necessary to preserve access to both mental health and physical health services for PLWH and mental health conditions.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Integrating mental health services into human immunodeficiency virus clinics: Lessons from task-sharing between clinical and lay healthcare providers in Ethiopia

Background

Globally, mental health problems are more common among people living with human immunodeficiency virus (PLHIV) than among the general population. Mental health problems affect human immunodeficiency virus (HIV) treatment adherence and retention. To address this challenge, partners used a task-sharing approach among lay healthcare works and clinicians to integrate mental health services into HIV services at pilot hospitals in the Amhara and Tigray regions of Ethiopia. In this model, trained lay healthcare workers proactively screened patients using a mental health screening tool and subsequently linked potential clients with trained clinicians working at HIV clinics for further diagnosis and treatment.

Methods

We retrospectively gathered secondary data, including demographic characteristics and diagnosis information, from mental health clinicians' and case managers' quarterly reports from HIV clinics during the implementation period (January 1, 2013 to March 31, 2014).

Results

During the initial three-month implementation period of the project (January to March 2013), case managers screened 5,862 PLHIV for mental health disorders. Case managers referred 687 (11.7%) patients with suspected mental health disorders to clinicians for further evaluation and management. Of the total patients screened by case managers in this period, clinicians confirmed that 454 (7.7%) had a mental health disorder. Overall, the concordance between the case managers' screening results and the clinicians' diagnoses was 67.8% over the 15-month pilot implementation period.

Conclusions

Routine screening of PLHIV for mental health disorders helps to proactively identify and manage patients with co-morbidities. The integration of mental health services into HIV care through a task-sharing approach is a feasible strategy that could increase access to mental health services among PLHIV.

Association between HIV status and psychological symptoms in perimenopausal women

OBJECTIVE

HIV-infected women are burdened by depression and anxiety, which may impact adherence to antiretroviral therapy and overall quality of life. Yet, little is known about the scope of psychological symptoms in the growing number of HIV-infected women reaching menopause, when affective symptoms are more prevalent in the general population. We conducted a longitudinal study to compare affective symptoms between perimenopausal HIV-infected and non-HIV-infected women.

METHODS

The Center for Epidemiologic Studies Depression Scale (CES-D), and the Generalized Anxiety Disorder scale (GAD-7) were completed at baseline and 12 months among 33 HIV-infected and 33 non-HIV-infected perimenopausal women matched by race, age, menstrual patterns, and BMI. Linear regression models estimated the relationship of baseline GAD-7 and CES-D scores with clinical factors.

RESULTS

All women were perimenopausal at baseline, and the vast majority remained perimenopausal throughout follow-up. HIV status was associated with higher baseline CES-D scores (median [interquartile range] 21 [12, 29] vs 10 [5, 14]; P = 0.03) and GAD-7 scores (7 [5, 15] vs 2 [1, 7]; P = 0.01), controlling for smoking, substance use, and antidepressant use. Depressive symptoms and anxiety remained significantly higher in the HIV-infected women at 12 months (P ≤ 0.01). Significant relationships of depressive symptoms (P = 0.048) and anxiety (P = 0.02) with hot flash severity were also observed.

CONCLUSIONS

Perimenopausal HIV-infected women experienced a disproportionately high level of affective symptom burden over a 12-month observation period. Given the potential for these factors to influence adherence to HIV clinical care and quality of life, careful assessment and referral for treatment of these symptoms is essential.

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

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

High prevalence of neurocognitive disorders observed among adult people living with HIV/AIDS in Southern Ethiopia: A cross-sectional study

BACKGROUND

Comprehensive care given to people living with HIV/AIDS is improving over time; however, their concurrent cognitive illness is still ignored, under screened and treated particularly in developing countries. And this problem is also striking in Ethiopia. Therefore, the objective of this study was to assess HIV-associated neurocognitive disorders and associated factors among adult people living with HIV/AIDS.

METHODS

An institution based cross sectional study was conducted from April to May, 2017 at Gamo Gofa zone public Hospitals. International HIV Dementia Scale was used to screen HIV associated neurocognitive disorders. Logistic regression analysis was used to assess predictors of neurocognitive disorders.

