Psychopathology in male and female HIV-positive and negative injecting drug users: longitudinal course over 3 years

The prevalence and outcomes of depression in older HIV-positive adults in Northern Tanzania: a longitudinal study

Studies of depression and its outcomes in older people living with HIV (PLWH) are currently lacking in sub-Saharan Africa. This study aims to investigate the prevalence of psychiatric disorders in PLWH aged ≥ 50 years in Tanzania focussing on prevalence and 2-year outcomes of depression. PLWH aged ≥ 50 were systematically recruited from an outpatient clinic and assessed using the Mini-International Neuropsychiatric Interview (MINI). Neurological and functional impairment was assessed at year 2 follow-up. At baseline, 253 PLWH were recruited (72.3% female, median age 57, 95.5% on cART). DSM-IV depression was highly prevalent (20.9%), whereas other DSM-IV psychiatric disorders were uncommon. At follow-up (n = 162), incident cases of DSM-IV depression decreased from14.2 to 11.1% (χ2: 2.48, p = 0.29); this decline was not significant. Baseline depression was associated with increased functional and neurological impairment. At follow-up, depression was associated with negative life events (p = 0.001), neurological impairment (p < 0.001), and increased functional impairment (p = 0.018), but not with HIV and sociodemographic factors. In this setting, depression appears highly prevalent and associated with poorer neurological and functional outcomes and negative life events. Depression may be a future intervention target.

Difference in the neurocognitive functions of WLWH and MLWH in an Italian cohort of people living with HIV

Based on the available literature, women living with HIV (WLWH) seem to show greater cognitive and emotional disadvantages than men living with HIV (MLWH). Our aim was to compare the cognitive performance of MLWH and WLWH in an Italian cohort of People Living With HIV (PLWH) and to analyse factors potentially contributing to sex differences in cognitive function. We ran a retrospective, cross-sectional analysis of a monocentric dataset of PLWH who were administered a standardized neuropsychological test battery (SNB) during routine clinical care. We enrolled 161 Italian PLWH who are on combined antiretroviral therapy (cART): 114 (70.8%) MLWH and 47 (29.2%) WLWH.

Global cognitive performance (composite z score) (GCP) was significantly higher in MLWH than WLWH [mean 0.19 (SD 0.85) vs − 0.13 (SD 0.96); p = 0.039]. Moreover, WLWH obtained significantly higher scores on the Zung Depression Scale than MLWH [mean 41.8 (SD 10.9) vs 36.7 (SD 9.2); p = 0.003]. However, there was no statistically significant direct effect between male sex and better GCP (p = 0.692) in the context of a mediation model. On the contrary, the associations between male sex and better GCP were mediated by higher level of education (a*b =  + 0.15, Bootstrap CI95 = 0.05 and 0.27) and a lower Zung depression score (a*b =  + 0.10, Bootstrap CI95 = 0.02 and 0.21).

In conclusion, the global cognitive performance of WLWH is lower than that of MLWH. However, other demographic and clinical factors besides sex might help explain differences in their neurocognitive functions and make it possible for us to monitor them and identify those patients most in need.

Mental Health in Women Living With HIV: The Unique and Unmet Needs

Women living with HIV (WLWH) experience depression, anxiety, and posttraumatic stress symptoms at higher rates than their male counterparts and more often than HIV-unaffected women. These mental health issues affect not only the well-being and quality of life of WLWH, but have implications for HIV management and transmission prevention. Despite these ramifications, WLWH are under-treated for mental health concerns and they are underrepresented in the mental health treatment literature. In this review, we illustrate the unique mental health issues faced by WLWH such as a high prevalence of physical and sexual abuse histories, caregiving stress, and elevated internalized stigma as well as myriad barriers to care. We examine the feasibility and outcomes of mental health interventions that have been tested in WLWH including cognitive behavioral therapy, mindfulness-based interventions, and supportive counseling. Future research is required to address individual and systemic barriers to mental health care for WLWH.

Gender differences among criminal justice-involved persons living with HIV interested in extended-release naltrexone treatment

Background: Previous research has shown gender differences with respect to entry into medication treatment of substance use disorders (SUDs), yet few have examined gender differences among participants consented to be treated with extended-release naltrexone (XR-NTX). Understanding gender differences is critical to developing interventions to overcome barriers to initiation of and retention on medication treatment for SUDs. Methods: Data from two double-blind placebo-controlled trials of XR-NTX among persons with HIV and alcohol or opioid use disorders leaving the criminal justice system (CJS) were analyzed for gender differences among clinical characteristics, mental health, drug use severity, and other domains. The study that recruited persons with alcohol use disorder (AUD) was conducted from September 2010-February 2016 at two sites in Connecticut (CT), and the opioid use disorder (OUD) study was conducted from September 2010-March 2016 at three sites in CT and one site in Massachusetts. Results: Baseline data were analyzed from 193 participants consented to be randomized to XR-NTX or placebo; 40 women and 153 men. Women were younger, had worse mental health severity, and were more likely to be diagnosed with cocaine use disorder. There were no statistical differences between men and women in the prescription of antiretroviral therapy (ART) or ART adherence. Conclusions: Women had greater mental health severity and a higher prevalence of cocaine use as compared to men, both of which are known to be barriers to engagement and retention on medication treatment for alcohol and opioid use disorders. For women with CJS involvement and living with HIV and SUDs, understanding factors that may affect initiation and retention on medication treatment of SUDs are necessary to improve treatment outcomes in women.

Longitudinal trajectories of emotional problems and unmet mental health needs among people newly diagnosed with HIV in China

INTRODUCTION

Concern over mental health morbidity affecting people living with HIV is increasing worldwide. The objective of this study was to describe the longitudinal trajectories of depression and anxiety, and mental health service utilization among people newly diagnosed with HIV.

METHODS

This was an observational cohort study that enrolled people newly diagnosed with HIV consecutively and followed them for one year in Changsha, China. Socio-demographic, clinical and psychological data were collected at the baseline and at one-year follow-up. Participants were recruited between March 1, 2013 and September 30, 2014. The final follow-up was in September 30, 2015.

RESULTS

Among 557 people newly diagnosed with HIV enrolled at the baseline, 410 (73.6%) completed the one-year follow-up survey (median (interquartile range) age at follow-up: 29 (25, 39) years; 376 men (91.7%)), and were included in the analysis. 39.3% and 30.2% of the 410 participants were screened with significant symptoms of depression and anxiety at baseline respectively. An overall drop in the prevalence of each condition was found at follow-up, however, 10.5% and 6.1% of participants were found to have persistent depression and anxiety. The results of mixed-effect models showed that bisexuality, homosexual transmission, other clinical symptoms (for example, not on antiretroviral therapy (ART)), non-disclosure, higher levels of HIV/AIDS-related stress, and lack of social support were associated with significant symptoms of depression and anxiety. One year after diagnosis, 8.3% had visited healthcare providers for emotional or psychological problems.

