Chronic Depression Increases Failure of HIV Care

Brian Pence, PhD, associate professor,Gillings School of Global Public Health, The University of North Carolina at Chapel Hill

Brian Pence, PhD

A recent study published in JAMA Psychiatry concluded that the greater chronicity of depression elevated the risk of missed appointments, treatment failure and mortality for adults living with HIV.

Study authors examined the association between increased chronicity of depression and multiple HIV care continuum indicators. The findings suggest the importance of promptly identifying and treating depression among adults in order to shorten the course and prevent the return of depression — ultimately improving patients’ outcomes.

"We know that depression is very common among those with HIV, we know it is widely underdiagnosed and undertreated, and we know it’s a big barrier to successful HIV care," lead author, Brian Pence, PhD, associate professor, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, told MD Magazine. "The sooner it’s identified, the sooner it can be addressed both as a health issue and as a barrier to care."

In the large clinical cohort study, a greater time spent with depression was associated in a dose-response fashion with a higher risk of missing appointments for care, a higher risk of detectable viral load and higher mortality rates.

Missed HIV primary care appointments were measured from administration appointment data and defined as whether a particular scheduled appointment was kept or missed. Detectable HIV viral load was defined as a HIV RNA viral load measure of 75 copies/mL or more based on the highest limit of detection among the viral load assays used during the study period. Mortality was defined as date of death from any cause.

The study comprised of 5927 patients with 2 or more assessments of depressive severity who were receiving HIV primary care at 6 geographically dispersed US academic medical centers from Sept. 22, 2005—Aug. 6, 2015.

Of the participants, the median age was 44 years old, approximately half of the participants were white and 84% were male. At the start of the study, most participants had CD4 T-cell counts of 350 cells/mm 3 or more (69.4%), were receiving antiretroviral therapy (77.4%) and had a suppressed viral load (63.4%).

The main study outcomes included missing a scheduled HIV primary care appointment, a detectable HIV RNA viral load ≥75 copies/mL and all-cause mortality. Consecutive depressive severity measures were converted into percentage of days with depression (PDD), following established methods of determining depression-free days. Depressive symptoms were assessed every 6 months.

"I think integrating mental health services into HIV care is key," Pence added. "Already many HIV clinics do their best to support the “whole patient” rather than just treat the infection. No one likes going around to multiple different health care providers, especially those facing insurance challenges as many people do who have HIV. And stigma makes many people reluctant to pursue a referral to a mental health agency."

Participants were followed for 10,767 person-years and during this time, researchers found the median PDD was 14%. A little less than a third of participants (31%) had no days with depression, while 4% reported depression every day.

During follow-up, 18.8% of scheduled visits were missed, 21.8% of viral loads were above the limit of detection and there were 158 deaths (1.5 deaths per 100 person-years).

Each 25% increase in PDD led to an 8% increase in the risk of missing a scheduled appointment (risk ratio, 1.08), a 5% increase in the risk of having a detectable viral load (risk ratio, 1.05) and a 19% increase in mortality risk (hazard ratio, 1.19).

Compared to those who did experience depression, those who were chronically depressed faced a 37% increase in the risk of missing appointments (risk ratio 1.37) a 23% increase in the risk of having a detectable viral load (risk ratio 1.23) and a doubled mortality risk (hazard ratio 2.02).

"Being able to offer mental health care as part of HIV clinical services, whether that be through the provider’s willingness to manage antidepressants and/or integration of additional behavioral health staff, will likely improve overall engagement in care," Pence said. "Integrating routine depression screening and making sure the results of that screening rapidly get to the entire clinical care team are a big first step."

Study results indicate that even short-term or mild depression like 1 in 4 days spent fully depressed or persistent mild depressive symptoms can have a meaningful negative outcome on treatment and survival.

“These findings, which suggest that systematic screening and enhanced treatment to shorten the duration of depressive illness may have multiple benefits, stand in contrast with the trend in HIV treatment guidelines toward less frequent monitoring of patients whose disease is stable with treatment,” researchers concluded.

The study, "Association of Increased Chronicity of Depression With HIV Appointment Attendance, Treatment Failure, and Mortality Among HIV-Infected Adults in the United States" was published in January 2018 in JAMA Psychiatry.

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