RESULT

A total of 684 study participants were included in this study with a response rate of 98%. Among them, 56% were females while 44% were males. The mean (±SD) age of the participants was 38.8±8.8years. The screening prevalence of HIV-associated neurocognitive disorder was 67.1% (95% CI; 63.6, 70.5). Body mass index 16 kg/m2 (AOR 4.389 (1.603-12.016)), being married (AOR 0.377 (0.213-0.666), unemployment status (AOR 3.181 (1.752-5.777) and being in WHO clinical stage T3 category/advancing stages of the disease (AOR 3.558 (1.406-9.006) were the key predictors of HIV-associated neurocognitive disorders among people living with HIV/AIDS.

CONCLUSION

In this study the screening prevalence of HIV-associated neurocognitive disorder is higher than the earlier reports in Ethiopia and Africa. This indicates that early screening strategies and policies for cognitive health in people living with HIV/AIDS should be given a top priority.

Mental Health Diagnoses, Symptoms, and Service Utilization in US Youth with Perinatal HIV Infection or HIV Exposure

Youth perinatally HIV infected (PHIV) or HIV exposed, but uninfected (PHEU), are aging into adolescence and adulthood with multiple complex risk factors for mental health (MH) problems and poor MH treatment utilization. Our aims were to estimate prevalence of MH diagnoses, clinically significant symptoms, and MH treatment utilization among youth with PHIV and among PHEU youth, 10-22 years old. We also aimed to identify correlates of diagnoses and treatment utilization. Analyses of data from standardized interviews, behavioral assessments, and chart review of 551 youth revealed that 36% had a previous or current MH diagnosis, with no significant HIV status group differences. Prevalence of clinically significant symptoms was 15% for both groups, of whom a third had no diagnosis, and half were not receiving treatment. Among youth with a current MH diagnosis, those with PHIV had greater utilization of services than PHEU youth (67% vs. 51%; p = 0.04). Factors associated with MH diagnoses and/or treatment utilization included caregiver characteristics, age and sex of child, HIV status, and stressful life events. Prevalence of MH diagnoses was higher than in the general population, but lower than in similar perinatally HIV-exposed cohorts, with some unmet service needs, particularly in PHEU youth. Family characteristics warrant careful consideration in early diagnosis and treatment of MH problems among youth affected by HIV.

Probable antenatal depression at antiretroviral initiation and postpartum viral suppression and engagement in care

OBJECTIVE

To estimate the association of probable antenatal depression with postpartum HIV care engagement among pregnant women in Malawi.

DESIGN

We conducted a prospective cohort study of 299 women who were initiating antiretroviral therapy (ART) through Option B+ at a government antenatal clinic in Malawi.

METHODS

Probable antenatal depression was assessed on the day of ART initiation with the validated Chichewa version of the Edinburgh Postnatal Depression Scale (EPDS). We estimated crude and adjusted risk differences (RD, aRD) of visit attendance and prevalence differences (PD, aPD) of viral suppression through 12 months post-ART initiation comparing women with versus without probable antenatal depression.

RESULTS

One in 10 women had probable antenatal depression. Most women were engaged in care through 12 months post-ART initiation: 85% attended all scheduled ART visits, and 81% were in care and virally suppressed. Women with and without probable antenatal depression had a comparable probability of attending all scheduled visits (RD: -0.02; 95% CI -0.16 to 0.12; aRD: -0.04; 95% CI -0.18 to 0.10), and of viral suppression (PD: -0.02; 95% CI -0.17 to 0.13; aPD: -0.01; 95% CI -0.17 to 0.15) in crude and adjusted analyses.

CONCLUSION

Probable antenatal depression was not associated with engagement in HIV care through 12 months post-ART initiation. In a population with high HIV care engagement, antenatal depression may not impair HIV-related outcomes.

Prevalence and incidence of probable perinatal depression among women enrolled in Option B+ antenatal HIV care in Malawi

BACKGROUND

Perinatal depression is a common condition of pregnancy and the postpartum period. Depression negatively affects engagement in HIV care, but systematic screening for perinatal depression is not done in most sub-Saharan African countries. Estimating the burden and timing of perinatal depression can help inform medical programs with the current scale-up of HIV care for pregnant women.