CONCLUSIONS

Despite the obvious need people newly diagnosed with HIV in China rarely seek professional help. Integrating depression and anxiety screening and referral into HIV care settings is warranted.

Do Symptoms of Depression Interact with Substance Use to Affect HIV Continuum of Care Outcomes?

Few studies examine how depression and substance use interact to affect HIV control. In 14,380 persons with HIV (PWH), we used logistic regression and generalized estimating equations to evaluate how symptoms of depression interact with alcohol, cocaine, opioid, and methamphetamine use to affect subsequent retention in care, maintaining an active prescription for ART, and consistent virologic suppression. Among PWH with no or mild depressive symptoms, heavy alcohol use had no association with virologic suppression (OR 1.00 [0.95-1.06]); among those with moderate or severe symptoms, it was associated with reduced viral suppression (OR 0.80 [0.74-0.87]). We found no interactions with heavy alcohol use on retention in care or maintaining ART prescription or with other substances for any outcome. These results highlight the importance of treating moderate or severe depression in PWH, especially with comorbid heavy alcohol use, and support multifaceted interventions targeting alcohol use and depression.

African born women living with HIV in the United States: unmet needs and opportunities for intervention

Africa born (immigrant) women comprise a disproportionate number of Black women living with HIV in the United States. Though they are at risk for mental health disorders, including psychological distress and depression, little is known about their experience with these important predictors of quality of life, retention in care and adherence to antiretroviral therapy. In this qualitative study, we used constructivist grounded theory to explore the psychosocial and mental health challenges of African born women living with HIV in Boston and New York City. We conducted one-on-one semi-structured interviews with 45 women. Major themes contributing to psychological distress and depressive symptoms included (1) pre-immigration HIV-related stigma; (2) persistent HIV-related stigma post-immigration, (3) undocumented immigration status, (4) economic insecurity, and (5) intimate partner violence (IPV). Many participants described ongoing depressive symptoms or histories of depressive episodes. Yet, most had not been formally diagnosed or treated for depression. Prayer, consultation with faith leadership, and support groups were described most frequently as useful interventions. Future research should explore these thematic areas among a larger, more representative sample of African born women living with HIV to determine differences by country of origin across thematic areas. These data would be useful to inform development of innovative and culturally appropriate interventions.

Cocaine-using substance abuse treatment patients with and without HIV respond well to contingency management treatment

HIV is common among individuals with substance use disorders, but relatively few studies have examined the impact of HIV status on response to substance abuse treatment. This secondary analysis compared patients seeking treatment for cocaine use with and without HIV in terms of substance use treatment outcomes. Primary treatment outcomes included treatment retention, longest duration of abstinence, and percent of negative samples; both substance use outcomes reflect abstinence from cocaine, alcohol and opioids concurrently. Participants (N=432) were enrolled in randomized clinical trials comparing contingency management (CM) to standard care, and 32 (7%) reported being positive for HIV. Overall, CM improved both treatment retention (average of 8.2weeks compared to 6.0weeks in the standard care condition) and longest duration of abstinence (average of 5.8weeks compared to 2.8weeks in the standard care condition). HIV status was not associated with treatment outcomes as a main effect, nor did it have an interaction effect with treatment condition. These results suggest a benefit of CM in substance abuse treatment irrespective of HIV status.

An assessment of the levels of perceived social support among older adults living with HIV and AIDS in Dublin

Objectives

To determine the level of perceived social support among older adults living with HIV and AIDS in Dublin.

Methods

The study utilized a cross-sectional survey design to collect data from 46 adults aged 50 years or older who are members of open heart house (OHH) in Ireland, a peer support network for people living with HIV and AIDS. Participants completed a set of interviewer-assisted questionnaires, which included the multidimensional measure of perceived social support (PSS) to assess the level of social support.

Results

Levels of PSS among participants were observed as follows: 54 % had low PSS, 33 % had a moderate PSS and 13 % had high PSS. A fifth of the study participants had a history of injection drug use (IDU) and this group reported higher PSS scores in general than non-IDU’s (H = 79.500, Z = −2.678, p = 0.006). PSS scores were observed to be higher in general among participants with longer duration of infection [H(2) = 7.856, p = 0.020].

Conclusion

Despite its limitations, this study provides vital information about the level of social support among older people living with HIV and AIDS at OHH Dublin. An unexpected but interesting finding was the positive relationship between IDU and PSS level. Formulation of strategies to enable older PLHA to be more proactive members of their community through a peer support network sponsored volunteer services should be encouraged.

Predictors of Attrition in a Cohort Study of HIV Infection and Methamphetamine Dependence

Longitudinal cohort studies of HIV and substance use disorders play an important role in understanding these conditions, but high rates of attrition can threaten their integrity and generalizability. This study aimed to identify factors associated with attrition in a 5-year observational cohort study of 469 individuals with and without HIV infection and methamphetamine (MA) dependence. Rates of attrition in our four study groups were approximately 24% in HIV-MA-, 15% in HIV+MA-, 56% in HIV-MA+, and 47% in HIV+MA+ individuals. Predictors of attrition in the overall cohort included history of MA, alcohol, and other substance dependence, learning impairment, reduced cognitive reserve, and independence in activities of daily living (all ps < .05), but varied somewhat by clinical group. Of particular note, enrollment in a neuroimaging substudy was associated with significantly boosted rates of retention in the MA groups. Results from this investigation highlight the complexity of the clinical factors that influence retention in cohort studies of HIV-infected MA users and might guide the development and implementation of targeted retention efforts.

Gender Differences in Severity and Correlates of Depression Symptoms in People Living with HIV in Ontario, Canada

This study investigates the differences in severity and correlates of depression symptoms among 1069 men and 267 women living with HIV in Ontario, Canada, who completed the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). Women had higher CES-D scores than that of men (median [interquartile range]: 13 [5-26] versus 9 [3-20], P = .0004). More women had total CES-D scores >15 (mild-moderate depression; 44% versus 33%, P = .002) and >21 (severe depression; 31% versus 23%, P = .003). Unlike men, at age 40, women’s scores increased yearly (0.4 per increased year, P = .005). The distribution of scores differed by gender: There was no difference in the 10th percentile of depression scores, 0 (95% confidence interval [CI]: 1.0-1.0) but the 75th percentile of depression scores for women was 6 (95% CI: 2.0-10.0) points higher than that of men. Important gender differences exist in depression symptoms and in correlates of symptoms in people living with HIV.

