Since the early years of the AIDS epidemic, depression has been associated with poorer outcomes in people living with HIV (PLWH). In the pre-HAART era, PLWH with depression experienced a more rapid decline in their CD4+ cell count,1 while in the HAART era, depression has been associated with a decreased adherence to treatment.2 Untreated depression has also been associated with increased mortality among women living with HIV.3
The Women's Interagency HIV Study is a national, multi-site, longitudinal natural history study of women with HIV and women at risk for HIV. The women are interviewed semiannually, and their blood is collected to measure CD4+ cell count and viral load. Cook and colleagues looked at HAART use in a subset of women in the cohort who were diagnosed with depression. Depression was measured by the Center for Epidemiologic Studies Depression Scale (CES-D). Logistic regression analysis was used to estimate the effect of mental health treatment on HAART use, controlling for time, CD4+ cell count, viral load, demographic factors (race and income) and substance use.
There were 1,371 women (67% of the seropositive cohort) who met the CES-D criteria for depression and had at least one follow-up visit. Eighty-two percent of the women were minorities (57% African American and 25% Hispanic), 42% had a history of any crack, cocaine or heroin use during the study, and 69% earned less than $12,000/year. The average age at entry to the study was 37.8 years. Forty-four percent of the women reported use of any antidepressant therapy during the study, and 67% reported any use of mental health therapy (37% for >12 months, 15% for >24 months). Fifty-two percent reported any HAART use during one or more study visits, with 38% for >12 months and 23% for >24 months.
In the regression model, treatment with antidepressants and therapy, and treatment with therapy alone, were both associated with increased use of HAART (P<.01 and P<.05, respectively), whereas treatment with antidepressants alone was not. Other factors associated with lower HAART use included African American race; recent crack, cocaine or heroin use (last 6 months); higher CD4+ cell count; and lower viral load. The likelihood of HAART use also increased over time.
This study underscores the importance of depression as a factor in the use of HAART, and adds to a growing body of evidence that the treatment of depression is important in ensuring that PLWH can access and benefit from potentially life-saving HAART medications. This study and others found that combination treatment with both antidepressants and therapy was more effective than antidepressants alone. However, the low rates of any kind of treatment for depression were of concern, and indicate that the needs of women with multiple barriers to care and treatment are not being met.
The study leaves some questions unanswered, including why the women were not on HAART (refusal or services not offered), and why they were not receiving mental health treatment (undiagnosed depression, no access to appropriate services, or refusal of offered services). Many studies have found that women with HIV are less likely to use new HIV treatments.4 Further study into these and other questions will help us to better understand the barriers to access, and will guide effective solutions. Improving the access to and use of psychopharmacologic treatments and mental health therapy by women may be one way to continue to decrease the current gender gap in HIV care and treatment.
Burack JH, Barrett DC, Stall RD, Chesney MA, Ekstrand ML, Coates TJ. Depressive symptoms and CD4 lymphocyte decline among HIV-infected men. JAMA. December 1, 1993; 270(21):2568-2573.
Ickovics, American Journal of Public Health, 2001.
Cook JA, Grey D, Burke J, et al. Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. Am J Public Health. July 2004;94(7):1133-1140.
Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA. June 23, 1999;281(24):2305-2315.