METHODS

Women (n = 299) initiating antiretroviral therapy for HIV were recruited from a government antenatal clinic in Malawi in 2015-2016 into a cohort study. Probable perinatal depression was assessed at enrollment and at 6 weeks and 3, 6, and 12 months postpartum with the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-9 (PHQ-9). We estimated point prevalence and incidence of depression as well as concordance between EPDS and PHQ-9 scores.

RESULTS

One in ten women screened positive for probable antenatal depression, whereas 1-6% screened positive postpartum. Sensitivity analyses to account for loss to follow-up suggested that postpartum depression prevalence could have ranged from 1-11%. At postpartum time points, 0-3% of participants screened positive for incident probable depression. EPDS and PHQ-9 scores were concordant for 96% of assessments during antenatal and postpartum visits.

LIMITATIONS

Lack of diagnostic psychiatric evaluation precludes actual diagnosis of major depression, and social desirability bias may have contributed to low postpartum scores.

CONCLUSIONS

Probable depression was more common during the antenatal period than postpartum among our participants. Given the association between depression and negative HIV outcomes, screening for depression during pregnancy should be integrated into antenatal HIV care.

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

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

Prevalence and factors associated with antenatal depressive symptoms among women enrolled in Option B+ antenatal HIV care in Malawi: a cross-sectional analysis

BACKGROUND

Option B+ has increased the number of pregnant women initiating antiretroviral therapy for HIV, yet retention in HIV care is sub-optimal. Retention may be affected by antenatal depression. However, few data exist on antenatal depression in this population.

AIM

Describe the prevalence and factors associated with antenatal depression among Malawian women enrolled in Option B+.

METHOD

At their first antenatal visit, women with HIV provided demographic and psychosocial information, including depression as measured with the locally validated Edinburgh Postnatal Depression Scale (EPDS). Prevalence ratios (PR) for factors associated with probable depression (EPDS ≥6) were estimated with log binomial regression.

RESULTS

9.5% (95% CI: 7.5-11.9%) of women screened positive for current depression, and 46% self-reported a history of depression or anxiety. Women were more likely to screen positive for current depression if they reported a history of depression (adjusted PR: 2.42; 95% CI: 1.48-3.95) or had ever experienced intimate partner violence (1.77; 1.11-2.81). Having an unintended current pregnancy (1.78; 0.99-3.21), being unmarried (1.66; 0.97-2.84), or employed (1.56; 1.00-2.44) had potential associations with probable depression.

CONCLUSIONS

Probable antenatal depression affected a notable proportion of women living with HIV, comparable to other global regions. Screening for antenatal depression in HIV care should be considered.

Viral suppression and viral rebound among young adults living with HIV in Canada

Describe the prevalence and covariates of viral suppression and subsequent rebound among younger (≤29 years old) compared with older adults.A retrospective clinical cohort study; eligibility criteria: documented HIV infection; resident of Canada; 18 years and over; first antiretroviral regimen comprised of at least 3 individual agents on or after January 1, 2000.Viral suppression and rebound were defined by at least 2 consecutive viral load measurements <50 or >50 HIV-1 RNA copies/mL, respectively, at least 30 days apart, in a 1-year period. Time to suppression and rebound were measured using the Kaplan-Meier method and Life Table estimates. Accelerated failure time models were used to determine factors independently associated with suppression and rebound.Younger adults experienced lower prevalence of viral suppression and shorter time to viral rebound compared with older adults. For younger adults, viral suppression was associated with being male and later era of combination antiretroviral initiation (cART) initiation. Viral rebound was associated with a history of injection drug use, Indigenous ancestry, baseline CD4 cell count >200, and initiating cART with a protease inhibitor (PI) containing regimen.The influence of age on viral suppression and rebound was modest for this cohort. Our analysis revealed that key covariates of viral suppression and rebound for young adults in Canada are similar to those of known importance to older adults. Women, people who use injection drugs, and people with Indigenous ancestry could be targeted by future health interventions.