Depression and resilience in women with HIV and early life stress: does trauma play a mediating role? A cross-sectional study

OBJECTIVES

The present study sought to assess the relationship between depressive symptomatology and resilience among women infected with HIV and to investigate whether trauma exposure (childhood trauma, other discrete lifetime traumatic events) or the presence of post-traumatic stress symptomatology mediated this relationship.

DESIGN

Cross-sectional study.

SETTING

Western Cape, South Africa.

PARTICIPANTS

A convenience sample of 95 women infected with HIV in peri-urban communities in the Western Cape, South Africa. All women had exposure to moderate-to-severe childhood trauma as determined by the Childhood Trauma Questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

We examined the relationship between depressive symptomatology and resilience (the Connor-Davidson Resilience Scale) and investigated whether trauma exposure or the presence of post-traumatic stress symptomatology mediated this relationship through the Sobel test for mediation and PLS path analysis.

RESULTS

There was a significant negative correlation between depressive symptomatology and resilience (p=<0.01). PLS path analysis revealed a significant direct effect between depression and resilience. On the Sobel test for mediation, distal (childhood trauma) and proximal traumatic events did not significantly mediate this association (p=> 0.05). However, post-traumatic stress symptomatology significantly mediated the relationship between depression and resilience in trauma-exposed women living with HIV.

CONCLUSIONS

In the present study, higher levels of resilience were associated with lower levels of self-reported depression. Although causal inferences are not possible, this suggests that in this sample, resilience may act as protective factor against the development of clinical depression. The results also indicate that post-traumatic stress symptoms (PTSS), which are highly prevalent in HIV-infected and trauma exposed individuals and often comorbid with depression, may further explain and account for this relationship. Further investigation is required to determine whether early identification and treatment of PTSS in this population may ameliorate the onset and persistence of major depression.

Health-related quality of life and physical functioning in people living with HIV/AIDS: a case-control design

BACKGROUND

Health-Related Quality of Life (HRQoL) and functional exercise capacity are important area of therapeutic interventions needed to improve the general health of People Living with HIV/AIDS (PLWH). However, the relationship between self-report and Performance-based Measure of Functional Capacity (PMFC) of PLWH is still obscure. This study compared the HRQoL and PMFC between a homogenous sample of clinical stage I PLWH and apparently healthy controls.

METHODS

This case-control study involved 74 consenting participants (37 PLWH and 37 controls) who completed the self-report SF-12 questionnaire and PMFC assessment using Six Minute Walk Test (6MWT). PMFC was expressed in terms of Six-Minute Walk Distance (6MWD), Six-Minute Walk Work (6MWW) and Maximum oxygen uptake (VO2max). Data were analyzed using descriptive statistics of mean and inferential statistics of independent t-test, ANOVA and Pearson's product moment correlation. Alpha level was set at 0.05.

RESULTS

There was no significant difference in the SF-12 Physical-health Component Score (PCS) of PLWH and the controls (p=0.782). However, the SF-12 Mental-health Component Score (MCS) of PLWH was higher than that of controls (p=0.040). 6MWD, 6MWW and VO2max were significantly lower for PLWH (p<0.05). Among PLWH, there was no significant gender differences in the PMFC (p>0.05) while PCS was higher among females. There was no significant correlation between PMFC variables and each of PCS and MCS for PLWH and controls (p>0.05) respectively.

CONCLUSION

Self-report physical health of clinical stage 1 PLWH and controls was comparable, while self-report mental health capacity was higher in PLWH than the controls. PMFC of PLWH was significantly lower compared to healthy controls without gender bias. Overall, self-report and performance-based measure of physical functional capacity of PLWH was not inter-related. Therefore understanding the factors that may influence exercise capacity of PLWH may help to develop effective exercise programmes for PLWH.

Prevalence of psychiatric disorders among young injection drug users

BACKGROUND

Studies of individuals in treatment for substance use have found high rates of psychiatric disorders, however little is known about the mental health of drug users not in treatment. This study aimed to assess the prevalence of lifetime and recent substance use and psychiatric disorders among young injection drug users (IDU) outside of a treatment setting.

METHODS

Participants were recruited through outreach and respondent-driven sampling. Trained interviewers administered the Psychiatric Research Instrument for Substance and Mental Disorders. Interviews were conducted at two field stations operated by Community Outreach Intervention Projects in Chicago. Participants were 570 young adults (18-25 years) who injected drugs in the previous 30 days. Heroin was the primary drug used in this sample. Past 12-month and lifetime substance use disorders and primary and substance-induced mental disorders were based on DSM-IV diagnostic criteria.

RESULTS

Nearly all participants met the criteria for heroin dependence. Multiple substance use disorders were common; cannabis was the most common substance involved after heroin, followed by alcohol and cocaine. Major depression, alcohol dependence, antisocial personality disorder, and borderline personality disorder were highly prevalent. Other psychiatric disorders were observed at levels consistent with other young adult samples.

CONCLUSIONS

Young IDU experience major depression, alcohol dependence, anti-social personality disorder, and borderline personality disorder at high rates, and multiple substance use disorders are common. Anxiety disorders in this population appear to be similar in prevalence to young adults in general.

Modified therapeutic community aftercare for clients triply diagnosed with HIV/AIDS and co-occurring mental and substance use disorders

This clinical trial evaluated a modified therapeutic community aftercare (MTC-A) program for a population triply diagnosed with HIV/AIDS, a substance use disorder, and a mental disorder. After six months of MTC residential treatment (MTC-R), subjects were randomly assigned to MTC-A (n=42) or to standard aftercare (C; n=34). Follow-up interviews at six and 12 months assessed eight outcome domains and adherence to prescribed HIV medication. A propensity model was used to re-balance the retrieved sample. At the six-month follow-up, High stratum MTC-A clients (those with greater psychological functioning and stable physical health at baseline) had greater improvement overall and for substance use and mental health than C clients in the same stratum. In contrast, C clients in the Low/Medium stratum (those with poorer psychological functioning and improved physical health) had more favorable outcomes overall and for substance use than their MTC-A counterparts; however, this stratum was not re-balanced effectively. Differences in HIV medication adherence were not detected. Clients with greater psychological functioning and stable health at treatment entry benefit more from the MTC-A program. In view of the potentially progressive nature of HIV, measuring physical and mental health during treatment and controlling for changes could be important in future research.

