In the Journals Plus

Depression jeopardizes HIV care

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February 21, 2018

Frequent depression increases the risk that patients with HIV will miss primary care appointments, experience treatment failure and die, according to study findings published today in JAMA.

In an observational clinical cohort of nearly 6,000 participants, Brian W. Pence, PhD, associate professor in the department of epidemiology at the University of North Carolina Gillings School of Global Public Health, and colleagues found that the percentage of days that a patient with HIV experienced depression showed a dose-response relationship with each of the three outcomes, and that even shortening the duration of depressive episodes could have important benefits in terms of care.

“Depression is one of the most common comorbidities affecting adults living with HIV, with prevalence estimates ranging from 20% to 40%,” Pence and colleagues wrote. “In addition to being a serious clinical concern, depression complicates the management of HIV: it has been linked to low adherence to antiretroviral therapy (ART), poor attendance at HIV primary care appointments, ART failure, accelerated clinical progression of HIV, and higher mortality rates.”

According to Pence and colleagues, most literature has oversimplified the burden that depression places on patients with HIV by categorizing them as either “depressed” or “not depressed” and focusing on a single HIV-related outcome rather than capturing the complexities of the issue. In contrast, Pence and colleagues said they adapted a measure commonly used in the depression treatment trial field — depression-free days — to capture the cumulative burden of depression over time and determine its effect on study participants.

They included 5,927 patients — including 5,000 men — who received HIV primary care from Sept. 22, 2005, to Aug. 6, 2015, at six academic medical centers located in geographically different regions. The median age of the patients was 44 years, and each had two or more assessments of depressive severity.

The main outcomes were missing a scheduled HIV primary care visit, a detectable HIV RNA viral load of 75 copies/mL or greater and all-cause mortality. Pence and colleagues said they used an established method to measure each patient’s percentage of days with depression (PDD).

During 10,767 person-years of follow-up, study participants had a median PDD of 14% and missed 18.8% of their scheduled primary care visits. Approximately 21.8% of viral loads were detectable and the mortality rate was 1.5 deaths per 100 person-years.

Pence and colleagues estimated that each 25% increase in PDD led to an 8% increase in the risk of missing a scheduled appointment, a 5% increase in the risk of a detectable viral load and a 19% increase in the mortality hazard. According to the researchers, this implies that a patient who experienced depression every day during the study period faced a 37% increased risk of missing appointments, a 23% increased risk for a detectible viral load and twice the mortality risk compared with a patient who experienced no days with depression.


“Even modest increases in the proportion of time spent with depression led to clinically meaningful increases in negative outcomes,” Pence and colleagues wrote. “These findings suggest the importance of promptly identifying and treating depression among adults living with HIV to shorten the course and prevent the return of their depressive illness and ultimately improve their clinical outcomes. – by Gerard Gallagher

Disclosures: The authors report no relevant financial disclosures.

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