In a study of U.S. veterans with HIV infection and depression, people who took antidepressant drugs according to schedule (good adherence) also took their antiretrovirals according to schedule most of the time.1 This finding is important because many people with HIV suffer from depression (feeling sad or unmotivated much of the time), and depression can negatively affect treatment of HIV and other diseases. The study also pinpointed other factors that affected antiretroviral and antidepressant adherence.
Depression is "a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or longer."2 Depression often affects people with HIV because of the many ongoing problems caused by HIV infection and other life problems. HIV providers may not notice depression in their patients because patients don't think about calling attention to "sadness" or "the blues." But depression is a disease that can be treated effectively with antidepressant drugs, with counseling (psychotherapy), or with both.
Much medical research shows that depression interferes with antiretroviral adherence in people with HIV. Poor adherence can lead to antiretroviral treatment failure and to development of resistant HIV that is more difficult to control. Prior research also shows that depressed HIV-positive people who take antidepressant medications have better adherence to antiretrovirals.
Veterans Affairs researchers conducted this new study to measure adherence in depressed HIV-positive veterans who were taking (1) antiretrovirals, (2) antidepressants, or (3) both antiretrovirals and antidepressants. The researchers also aimed to identify factors that made good adherence more or less likely. Finally, they wanted to see if people with good antidepressant adherence also had good antiretroviral adherence, and if people with good antiretroviral adherence also had good antidepressant adherence.
This adherence study is part of a larger trial called HIV Translating Initiatives for Depression into Effective Solutions (HI-TIDES).3,4 The goal of HI-TIDES was to see if a new approach to caring for HIV-positive people with depression worked better than the standard approach used in many HIV clinics.
To be included in HI-TIDES, veterans had to have major depression,2 had to be cared for at one of three Veterans Administration HIV clinics, had to be at least 18 years old, and had to have telephone access. Study participants could not be thinking about suicide, could not have significant cognitive impairment (problems with memory, language, thinking, or judgment), and could not have had a major mental disease (bipolar disorder, manic depression, or schizophrenia).
All study participants took standard tests to detect signs of depression, to rate the severity of depression, and to identify mental disorders such as depression, anxiety, attention-deficit-hyperactivity disorder, and anorexia.
Everyone in the adherence study had depression. All of them reported the number of pills per day they were supposed to take and the number of pills they skipped taking for each antiretroviral or antidepressant for the past 4 days. The researchers used these results to figure whether people had less than 90% adherence or 90% or better adherence.
Finally, the researchers used standard statistical methods to identify factors that affected adherence to antiretrovirals and adherence to antidepressants. This type of analysis can single out factors that affect adherence regardless of what other adherence risk factors a person has.
The adherence study focused on 225 HIV-positive veterans with depression, including 192 (85%) taking antiretrovirals, 146 (65%) taking antidepressants, and 113 (50%) taking both antiretrovirals and antidepressants. Almost all study participants (97%) were men, and most (93%) graduated from high school.
Most study participants (60%) were African American, a proportion that reflects the HIV rate by race across the United States. Age in this study group averaged 50, which is somewhat older than the average age of HIVpositive people in the United States.
According to standard test results, more than 75% of study participants had major depression, and 75% had at least one other mental health disorder.
Two thirds to three quarters of study participants reported 90% or better adherence, depending on whether they were taking antiretrovirals, antidepressants, or both antiretrovirals and antidepressants:
Statistical analysis singled out four factors that affected chances or antiretroviral adherence or antidepressant adherence, regardless of whatever other risk factors a person had (Figure 1): Older age and less severe HIV symptoms independently raised chances of 90% or better antiretroviral adherence. More education lowered chances of good antiretroviral adherence. Having a generalized anxiety disorder independently raised chances of 90% or better antidepressant adherence.
Figure 1. Three factors independently affected chances of 90% or better antiretroviral adherence in a study of 225 U.S. veterans with HIV and depression. One factor independently raised chances of 90% or better antidepressant adherence.
Further analysis determined that good antidepressant adherence predicted good antiretroviral adherence. In other words, people who took their antidepressants on schedule 90% of the time or more also usually took their antiretrovirals on schedule 90% of the time or more. However, antiretroviral adherence did not predict who would take their antidepressants on schedule.
This study found high rates of adherence to antiretrovirals and antidepressants in HIV-positive U.S. veterans with depression.1 Three quarters of study participants taking antiretrovirals took them on schedule at least 90% of the time, and three quarters of those taking antidepressants took them on schedule at least 90% of the time. Among people prescribed both antiretrovirals and antidepressants, two thirds took both on schedule at least 90% of the time.
Poor antiretroviral adherence (missing doses) can result in treatment failure and can allow HIV to become resistant to the antiretrovirals you're taking. Resistant virus may no longer respond to those antiretrovirals or to other antiretrovirals in the same drug class, and that makes planning another antiretroviral combination more difficult.
People with untreated depression run a high risk of poor antiretroviral adherence when they become too sad or unmotivated to care about their health. That's why it's important for HIV-positive people with depression to talk to their HIV provider about their feelings and to begin treatment for depression if necessary. Depression can be treated with drugs (antidepressants), with counseling (psychotherapy), or with both.
The National Library of Medicine has a useful guide to depression online (see link at reference 2 below). The National Institute of Mental Health (NIMH) has helpful online booklets about depression, including booklets en Español, easy-to-read booklets, and a booklet on depression in people with HIV. To find them, click here. The NIMH lists the following signals of depression:
Several studies done before this one found that depressed HIV-positive people taking antidepressants had better adherence to antiretrovirals. This new study confirms that people with good adherence to antidepressants are more likely to have good adherence to antiretrovirals. Good adherence to both types of medicine is necessary to control depression and to control HIV.
Among people taking antidepressants, it may be necessary to continue taking these drugs for a while even after feelings of depression disappear. One study showed that fewer than half of people completed a recommended 6-month course of antidepressant therapy.5 Stopping antidepressant therapy before the recommended date can allow symptoms of depression to reappear.
This study identified four factors that affect chances of adherence to antiretrovirals or antidepressants (Figure 1). Older people had better antiretroviral adherence in this study, as in several earlier studies. That could mean older people generally take greater responsibility for their own health than younger people. Even young people with HIV should realize that HIV infection and depression are serious illnesses: HIV cannot be controlled without good antiretroviral adherence, and good adherence to antidepressants is essential if your provider prescribes them.
The study also found that people with less severe HIV symptoms adhered to antiretrovirals better than people with more severe symptoms. The researchers suggest that people who feel better when their HIV symptoms improve may be more motivated to maintain their good health by taking their antiretrovirals as scheduled. People who still have symptoms of HIV infection after they begin treatment should realize that taking antiretrovirals regularly is necessary to control their HIV symptoms.
Unlike some previous studies, this study found that people with more education had worse antiretroviral adherence. The researchers point out that this finding is hard to interpret because almost all study participants had at least a high-school education.
People with an anxiety disorder had better adherence to antidepressants than people without anxiety. The researchers say that could mean that people with anxiety and a tendency to worry may pay more attention to adherence. At the same time, no one wants to have continuing anxiety, and people with ongoing anxiety should talk about it with their provider. There are effective treatments for anxiety disorder.
The researchers point out an important limitation of their study: All study participants were veterans, almost all of them were men, and the average age was older than in most HIV groups in the United States. So findings may not apply to other HIV groups, including women and younger people. But the study did include a high proportion of African-American men with HIV. And the study provides important reminders for everyone with HIV about getting treatment for depression and taking antidepressants and antiretrovirals regularly, according to your provider's instructions.