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

Background

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

Methods

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

Results

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

Conclusions

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

The association between HIV clinical disease severity and psychiatric disorders as seen in Western Romania

HIV disease continues to be a serious health issue all over the world. By the end of 2016, 36.7 million people were living with HIV, 1.8 million people became newly infected and 1 million died of HIV-related causes/diseases. In order to develop effective treatment strategies, is important to assess the risk factors that affect negatively the HIV-positive patients. HIV-infected patients are at high risk of developing psychiatric disorders in every stage of the illness. Psychiatric disorders can negatively influence the treatment adherence, induce risk behavior and influence the quality of life. The purpose of this study is to determine if the severity of HIV disease is associated with increased frequency of psychiatric disorders. We evaluated 101 HIV-positive patients receiving antiretroviral therapy in Western Romania via Psychiatric Diagnostic Screening Questionnaire (PDSQ). We conducted a risk analysis in order to see if the patients have a higher risk of developing psychiatric disorders depending on HIV serostatus factor (HIV asymptomatic, symptomatic, AIDS converted). Our study shows that, the patients having AIDS and symptomatic HIV have a higher prevalence for the most common psychiatric disorders: major depressive disorder (OR = 5.81;p < 0.001), panic disorder (OR = 3.11; p = 0.016), agoraphobia (OR = 4.31; p = 0.024), social phobia (OR = 2.81; p = 0.038), generalized anxiety disorder (OR = 4.79; p = 0.006), somatization (OR = 8.72; p < 0.0010) and hypochondria (OR = 4.66; p = 0.0013). Symptomatic HIV and AIDS converted serostatus is also a risk factor for post-traumatic stress disorder, obsessive-compulsive disorder and psychosis. The main conclusion of this study is that the more severe HIV clinical disease was associated with increased frequency of psychiatric disorders. As a consequence, we conclude that psychiatric disorders and HIV/AIDS treatment should be addressed simultaneously, depending on the risk specific factors such as the HIV infection stage and, due to psychiatric repercussions of HIV is expected to become more relevant in the coming years.

Social Support as a Key Protective Factor against Depression in HIV-Infected Patients: Report from large HIV clinics in Hanoi, Vietnam

Depression is the most common mental health issue among people living with HIV/AIDS (PLWHA). This study explored how different types and sources of social support are associated with depression among HIV-infected patients in Vietnam. We carried out a cross-sectional survey on 1,503 HIV-infected patients receiving antiretroviral therapy at two HIV clinics in Hanoi in 2016. Depression was prevalent in 26.2% of participants. Higher score of social support, especially emotional/informational support and positive social interaction, showed significant association with lower depression rate. Although family was primary source of all types of social support, receiving emotional/informational support not only from family but also from outside of family correlated with a lower proportion of depression. In countries with constrained social resources and/or with family-oriented social structures, as in Vietnam, expanding social networks between HIV populations and society is a potentially important option for reducing depression.

The Combined Roles of Nonsomatic Depressive Symptomatology, Neurocognitive Function, and Current Substance Use in Medication Adherence in Adults Living With HIV Infection

Depression, global neurocognitive (GNC) function, and substance use disorders (SUDs) are each associated with medication adherence in persons living with HIV (PLWH). Because somatic symptoms can inflate depression scores in PLWH, the role of nonsomatic depressive symptomatology (NSDS) should be considered in adherence. However, the combined roles of NSDS, GNC function, and current SUDs in predicting combined antiretroviral therapy (cART) adherence remain poorly understood. Forty PLWH (70% Latina/o; 30% non-Hispanic White) completed psychiatric/SUD, neurocognitive, and self-report cART adherence evaluations. Higher NSDS was associated with suboptimal adherence (p < .01), but optimal and suboptimal adherers did not differ in GNC function or current SUDs. Only NSDS was associated with suboptimal adherence, after accounting for GNC function and SUDs (p = .01). NSDS uniquely predicted self-reported adherence, beyond GNC function and current SUDs among ethnically diverse PLWH. Methodological issues between present and prior studies should also be considered.

Simple and practical screening approach to identify HIV-infected individuals with depression or at risk of developing depression

OBJECTIVES

Studies have shown that depression and other mental illnesses are under-diagnosed among HIV-infected individuals. The aim of this study was to evaluate the use of mental health history and questionnaire-based screening instruments to identify HIV-infected individuals at risk of depression.

