Adherence to HIV care visits was associated more with mental health conditions before starting antiretroviral treatment than with recent depressive symptoms, while a detectable viral load was related to such symptoms, a new study published in Clinical Infectious Diseases has shown. Depression has previously been found to be linked to lower adherence to medication regimens, but the evidence has been unclear as to whether this also impacted clinic attendance. Study authors suggest that a higher viral load among people living with HIV who are depressed is more likely due to less-than-stellar adherence to drug schedules or the biological effect of depression on the ability of the virus to replicate than to missing doctor's appointments.
In the study, 1,057 adults living with HIV, but not yet on antiretroviral treatment, who had completed questionnaires on depressive symptoms, among other questions, were followed between 2005 and 2011 for a median of two years. The study population was drawn from the Centers for AIDS Research Network of Integrated Clinic Systems Cohort (CNICS), which includes more than 32,000 people living with HIV at eight U.S. medical centers in major urban areas. The study included six of these centers. Participants were mostly cisgender men (88%), and almost half were white (49%). The most common mode of HIV acquisition was male-to-male sex (69%), followed by heterosexual sex (17.8%) and intravenous drug use (10.4%).
Because viral load tests were not as sensitive in 2005 as they are now, the threshold for a detectable viral load was set relatively high, at 75 copies/mL. A score of 10 or above on the Patient Health Questionnaire-9 (PHQ-9), a common assessment tool with scores ranging from 0 to 27, was deemed to indicate symptoms consistent with major depressive disorder. That score is the clinical threshold for prescribing antidepressants.
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Thirty-five percent of participants had a previous mental health diagnosis, and 15% had been prescribed antidepressants. Close to a third (30%) showed recent depression symptoms at baseline (start of HIV treatment); 27% of that group had been previously diagnosed with depression. Drug use (23%) and at-risk alcohol consumption (20%) were common at baseline.
In unadjusted statistics, recent depressive symptoms conferred a 37% higher risk of having a detectable viral load over time compared with not having any depressive symptoms. After adjustment for confounders, the risk remained 28% higher for those with depression compared with no depression. Higher depression scores also conferred a greater risk of a detectable viral load, although there was little data at the high end of the scale.
The unadjusted model also yielded a 24% greater risk of missing HIV care appointments if one had recent depressive symptoms compared with no such symptoms. However, once the model was adjusted for pre-existing mental health conditions and lagged measures of depressive or anxiety symptoms, that difference disappeared. "These results suggest that for new [antiretroviral treatment] users, recent depressive symptoms are a risk factor for unsuppressed viral load, while pre-existing mental health conditions may play a larger role in HIV appointment adherence," study authors concluded.
Another study by some of the same authors, which also drew on a subset of CNICS participants, found that the length of depressive episodes impacted not only viral load and missed appointments, but also mortality. In that study, each 25% increase in the percentage of days with depression increased the chance of death by 19%. "Greater chronicity of depression increased the likelihood of failure at multiple points along the HIV care continuum," the authors of that study commented.
In his review of that earlier study, David Fawcett, Ph.D., LCSW, noted that depression is three times as common in people living with HIV than in the general population. In addition to stigma and similar social causes, neurobiological changes caused by the virus itself, as well as the side effects of some antiretrovirals, may be to blame, he said. Given that about 30% of people living with HIV resist standard psychotherapeutic treatment for depression, he called for novel approaches to deliver the needed care.
One such approach is to use trained lay people to deliver mental health care. In the U.S., regulations prohibit treatment to be dispensed by non-professionals, Fawcett told TheBodyPRO. However, peer counselors can be helpful as mental health case managers, outreach workers, and in other roles. "I have worked with peers in such a system and found it was greatly beneficial, especially in increasing other clients' initial levels of comfort and trust. It is important that peers know the limits of their training and refer to a professional when necessary," he explained.
The authors of both studies agree that routine screening for depressive symptoms is needed to keep people living with HIV virally suppressed and engaged in their care. Additional support may be necessary for those with a history of mental health issues to ensure that they don't miss appointments, they noted. Trained lay people may be helpful in providing some of that support.
Barbara Jungwirth is a freelance writer and translator based in New York.
Follow Barbara on Twitter: @reliabletran.