The influence of depression on the progression of HIV: direct and indirect effects

The authors suggest a theoretical model of pathways of HIV progression, with a focus on the contributions of depression-as well as secondary, behavioral and emotional variables. Literature was reviewed regarding (a) comorbid depression and the direct physiological effects on HIV progression and (b) intermediary factors between HIV and disease progression. Intermediary factors included (a) substance use, (b) social support, (c) hopelessness, (d) medication nonadherence, and (e) risky sexual behavior and the contraction of secondary infections. The authors suggest direct physiological pathways from depression to HIV progression and indirect pathways (e.g., behavioral, social, and psychological). In addition to depression, substance use, poor social support, hopelessness, medication nonadherence, and risky sexual behavior seem to be integral in HIV progression. Based on the individual relationships of these variables to depression and HIV progression, a comprehensive multipath model, incorporating all factors, serves to explain how severe emotional distress may lead to accelerated progression to AIDS.

Use of Medicaid data to explore community characteristics associated with HIV prevalence among beneficiaries with schizophrenia

OBJECTIVES

People with severe mental illness (SMI) may be at increased risk for several adverse health conditions, including HIV/AIDS. This disproportionate disease burden has been studied primarily at the individual rather than community level, in part due to the rarity of data sources linking individual information on medical and mental health characteristics with community-level data. We demonstrated the potential of Medicaid data to address this gap.

METHODS

We analyzed data on Medicaid beneficiaries with schizophrenia from eight states that account for 66% of cumulative AIDS cases nationally.

RESULTS

Across 44 metropolitan statistical areas (MSAs), the treated prevalence of HIV among adult Medicaid beneficiaries diagnosed with schizophrenia was 1.56% (standard deviation = 1.31%). To explore possible causes of variation, we linked claims files with a range of MSA social and contextual variables including local AIDS prevalence rates, area-based economic measures, crime rates, substance abuse treatment resources, and estimates of injection drug users (IDUs) and HIV infection among IDUs, which strongly predicted community infection rates among people with schizophrenia.

CONCLUSIONS

Effective strategies for HIV prevention among people with SMI may include targeting prevention efforts to areas where risk is greatest; examining social network links between IDU and SMI groups; and implementing harm reduction, drug treatment, and other interventions to reduce HIV spread among IDUs. Our findings also suggest the need for research on HIV among people with SMI that examines geographical variation and demonstrates the potential use of health-care claims data to provide epidemiologic insights into small-area variations and trends in physical health among those with SMI.

Tobacco and other factors have a negative impact on quality of life in hepatitis C patients

Hepatitis C virus (HCV) is known to adversely affect general, social, emotional and mental health domains. This study was designed to identify variables that may be associated with these measurable outcomes. We conducted a cross-sectional retrospective review of demographic and clinical data from 800 patients with HCV evaluated between January 1998 and November 2007. Data were collected using a standardized questionnaire filled out by the patients at the first encounter. Variables evaluated included fibrosis stages (i.e. FS0/1/2 vs FS3/4), demographics, comorbid health conditions, tobacco and alcohol use, high-risk social behaviours and laboratory data. Variables assessed were depression, fatigue, problems sleeping and loss of interest in sex. Statistical analysis was performed using univariate and multivariate logistic regression. Depression (29.3%) in our HCV study population was associated with female gender, tobacco use, hyperlipidemia, history of heavy alcohol use and intravenous drug use. Fatigue (44.6%) was associated with end-stage renal disease, past and current tobacco use and current alcohol use. Difficulty sleeping (13.8%) was associated with past and current tobacco use, current alcohol use and diabetes. Loss of interest in sex (7.7%) was associated with current tobacco use, multiple risk factors for HCV and age at time of evaluation. Fibrosis stage (FS) also had a significant positive association with alcohol use (OR 2.61; P = 0.003) and tobacco use (OR 2.00; P = 0.002). Smoking and alcohol use have a significant negative impact on the presence of depression, fatigue, difficulty sleeping and loss of interest in sex in HCV patients. Practitioners should be aware of these associations, particularly tobacco use, which significantly and negatively impacted every variable evaluated.

Rates of mood and anxiety disorders and contributors to continued heroin use in methadone maintenance patients: A comparison by HIV status

The frequency of mood and anxiety disorders is elevated among individuals with a history of intravenous drug abuse and among those with human immunodeficiency virus (HIV), and these disorders are associated with continued substance use despite treatment. The present study examined rates of mood and anxiety disorders, and recent heroin use, among HIV-infected and HIV-noninfected patients receiving methadone maintenance therapy. Participants were 160 (80 HIV-infected, 80 HIV-noninfected) methadone patients. Clinician-administered, semistructured interviews were used to identify unipolar and bipolar depression, and four major anxiety disorders (panic disorder with agoraphobia [PDA], generalized anxiety disorder [GAD], post-traumatic stress disorder [PTSD], and social anxiety disorder [SAD]). Toxicology screens and self-reporting were used to assess heroin, cocaine, marijuana, and alcohol use over the past month. The entire sample met criteria for at least one psychiatric disorder other than substance dependence. Substantial proportions of participants met criteria for major depressive disorder (55.6%), bipolar I, bipolar II, or cyclothymia (6.4%), PDA (34.4%), GAD (22.5%), SAD (16.9%), and PTSD (34.4%). A greater proportion of HIV-infected participants met criteria for SAD (χ² = 5.03), and a greater proportion of HIV-noninfected participants met criteria for GAD (χ² = 5.39, P < 0.01). About 14% of participants continued to use heroin over the past month, a significantly greater proportion of whom were HIV-infected. In adjusted analyses, none of the mood or anxiety disorders emerged as significant predictors of recent heroin use, but being HIV-infected did. This study highlights the high rate of psychopathology and continued heroin use despite substance abuse treatment, and underscores the need for interventions that help mitigate these problems among methadone patients.

