Every one-unit higher depression or anxiety score independently raised odds of imperfect antiretroviral adherence in Chinese men who have sex with men (MSM) newly diagnosed with HIV. Compared with no anxiety, "likely anxiety" boosted imperfect adherence odds almost five-fold.
Meta-analysis of 111 studies in low-, middle- and high-income countries determined that only an average of 71% of participants had at least 80% antiretroviral adherence to antiretroviral therapy (ART). Prevalence of depression and anxiety runs high in HIV populations, and either condition may interfere with good adherence. Because MSM account for more than 20% of new HIV infections in China, the country has adopted treatment as prevention (TasP) for this group. A U.S.-Chinese team conducted this prospective study to determine whether depression and anxiety affect antiretroviral adherence in MSM starting treatment for newly diagnosed HIV.
The analysis involved MSM in Beijing who started ART in a two-phase trial of methods to improve HIV testing and linkage to care. Every three months men self-reported antiretroviral adherence as "perfect" (missing no doses in the past three months) or "imperfect." Participants had at least one adherence measurement during 12 months of follow-up.
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Researchers used the Hospital Anxiety and Depression Scale (HADS) to measure anxiety and depression separately on 21-point scales with 0 to 7 considered normal, 8 to 10 borderline anxiety or depression and 11 to 21 likely anxiety or depression. To assess the impact of anxiety and depression on adherence, the investigators used two mixed-effect logistic regression models. Model 1 considered age, initial trial intervention assignment, study site, education, social support, stigma and drug and alcohol use; model 2 considered all those variables except drug and alcohol use.
There were 228 study participants with a median age of 28 years. While 82% had at least a college education, 87% were employed. Almost half came to Beijing from small cities or townships. Many had used alcohol (56%) or drugs (37%) in the past three months. At baseline, about one-quarter had likely depression (23%) or likely anxiety (29%). Proportions of men reporting perfect adherence were 92% at three months, 89% at six months, 88% at nine months and 88% at 12 months.
Model 1 determined that every one-unit higher depression score raised odds of imperfect adherence 16% (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 1.02 to 1.32), while every one-unit higher anxiety score raised odds of imperfect adherence 17% (aOR 1.17, 95% CI 1.03 to 1.33). Results were similar in Model 2. Compared with men who had a normal anxiety score, those with likely anxiety had almost five-fold higher odds of imperfect adherence in model 1 (aOR 4.79, 95% CI 1.12 to 20.50) and model 2 (aOR 4.83, 95% CI 1.12 to 20.71). Likely depression did not independently affect odds of imperfect adherence.
The authors note that their findings on how depression and anxiety affect antiretroviral adherence are consistent with three previous systematic reviews analyzing studies from countries around the world. The researchers suggest that peer counseling and support may be appropriate for MSM with mild or moderate anxiety or depression. "For severe cases," they propose, "antidepressant or anxiety medications may be given apart from peer counseling and support." For MSM starting antiretroviral therapy, "intensive early interventions ... beyond routine counseling" may improve adherence.
Mark Mascolini writes about HIV infection.