METHODS

The Beck Depression Inventory II (BDI-II) was used to assess the prevalence and severity of depressive symptoms among HIV-infected individuals attending two out-patient clinics in Denmark. HIV-infected individuals with a BDI-II score ≥ 20 were offered a clinical evaluation by a consultant psychiatrist. The BDI-II score was compared to the outcome of mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool.

RESULTS

A total of 501 HIV-infected individuals were included in the study. Symptoms of moderate/major depression (BDI-II score ≥ 20) were observed in 111 patients (22%); 65 of these patients consulted a psychiatrist, of whom 71% were diagnosed with a co-existing disorder. The BDI-II score was compared to the outcome of a mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool. The two questions showed a sensitivity and specificity of 95% and 68%, respectively, for diagnosis of current depression or risk of depression. A previous psychiatric history and substance abuse were independently associated with an increased risk of depression.

CONCLUSIONS

We suggest that the mental health of HIV-infected individuals should be reviewed and a "risk-flag" three-step approach should be used (1) to screen routinely with the two verbal questions suggested by the EACS, (2) to identify whether there is a risk of depression and then screen with the BDI-II, and (3) to identify whether there is still a risk and then perform a full evaluation and obtain an accurate psychiatric diagnosis by a psychiatrist.

HIV patient and provider feedback on a telehealth collaborative care for depression intervention

In the HIV Translating Initiatives for Depression into Effective Solutions project, we conducted a randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care in Veterans Health Administration HIV clinics in the US. An offsite HIV depression care team including a psychiatrist, a depression care manager (DCM), and a clinical pharmacist provided collaborative care using a stepped-care model of treatment and made recommendations to providers through the electronic health record system. The DCM delivered care management to HIV patients through phone calls, performing routine assessments and providing counseling in self-management and problem-solving. The DCM documented all calls in each patient's electronic medical record. In this paper we present results from interviews conducted with patients and clinical staff in a multi-stage formative evaluation (FE). We conducted semi-structured FE interviews with 26 HIV patients and 30 clinical staff at the three participating sites during and after the trial period to gather their experiences and perspectives concerning the intervention components. Interviews were transcribed verbatim and analyzed using rapid content analysis techniques. Patients reported high satisfaction with the depression care manager (DCM) phone calls. Both HIV and mental health providers reported that the DCM's chart notes in the electronic health record were very helpful, and most felt that a dedicated DCM for HIV patients is ideal to meet patient needs. Sites encountered barriers to achieving and maintaining universal depression screening, but had greater success when such screening was incorporated into routine intake processes. FE results demonstrated that depression care management via telehealth from an offsite team is acceptable and helpful to both HIV patients and their providers. Given that a centralized offsite depression care team can deliver effective, cost-effective, cost-saving services for multiple HIV clinics in different locations with high patient and provider satisfaction, broad implementation should be considered.

Examining the interplay between depression, motivation, and antiretroviral therapy adherence: a social cognitive approach

A large body of research identifies depressive symptoms as a barrier to optimal antiretroviral therapy (ART) adherence, whereas treatment motivation has been characterized as a facilitator. There is evidence, however, that these patterns may not hold for some ART patients despite the widespread use of motivational techniques aimed at promoting adherence. Little is known about how the interplay between different levels of depressive symptoms and variations in the types and levels of motivation may influence ART adherence. The purpose of this study was to examine the relationship between depressive symptoms, two types of motivation, and adherence, with self-efficacy as a mediator. The sample consisted of 121 ART patients who reported various levels of depressive symptoms (mean age = 41 years; 84% African-American; and 68% female). Path analysis revealed that self-efficacy fully mediated the relationship between the three predictor variables (depressive symptoms, intrinsic motivation, and extrinsic motivation) and adherence, χ²(3, N = 121) = .78, RMSEA = .00, SRMR = .02, CFI = 1.00, NNFI = 1.06. Findings suggest that interventions using motivational techniques to build adherence among patients with varying levels of depressive symptoms should address the role of treatment self-efficacy to improve their effectiveness.