Antiretroviral use among active injection-drug users: the role of patient-provider engagement and structural factors

HIV-seropositive, active injection-drug users (IDUs), compared with other HIV populations, continue to have low rates of highly active antiretroviral therapy (HAART) use, contributing to disparities in their HIV health outcomes. We sought to identify individual-level, interpersonal, and structural factors associated with HAART use among active IDUs to inform comprehensive, contextually tailored intervention to improve the HAART use of IDUs. Prospective data from three semiannual assessments were combined, and logistic general estimating equations were used to identify variables associated with taking HAART 6 months later. Participants were a community sample of HIV-seropositive, active IDUs enrolled in the INSPIRE study, a U.S. multisite (Baltimore, Miami, New York, San Francisco) prevention intervention. The analytic sample included 1,225 observations, and comprised 62% males, 75% active drug users, 75% non-Hispanic blacks, and 55% with a CD4 count <350; 48% reported HAART use. Adjusted analyses indicated that the later HAART use of IDUs was independently predicted by patient-provider engagement, stable housing, medical coverage, and more HIV primary care visits. Significant individual factors included not currently using drugs and a positive attitude about HAART benefits even if using illicit drugs. Those who reported patient-centered interactions with their HIV primary care provider had a 45% greater odds of later HAART use, and those with stable housing had twofold greater odds. These findings suggest that interventions to improve the HIV treatment of IDUs and to reduce their HIV health disparities should be comprehensive, promoting better patient-provider engagement, stable housing, HAART education with regard to illicit drug use, and integration of drug-abuse treatment with HIV primary care.

Gender differences in social support and depression among injection drug users in Houston, Texas

BACKGROUND

Injection drug is the second most frequent HIV/AIDS exposure in the United States. Social support and depression may mediate risky behaviors among drug injectors.

OBJECTIVES

To describe differences in perceived social support and depressive symptoms between male and female injection drug users, and to describe factors associated with depressive symptoms.

METHODS

Using respondent-driven sampling, we recruited and interviewed injection drug users in Houston, Texas. Data were from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance Program. We used the short Center for Epidemiologic Studies Depression Scale (CES-D 10) and scales for perceived social support from family, friends, and significant others from the Multidimensional Scale of Perceived Social Support. Four-hundred seventy-one participants had complete data and were included in this analysis.

RESULTS

Seventy-five percent of male and female participants had CES-D scores indicating depressive symptoms. In a multivariate logistic regression, depressive symptoms among men were positively associated with frequent use of speedballs (injecting heroin and cocaine together) and never having tested for HIV, and negatively associated with perceived social support from a special person. Among women, depressive symptoms were positively associated with currently smoking cigarettes, having no health insurance, and more years of injection drug use, and negatively associated with perceived social support from a special person.

CONCLUSIONS

Lack of social support from a special person or significant other was associated with depressive symptoms in both males and females. Our findings suggest that depression and social support should be addressed when developing HIV prevention programs among injection drug users.

Validity of the K-10 in detecting DSM-IV-defined depression and anxiety disorders among HIV-infected individuals

It has been suggested that an HIV diagnosis may increase the likelihood of mental disorders among infected individuals and that the progression of HIV may be hastened by mental disorders like anxiety and depression. Therefore, a brief screening measure, with good sensitivity/specificity for psychiatric diagnoses that could be given to HIV-infected individuals would be useful. We assessed the validity of the K-10, using the MINI International Neuropsychiatric Interview as the gold standard, in a sample of 429 HIV-infected adults enrolled in HIV care and treatment services near Cape Town, South Africa. There was significant agreement between the K-10 and the MINI-defined depressive and anxiety disorders. A receiver operating characteristic (ROC) curve analysis indicated that the K-10 showed agreeable sensitivity and specificity in detecting depression (area under the ROC curve, 0.77), generalized anxiety disorder (0.78), and posttraumatic stress disorder (PTSD) (0.77). The K-10 may be a useful screening measure for detecting mood and anxiety disorders, including PTSD, in patients with HIV/AIDS.

Gender differences in discontinuation of antiretroviral treatment regimens

BACKGROUND

Reported reasons for change or discontinuation of antiretroviral therapy ([delta]ART) include adverse events, intolerability, and nonadherence. Little is known how reasons for [delta]ART differ by gender.

METHODS

In a retrospective cohort study, rates and reasons for [delta]ART alterations in a large University-based HIV clinic cohort were evaluated. Logistic regression analyses were used to evaluate the relationship between reasons for [delta]ART and gender. Cox proportional hazard models were used to investigate time to [delta]ART.

RESULTS

In total, 631 HIV-positive individuals were analyzed. Women (n = 164) and men (n = 467) were equally likely (53.0% and 54.4%, respectively) to discontinue treatment within 12 month of initiating a new regimen. Reasons for [delta]ART, however, were different based on gender--women were more likely to [delta]ART due to poor adherence [adjusted odds ratio (OR), 1.44; 95% confidence interval (CI): 0.85 to 2.42], dermatologic symptoms (adjusted OR, 2.88; 95% CI: 1.01 to 8.18), neurological reasons (adjusted OR, 1.82; 95% CI: 0.98 to 3.39), constitutional symptoms (adjusted OR, 2.23; 95% CI: 1.10 to 4.51), and concurrent medical conditions (adjusted OR, 2.03; 95% CI: 1.00 to 4.12).

CONCLUSIONS

Although the rates of [delta]ART are similar among men and women in clinical practice, the reasons for treatment changes are different based on gender. The potential for unique patterns of adverse events and poor adherence among women requires further investigation.

Stigma, disclosure, and depressive symptoms among informal caregivers of people living with HIV/AIDS

Informal care receipt is associated with better HIV treatment outcomes among patients vulnerable to treatment failure. Yet, informal caregiving can be highly stressful, leading to distress and cessation of caregiving. Research on factors contributing to informal caregivers' psychological distress may advance our understanding of how to improve caregivers' well-being and sustained HIV caregiving for a vulnerable population. We examined relationships among caregiver stigma, disclosure, and depressive symptoms in a cross-sectional sample of 207 informal caregivers of people living with HIV/AIDS (PLWHAs) in Baltimore, Maryland. Caregivers were primarily African American, low-income, urban adults participating in the Action, Resources, and Knowledge (ARK) study (2003-2005), which recruited urban PLWHAs and their main supporters. Results indicated that among caregivers, HIV caregiving-related stigma was associated with more depressive symptoms, while disclosure of caregiving status was associated with fewer symptoms. We also explored the buffering effect of disclosure in the relationship between stigma and depressive symptoms. Results indicated that among those who reported greater stigma, there was a significant decrease in depressive symptoms as the number of disclosures increased. In contrast, participants who indicated lower stigma had consistently fewer depressive symptoms regardless of number of disclosures. These results suggest the need for interventions to address high levels of depressive symptoms among informal HIV caregivers, particularly those who report greater caregiving stigma and less disclosure of their caregiver status. In addition, future research should examine these relationships further using longitudinal data from informal caregivers and their care recipients.

