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Women, HIV and Depression

By Sarah Swofford and Kialing Perez, M.D.

Summer 2006

According to the National Institutes of Health, women are far more likely than men to suffer from depression. Some NIH statistics show a two-to-one ratio of women with depression compared to men, regardless of race, ethnicity, and/or economic status. Studies so far have not clearly shown why this gender difference exists but it is believed that certain experiences that are unique in women's lives are at play, such as social and biological factors. A primary reason that is often cited is the burden related to many women's role of being primary caregivers. Often women forsake getting health and mental health treatment for themselves when they have caregiving responsibilities. Lack of economic resources, education, and social support are also factors that seem to contribute to women's higher incidence of depression.

HIV positive women who also suffer from depression have an increased health burden.

Women-focused research is often lacking in many fields and studies on HIV and mental health as it specifically relates to women are unfortunately no exception. However, the small amount of research available on this topic seems to suggest that HIV positive women have an increased risk of suffering from depressive symptoms. Additionally, studies have found links between the mental health of HIV positive women and disease progression. It's been demonstrated that HIV positive women with major depression go to their medical visits with less regularity, are less adherent to their treatment, are more likely to progress quickly to AIDS, and have a higher mortality rate. A better understanding of depression in HIV positive women can help to not only slow disease progression, but also may also improve adherence to HAART (highly active antiretroviral therapy). Service providers who care for HIV positive women must also consider the mental heath of their patients, along with their HIV care.

Some research has been done to attempt to establish a relationship between depression and disease progression in women with HIV. A 2005 study by the University of Pennsylvania Department of Psychology (Cruess, DG ) found that women who recovered from depression had significant increases in natural killer cell activity (a type of white blood cell involved in the immune response). Taking into consideration that HIV can also decrease the number of cells involved in the immune response, the presence of depression could further compromise the health of the immune system.

The Women's Interagency HIV Study (WIHS) is the most comprehensive study on depression and HIV positive women. Between 1994 and 2001, 1,716 women with HIV were followed in clinics in Brooklyn, Bronx, Chicago, Los Angeles, San Francisco, and Washington D.C. It found that the incidence of death was 1.7 times higher in chronically depressed women with HIV than those without depression, after controlling for other factors such as CD4 counts, viral load, and the use of HAART. For those women who established contact with a mental health provider, the risk of death was decreased by half. The study also found that women using HAART had a lower risk of depression, but that chronically depressed HIV-positive women who died had a severe clinical depression in the year before their death. This means that diagnosing depression not only improves treatment adherence but also influences disease progression and mortality through mechanisms that are not clearly understood.

An analysis of the women in the WIHS found that HIV-positive women with behavioral disorders have less of a chance of initiating or maintaining adherence to HAART. A study published in the Journal of the International Neuropsychological Society in 2002 determined that the incidence of behavioral disorders was higher for HIV-positive women as compared to HIV-negative women. It was also found that that those women who were not taking HAART had a twice higher incidence to have some neuropsychological impediment.

According to a study by the University of Sao Paolo School of Medicine in the Brazilian Journal of Psychiatry in 2006, symptomatic HIV-positive women have a higher incidence of depression than asymptomatic HIV-positive women. The article notes the lack of research on the onset and progression of depression throughout the clinical course of HIV/AIDS, pointing out the continued need to establish a relationship between HIV disease progression and depression.

Studies show that there is a direct correlation between depression and HIV disease progression. It has also been observed that adherence to HAART and initiating treatment is less likely in chronically depressed HIV positive women. Mental health services, antidepressant medications and psychological therapy are necessities to improve the lives (and in some cases save the lives) of HIV positive women with depression. It is extremely important that HIV positive patients have a treatment plan that includes psychological evaluation, not only to improve adherence to HIV treatment and social support, but also as studies show, to improve the immune response that could be additionally deteriorated by mental illness.

Sarah Swofford is an HIV Health Educator at ACRIA. Kialing Perez, M.D., is a resident in Internal Medicine at Flushing Hospital.

English translation by Luis Scaccabarrozzi.

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