Medication adherence in Alzheimer's disease: The mediator role of mindfulness

BACKGROUND

Medication adherence is often assessed based on compliance to the dosage and frequency of physician's prescription. Cognitive impairment is one of the biggest barriers in elderly patients with Alzheimer's disease (AD), who are usually polymedicated with different oral drugs. Transdermal drug delivery, also requires mobility abilities, reinforcing the role of patients' caregivers.

OBJECTIVE

To evaluate the relationship between psychological variables such as social support, family satisfaction, psychological morbidity, awareness of the disease, coping, mindfulness and medication adherence, in patients with AD, taking in consideration the patient's perspective.

DESIGN

Cross-sectional and quantitative study including 128 patients with mild AD.

RESULTS

Medication adherence showed a positive relationship with social support, mindfulness, family satisfaction and awareness of the disease. Mindfulness was a mediator in the relationship between awareness of the disease and medication adherence.

CONCLUSIONS

This study reinforces the importance of psychological assessment in medication adherence in mild AD patients, specially the role of mindfulness. Intervention programs to promote mindfulness may have a potential dual benefit, preserving cognitive skills and promoting medication adherence.

A Structural Equation Model of HIV-related Symptoms, Depressive Symptoms, and Medication Adherence

Adherence to combined antiretroviral therapy (cART) remains critical in management of HIV infection. This study evaluated depression as a potential mechanism by which HIV-related symptoms affect medication adherence and explored if particular clusters of HIV symptoms are susceptible to this mechanism. Baseline data from a multi-visit intervention study were analyzed among 124 persons living with HIV (PLWH). A bifactor model showed two clusters of HIV-related symptom distress: general HIV-related symptoms and gastrointestinal (GI) symptoms. Structural equation modeling showed that both general HIV-related symptoms and GI symptoms were related to higher levels of depressive symptoms, and higher levels of depressive symptoms were related to lower levels of medication adherence. Although general HIV-related symptoms and GI symptoms were not directly related to adherence, they were indirectly associated with adherence via depression. The findings highlight the importance of early recognition and evaluation of symptoms of depression, as well as the underlying physical symptoms that might cause depression, to improve medication adherence.

Predictors of depression recovery in HIV-infected individuals managed through measurement-based care in infectious disease clinics

BACKGROUND

Treatment of comorbid chronic disease, such as depression, in people living with HIV/AIDS (PLWHA) increasingly falls to HIV treatment providers. Guidance in who will best respond to depression treatment and which patient-centered symptoms are best to target is limited.

METHODS

Bivariable analyses were used to calculate hazard ratios for associations between baseline demographic, mental health-related, and HIV-related factors on time to first depression remission among PLWHA enrolled in a randomized trial of measurement-based antidepressant management. Time-updated factors also were analyzed at time of antidepressant (AD) initiation/adjustment and 8 weeks post AD initiation/adjustment.

RESULTS

Baseline comorbid depression and anxiety; comorbid depression, anxiety and substance abuse; and generalized anxiety disorder predicted a slower time to first remission. Being on ART but non-adherent, having panic disorder, having a history of a major depressive episode, or having been in HIV care for >10 years prior to study initiation predicted a faster time to first remission. Sleep difficulty or fatigue at the time of AD initiation/adjustment predicted a slower time to remission. In non-remitters at 8 weeks post AD initiation/adjustment, sleep difficulty, anxiety, and fatigue each predicted a slower time to remission.

LIMITATIONS

Remission was determined by PHQ-9 scores, not diagnostic criteria. The results may apply only to depression recovery in this particular model of treatment. We conducted only exploratory analyses to determine magnitude of effects.

CONCLUSIONS

Baseline comorbid anxiety with or without substance abuse predicts slower time to depression remission among PLWHA treated in HIV clinics. Targeting anxiety or fatigue at the time of AD initiation/adjustment or sleep difficulty, anxiety, and fatigue at 8 weeks post AD initiation/adjustment could shorten time to depression remission in this model.