Influence of coping, social support, and depression on subjective health status among HIV-positive adults with different sexual identities

The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups.

Factors associated with depressive symptoms in African American crack cocaine smokers

Few studies have examined factors associated with depressive symptoms in crack cocaine smokers, although cocaine use has been linked to depression. The purpose of this study was to identify correlates of depressive symptoms in a sample of 799 HIV-positive and HIV-seronegative African-American crack cocaine smokers. Multiple regression modelling revealed that anxiety was strongly and positively associated with depressive symptoms. In addition, being female and more frequent crack smoking were also found to be associated. Higher self-esteem and decision-making confidence were found to be associated with less often experiencing depressive symptoms. The model accounted for 64% of the variance in the data. It was noteworthy that HIV infection, as such, was not associated with depressive symptoms. The study has important implication for mental health and health promotion interventions targeting crack cocaine smokers.

HIV and depression: 2008 review and update

Since the earliest days of the AIDS epidemic, clinicians have been concerned about the prevalence of depression among their patients. Epidemiologists, psychiatrists, psychologists, sociologists, and a broad array of other specialists have studied this topic, trying to determine the prevalence of depressive disorders and depressive symptoms as well as antecedents, correlates, and consequences. This review addresses the methodologic difficulties in determining depression prevalence, major findings regarding rates of disorder and correlates among different segments of the HIV community, effects of depression on HIV illness progression, psychopharmacologic and psychotherapeutic treatment findings, and behavioral effects of depression, such as its impact on medication adherence, employment, and risk behavior. Finally, the article summarizes international studies of depression prevalence in developing countries and the challenges regarding cross-national diagnostic definitions and measures.

Validity of Self-Reported Adherence Among Injection Drug Users

Background: In Vancouver, the availability of prescription refill data for all HIV-infected individuals plus a prospective cohort of injection drug users (IDUs) permitted an examination of the validity of self-reported highly active antiretroviral therapy (HAART) adherence among IDUs. Methods: Self-reported HAART adherence among Vancouver Injection Drug Users Study participants was compared with pharmacy refill rates from the British Columbia Drug Treatment Program database. Pearson's correlation coefficient and Pearson's χ2 test were used to assess associations between adherence as measured by self-report and pharmacy refill data. Results: Among 88 HIV-infected IDUs, 48 (55%) had an adherence rate of ≥75% as measured by pharmacy refill adherence, whereas 81 (92%) had an adherence rate of ≥75% as measured by self-report. Self-reported adherence was not statistically associated with pharmacy refill adherence ( P > .1). Conclusion: These findings suggest that the validity of self-report measures may be limited when applied to community-recruited IDUs.

Two-year prospective study of major depressive disorder in HIV-infected men

OBJECTIVE

The risks and factors contributing to major depressive episodes in HIV infection remain unclear. This 2-year prospective study compared cumulative rates and predictors of a major depressive episode in HIV-infected (HIV+) men (N=297) and uninfected (HIV-) risk-group controls (N=90).

METHODS

By design participants at entry were without current major depression, substance dependence or major anxiety disorder. Standardized neuromedical, neuropsychological, neuroimaging, life events, and psychiatric assessments (Structured Clinical Interview for DSM III-R) were conducted semi-annually for those with AIDS, and annually for all others.

RESULTS

Lifetime prevalence of major depression or other psychiatric disorder did not differ at baseline between HIV+ men and controls. On a two-year follow-up those with symptomatic HIV disease were significantly more likely to experience a major depressive episode than were asymptomatic HIV+ individuals and HIV-controls (p<0.05). Episodes were as likely to be first onset as recurrent depression. After baseline disease stage and medical variables associated with HIV infection were controlled, a lifetime history of major depression, or of lifetime psychiatric comorbidity (two or more psychiatric disorders), predicted subsequent major depressive episode (p<0.05). Neither HIV disease progression during follow-up, nor the baseline presence of neurocognitive impairment, clinical brain imaging abnormality, or marked life adversity predicted a later major depressive episode.

LIMITATIONS

Research cohort of men examined before era of widespread use of advanced anti-HIV therapies.

CONCLUSIONS

Symptomatic HIV disease, but not HIV infection itself, increases intermediate-term risk of major depression. Prior psychiatric history most strongly predicted future vulnerability.

Meta-analysis of depression and substance use and impairment among intravenous drug users (IDUs)

AIMS

To evaluate, among intravenous drug users (IDUs), the hypothesized positive association of depression with substance-related behaviors including concurrent drug use and impairment, future drug use and impairment, alcohol use and impairment, needle sharing and substance use treatment participation, and to identify moderators of these associations.

DESIGN

Meta-analysis of reports on IDUs published in English in peer-reviewed journals since 1986 that contained data on depression and substance use outcome(s) with no restrictions on range of depression scores to select the sample.

SETTING

Fifty-five reports containing 55 samples met criteria, including 42 (76%) samples from clinical venues and 13 (24%) that were community-based.

PARTICIPANTS

Mean age was 34.3 (standard deviation = 4.5) years, comprising approximately 68% men and 43% white, non-Hispanic subjects.

MEASUREMENTS

Depression was assessed with the Beck Depression Inventory, Center for Epidemiological Studies Depression Scale (CES-D) and other validated scales or diagnostic interviews. The Addiction Severity Index was the most frequently used measure of substance-related outcomes.

FINDINGS

A priori hypotheses pertaining to depression and the substance-related variables were supported, with the exception of the predicted association of depression and future drug use and impairment. Effect sizes were small. Moderating effects of gender were identified, including greater associations of depression with substance use treatment participation and needle sharing among women and a greater association of depression with future drug use and impairment among men. Effect sizes of moderators were large.

CONCLUSIONS

Depression is associated with several substance-related behaviors, and select associations are stronger according to gender. Prospective associations of depression with future drug use and impairment are not immediately evident, but could be examined in subsequent research.

