In a study of U.S. veterans with HIV infection and depression, people who took antidepressant drugs according to schedule (good adherence) also took their antiretrovirals according to schedule most of the time.1 This finding is important because many people with HIV suffer from depression (feeling sad or unmotivated much of the time), and depression can negatively affect treatment of HIV and other diseases. The study also pinpointed other factors that affected antiretroviral and antidepressant adherence.
Depression is "a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or longer."2 Depression often affects people with HIV because of the many ongoing problems caused by HIV infection and other life problems. HIV providers may not notice depression in their patients because patients don't think about calling attention to "sadness" or "the blues." But depression is a disease that can be treated effectively with antidepressant drugs, with counseling (psychotherapy), or with both.
Much medical research shows that depression interferes with antiretroviral adherence in people with HIV. Poor adherence can lead to antiretroviral treatment failure and to development of resistant HIV that is more difficult to control. Prior research also shows that depressed HIV-positive people who take antidepressant medications have better adherence to antiretrovirals.
Veterans Affairs researchers conducted this new study to measure adherence in depressed HIV-positive veterans who were taking (1) antiretrovirals, (2) antidepressants, or (3) both antiretrovirals and antidepressants. The researchers also aimed to identify factors that made good adherence more or less likely. Finally, they wanted to see if people with good antidepressant adherence also had good antiretroviral adherence, and if people with good antiretroviral adherence also had good antidepressant adherence.
This adherence study is part of a larger trial called HIV Translating Initiatives for Depression into Effective Solutions (HI-TIDES).3,4 The goal of HI-TIDES was to see if a new approach to caring for HIV-positive people with depression worked better than the standard approach used in many HIV clinics.
To be included in HI-TIDES, veterans had to have major depression,2 had to be cared for at one of three Veterans Administration HIV clinics, had to be at least 18 years old, and had to have telephone access. Study participants could not be thinking about suicide, could not have significant cognitive impairment (problems with memory, language, thinking, or judgment), and could not have had a major mental disease (bipolar disorder, manic depression, or schizophrenia).
All study participants took standard tests to detect signs of depression, to rate the severity of depression, and to identify mental disorders such as depression, anxiety, attention-deficit-hyperactivity disorder, and anorexia.
Everyone in the adherence study had depression. All of them reported the number of pills per day they were supposed to take and the number of pills they skipped taking for each antiretroviral or antidepressant for the past 4 days. The researchers used these results to figure whether people had less than 90% adherence or 90% or better adherence.
Finally, the researchers used standard statistical methods to identify factors that affected adherence to antiretrovirals and adherence to antidepressants. This type of analysis can single out factors that affect adherence regardless of what other adherence risk factors a person has.
The adherence study focused on 225 HIV-positive veterans with depression, including 192 (85%) taking antiretrovirals, 146 (65%) taking antidepressants, and 113 (50%) taking both antiretrovirals and antidepressants. Almost all study participants (97%) were men, and most (93%) graduated from high school.
Most study participants (60%) were African American, a proportion that reflects the HIV rate by race across the United States. Age in this study group averaged 50, which is somewhat older than the average age of HIVpositive people in the United States.
According to standard test results, more than 75% of study participants had major depression, and 75% had at least one other mental health disorder.
Two thirds to three quarters of study participants reported 90% or better adherence, depending on whether they were taking antiretrovirals, antidepressants, or both antiretrovirals and antidepressants:
Statistical analysis singled out four factors that affected chances or antiretroviral adherence or antidepressant adherence, regardless of whatever other risk factors a person had (Figure 1): Older age and less severe HIV symptoms independently raised chances of 90% or better antiretroviral adherence. More education lowered chances of good antiretroviral adherence. Having a generalized anxiety disorder independently raised chances of 90% or better antidepressant adherence.
Figure 1. Three factors independently affected chances of 90% or better antiretroviral adherence in a study of 225 U.S. veterans with HIV and depression. One factor independently raised chances of 90% or better antidepressant adherence.
Further analysis determined that good antidepressant adherence predicted good antiretroviral adherence. In other words, people who took their antidepressants on schedule 90% of the time or more also usually took their antiretrovirals on schedule 90% of the time or more. However, antiretroviral adherence did not predict who would take their antidepressants on schedule.
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