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

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

Persistent CSF but not plasma HIV RNA is associated with increased risk of new-onset moderate-to-severe depressive symptoms; a prospective cohort study

Major depressive disorder is the most common neuropsychiatric complication in human immunodeficiency virus (HIV) infections and is associated with worse clinical outcomes. We determined if detectable cerebrospinal fluid (CSF) HIV ribonucleic acid (RNA) at threshold ≥50 copies/ml is associated with increased risk of depression. The CNS HIV Anti-Retroviral Therapy Effects Research (CHARTER) cohort is a six-center US-based prospective cohort with bi-annual follow-up of 674 participants. We fit linear mixed models (N = 233) and discrete-time survival models (N = 154; 832 observations) to evaluate trajectories of Beck Depression Inventory (BDI) II scores and the incidence of new-onset moderate-to-severe depressive symptoms (BDI ≥ 17) among participants on combination antiretroviral therapy (cART), who were free of depression at study entry and received a minimum of three CSF examinations over 2496 person-months follow-up. Detectable CSF HIV RNA (threshold ≥50 copies/ml) at any visit was associated with a 4.7-fold increase in new-onset depression at subsequent visits adjusted for plasma HIV RNA and treatment adherence; hazard ratio (HR) = 4.76, (95 % CI 1.58-14.3); P = 0.006. Depression (BDI) scores were 2.53 points higher (95 % CI 0.47-4.60; P = 0.02) over 6 months if CSF HIV RNA was detectable at a prior study visit in fully adjusted models including age, sex, race, education, plasma HIV RNA, duration and adherence of CART, and lifetime depression diagnosis by Diagnostic Statistical Manual (DSM-IV) criteria. Persistent CSF but not plasma HIV RNA is associated with an increased risk for new-onset depression. Further research evaluating the role of immune activation and inflammatory markers may improve our understanding of this association.

Frequency of and Risk Factors for Depression among Participants in the Swiss HIV Cohort Study (SHCS)

Objectives

We studied the incidence and prevalence of, and co-factors for depression in the Swiss HIV Cohort Study.

Methods

Depression-specific items were introduced in 2010 and prospectively collected at semiannual cohort visits. Clinical, laboratory and behavioral co-factors of incident depression among participants free of depression at the first two visits in 2010 or thereafter were analyzed with Poisson regression. Cumulative prevalence of depression at the last visit was analyzed with logistic regression.

Results

Among 4,422 participants without a history of psychiatric disorders or depression at baseline, 360 developed depression during 9,348 person-years (PY) of follow-up, resulting in an incidence rate of 3.9 per 100 PY (95% confidence interval (CI) 3.5–4.3). Cumulative prevalence of depression during follow-up was recorded for 1,937/6,756 (28.7%) participants. Incidence and cumulative prevalence were higher in injection drug users (IDU) and women. Older age, preserved work ability and higher physical activity were associated with less depression episodes. Mortality (0.96 per 100 PY, 95% CI 0.83–1.11) based upon 193 deaths over 20,102 PY was higher among male IDU (2.34, 1.78–3.09), female IDU (2.33, 1.59–3.39) and white heterosexual men (1.32, 0.94–1.84) compared to white heterosexual women and homosexual men (0.53, 0.29–0.95; and 0.71, 0.55–0.92). Compared to participants free of depression, mortality was slightly elevated among participants with a history of depression (1.17, 0.94–1.45 vs. 0.86, 0.71–1.03, P = 0.033). Suicides (n = 18) did not differ between HIV transmission groups (P = 0.50), but were more frequent among participants with a prior diagnosis of depression (0.18 per 100 PY, 95%CI 0.10–0.31; vs. 0.04, 0.02–0.10; P = 0.003).

Conclusions

Depression is a frequent co-morbidity among HIV-infected persons, and thus an important focus of care.

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.

Lifelong antiretroviral therapy or HIV cure: The benefits for the individual patient

There are an estimated 35 million people living with human immunodeficiency virus (HIV) globally, 19 million of whom are unaware of their HIV status and, in the absence of antiretroviral therapy (ART), will have a shortened life expectancy. Although ART remains the "gold standard" for treatment of HIV infection, the requirement for lifelong treatment poses multiple challenges for the patient. These include stigma, an untenable pill burden, side effects, and the threat of viral resistance in the case of non-compliance. This review evaluates the challenges of accessing, delivering, and sustaining ART for people living with HIV and will discuss the case for pursuing a goal of HIV cure, the potential benefits of such a cure for the individual patient, and the current potential candidates for such a cure.