Common mental disorders among HIV-infected individuals in South Africa: prevalence, predictors, and validation of brief psychiatric rating scales

Despite the high prevalence of both mental disorders and HIV infection in much of sub-Saharan Africa, little is known about the occurrence of mental health disorders among HIV-infected individuals. We conducted a cross-sectional study among individuals enrolled into HIV care and treatment services near Cape Town, South Africa. Psychiatric diagnoses were measured using the Mini-International Neuropsychiatric Interview (MINI) administered by trained research nurses. In addition, all participants were administered brief rating scales for depression (the Center for Epidemiological Studies Depression Scale [CES-D]), posttraumatic stress disorder (PTSD), the Harvard Trauma Questionnaire (HTQ), and alcohol dependence/abuse (the Alcohol Use Disorders Identification Test [AUDIT]). The median age among the 465 participants was 33 years and 75% were female; 48% were receiving antiretroviral therapy. Overall, the prevalence of depression, PTSD and alcohol dependence/abuse was 14% (n = 62), 5% (n = 24), and 7% (n = 35), respectively. In multivariate analysis, the prevalence of all disorders was significantly higher among individuals who spoke Afrikaans compared to Xhosa. While the AUDIT showed excellent sensitivity and specificity in detecting MINI-defined dependence/abuse (area under the receiver-operating characteristic curve, 0.96), the HTQ and CES-D had lower performance characteristics in detecting PTSD (0.74) and depression (0.76), respectively. These data demonstrate high levels of depression, PTSD and alcohol dependence/abuse among HIV-infected individuals in this setting. Additional research is required to refine these rating scales for maximum applicability in cross-cultural populations. More generally, HIV care and treatment services represent an important venue to identify and manage individuals with common mental disorders in resource-limited settings.

Microsocial environmental influences on highly active antiretroviral therapy outcomes among active injection drug users: the role of informal caregiving and household factors

Active injection drug users (IDUs) are at high risk of unsuccessful highly active antiretroviral therapy (HAART). We sought to identify baseline factors differentiating IDUs' treatment success versus treatment failure over time among those taking HAART. Interventions for Seropositive Injectors-Research and Evaluation (INSPIRE) study participants were assessed at baseline and at 6- and 12-month follow-ups. Multinominal regression determined baseline predictors of achieving or maintaining viral suppression relative to maintaining detectable viral loads over 12 months. Of 199 participants who were retained and remained on HAART, 133 (67%) had viral load change patterns included in the analysis. At follow-up, 66% maintained detectable viral loads and 15% achieved and 19% maintained viral suppression. Results indicated that those having informal care (instrumental or emotional support) were 4.6 times more likely to achieve or maintain viral suppression relative to experiencing treatment failure. Those who maintained viral suppression were 3.5 times less likely to live alone or to report social discomfort in taking HAART. Study results underscore the importance of microsocial factors of social network support, social isolation, and social stigma for successful HAART outcomes among IDUs. The findings suggest that adherence interventions for IDUs should promote existing informal HIV caregiving, living with supportive others, and positive medication-taking norms among social networks.

Attitudes toward menopause in HIV-infected and at-risk women

OBJECTIVE

To study attitudes toward menopause in women with or at risk of human immunodeficiency virus (HIV) aged 35 to 60 in New York City, NY, USA.

DESIGN

Data were obtained at the baseline interview in a cohort study of menopause. Of 502 participating women, 92 were postmenopausal and 162 were perimenopausal.

RESULTS

Overall, 37.5% of women had a relatively favorable attitude toward menopause. African Americans had a 72% greater odds of a positive attitude (OR = 1.72, 95% CI 1.16-2.57) than all other groups after adjusting for covariates. Hispanic women had the least favorable view of menopause. Experience of > 3 menopausal symptoms and negative life events-being a witness to a murder, and the death ofa child-were significantly associated with negative attitudes towards menopause (OR = 0.62, 95% CI 0.42-0.93 and OR = 0.64, 95% CI 0.43-0.93, respectively). Depressive symptoms, street drug use, and having a domestic partner, which is significant in single variable analyses, did not remain independent predictors in multivariate results. HIV status, menopause status, and age at interview were not associated with menopause attitudes.

CONCLUSIONS

HIV-infected, drug-using, low-income women showed generally unfavorable attitudes towards menopause. High stress life events coupled with a high prevalence of depressive symptoms indicate this population has special needs marked by the menopause transition into older age.

Externalizing behaviors among children of HIV seropositive former and current drug users: parent support network factors as social ecological risks

Children affected by their parents' dual drug use and HIV/AIDS face considerable challenges to their psychosocial development, including parent dysfunction and foster care placement. While HIV/AIDS may increase parents' mobilization of social support, their drug use may restrict who is available to help them, with potential implications to the adjustment of their children with whom they remain in contact. This study sought to identify dually affected children's living situations, and parent and parent's support network factors as correlates of children's externalizing problem behaviors. An urban community sample of 462 HIV seropositive, current or former drug-using parents were queried about their children aged 5-15 years old. One hundred ninety-four children were reported by 119 parents. The outcome was children's externalizing behaviors of ever having been suspended or expelled from school, criminal-justice system involvement, or illicit drug or heavy alcohol use. Independent variables included kin and drug users in parent's support network. Generalized estimating equations were used to adjust for the potential correlation of children of the same parent. Among parents, 63% were mothers, 57% current opioid or cocaine users, 85% were African American, 35% had AIDS or CD<200, and 53% had high depressive symptoms (CES-D>or=16); median age was 38. Among children, median age was 12; 23% lived with the nominating parent, 65% with other family, and 11% in non-kin foster care. While only 34% of parents reported child custody, 43% reported daily contact with their child, and 90% reported high emotional closeness. Parents reported externalizing behaviors among 32% of the children. Logistic regression indicated that externalizing behavior was positively associated with parent's physical limitations and proportion of illicit drug users in parent's support network. A significant interaction was found indicating that the effect of parent's support network-level drug use was greater for children living with versus not living with the parent. The model adjusted for parent's current drug use and depressive symptoms, which were not significant. Results indicate that while only a minority of these dually affected children lived with the parent, the parents' physical limitations and embeddedness in drug using support networks, particularly if living with their children, was associated with the children's maladjustment. It is plausible that these factors interfere with parenting, expose the children to conflict or adverse social influences, or obligate children to assume caregiving for their parent. While dually affected children's contact with their parents may have important benefits, results suggest it presents ongoing needs for intervention with the children, their parents, and caregivers.

Depressive symptomatology among HIV-positive women in the era of HAART: a stress and coping model

OBJECTIVE

An enhanced stress and coping model was used to explain depression among HIV-positive women in healthcare and community settings where highly active anti-retroviral treatment (HAART) was commonplace.

METHOD

HIV-infected women in four cities (N=978) were assessed, cross-sectionally, for mental and physical health, stress, social support, and other background factors.

RESULTS

Self-reported level of depressive symptomatology was high. Number of physical symptoms, illness intrusiveness, and perceived stress were positively associated with depressed mood, while coping self-efficacy and social support were negatively associated. Stress mediated the effect of health status on depression and coping self-efficacy mediated the effect of psychosocial resources on depression. Our enhanced stress and coping model accounted for 52% of variance in depressive symtpomatology.

CONCLUSIONS

Interventions focused on improving coping self-efficacy, bolstering social supports, and decreasing stress in the lives of HIV-positive women may help to reduce the negative effects of HIV disease on mood.

"I thought there was no hope for me": a behavioral intervention for urban mothers with problem drinking

In this article, the authors evaluate the effects of a behavioral intervention for mothers with problem drinking who were infected with, or at risk for, HIV. They randomly selected 25 mothers from a larger longitudinal randomized controlled intervention trial for a qualitative interview. The authors found that mothers' participation in the program was facilitated by the development of a strong therapeutic alliance with the intervention facilitator and the use of a harm reduction approach toward alcohol and/or drug abuse. Mothers also reported that training in coping skills and the emphasis on parent-adolescent relationships were beneficial for program engagement and behavior change. The authors conclude from these results that treatment approaches that take into account the complexity of urban mothers' lives and substance use patterns can successfully engage and treat these women at high risk for adverse outcomes.

Depressive symptoms in HIV disease

Although depressive symptoms are common in people living with HIV/AIDS, their reported prevalence varies greatly across HIV-positive populations, ranging from 21% to 97%. Comparing these rates is complicated by the varied conceptualization of depression as a major depressive disorder (clinical depression) or depressive symptoms, and by the use of multiple methods of measurement. Knowledge of predictors of depressive symptoms can assist health care providers in the identification of those who are most at risk. Appropriate diagnosis, treatment, and referral are critical, because depressive symptoms have been associated with poorer disease outcomes. Additionally, self-management symptoms can be used to supplement more traditional treatment methods.

Persistence of psychiatric disorders in a cohort of HIV/AIDS patients in South Africa: a 6-month follow-up study

BACKGROUND

Psychiatric disorders in HIV/AIDS are common, emerging soon after diagnosis or during the subsequent course of illness. However, there are few prospective studies on the rates of psychiatric disorders in HIV/AIDS, particularly in the context of the developing world.

METHODS

Sixty-five patients with recently diagnosed HIV were interviewed on presentation to a hospital-based HIV clinic and then 6 months later. On both interviews, the patients were assessed using the MINI International Neuropsychiatric Interview, the Carver Brief COPE, and the Sheehan Disability Scale. Exposure to negative life events and risk behaviors was also evaluated.

RESULTS

The overall prevalence of psychiatric disorders in the follow-up period remained high (56% of patients had at least one psychiatric disorder at baseline, and 48% of patients had at least one psychiatric disorder at 6 months). Depression and posttraumatic stress disorder (PTSD) were the most prevalent disorders at both baseline (34.9% and 14.8%) and follow-up (26% and 20%), respectively. More than half of all patients with depression at baseline improved (16 of 29; 55.1%). However, there was a new onset of both depression (4 of 49; 8.1%) and PTSD (12 of 17; 70.5%) on follow-up. In univariate analysis, depression on follow-up was significantly associated with: (a) disability in work/social/family functioning, (b) greater number of negative life events, and (c) a decline in CD4 lymphocyte count. Univariate analysis also revealed that a diagnosis of PTSD on follow-up was significantly associated with (a) a longer duration of infection and (b) baseline disability in work/social/family functioning. However, in multivariate analysis, only disability scores predicted the diagnoses of major depression and PTSD on follow-up assessment. Persistence of risky sexual behaviour was also noted, with a significantly higher number of participants reporting nonuse of condom on follow-up. There appeared to be a shift from maladaptive coping behaviors to more adaptive coping behaviors over the 6-month period.

CONCLUSION

The rate of psychiatric disorders in HIV/AIDS patients was consistent over time. These findings emphasize the importance of regular evaluation for psychiatric disorders in HIV/AIDS patients, not only at the commencement of treatment but also during subsequent follow-up visits.

Dyadic HIV status and psychological distress among women on methadone

PURPOSE

Studies examining the association between psychological distress and HIV status among women belonging to populations at elevated risk for HIV have found mixed results. The goal of this study is to shed greater insight into possible explanations for the mixed findings of the earlier studies. Specifically, we examine psychological distress as a function of dyadic HIV status--that is, the combination of a participant and her partner's HIV statuses--among women attending methadone maintenance treatment programs (MMTPs).

METHODS

A random sample of 349 female MMTP patients involved in intimate relationships provided self-reported data via structured, face-to-face interviews. Hypothesis testing involved multiple linear regression with 3 orthogonal contrast codes constructed from dyadic HIV status.

RESULTS

Levels of psychological distress did not differ significantly between HIV-negative and HIV-positive women. HIV-negative women with HIV-positive partners reported significantly greater global levels, number of symptoms, and symptom severity of psychological distress compared to those with HIV-negative partners. HIV-positive participants with HIV-positive partners reported significantly lower global levels and symptom severity of psychological distress compared to those with HIV-negative partners.

CONCLUSION

Findings support that psychological distress appears to differ as a function of the combination of a woman and her partner's HIV status rather than the woman's HIV status alone. Thus, dyadic HIV status represents an important factor with respect to the mental health needs of women in drug treatment.

Affective disorders in patients with HIV infection: impact of antiretroviral therapy

At the beginning of the AIDS pandemic, affective disorders (such as depressed mood) were seen in a considerable number of HIV-1-infected individuals. These disorders were a result of the poor physical condition of the patients, brain involvement by the virus (e.g. encephalopathy) or a reaction to disadvantageous living conditions (losing friends, jobs, etc.). In the era of highly active antiretroviral therapy (HAART), mental illness related to physical weakness is declining, as is the incidence of HIV-1-associated encephalopathy. However, depressed mood and fatigue caused by efavirenz (a standard component of HAART) is becoming increasingly important, particularly in individuals who are infected long-term with HIV-1. Whatever the cause of affective disorders, their presence has been shown to negatively influence adherence to HAART and HIV-1 disease progression. Specialist knowledge of HIV-1 infection, and HAART and its psychiatric complications (particularly in subgroups of patients such as drug abusers and older people), is needed to care adequately for patients. Furthermore, prospective studies are needed to more fully differentiate between the various aetiologies of affective disorders seen in individuals living with HIV/AIDS and to determine their incidence and prevalence. Such information is important to ensure that affective disorders are recognised and adequately treated, which will in turn improve the efficacy of HAART.

Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy

There is a high prevalence of substance abuse and psychiatric disorders among HIV-infected individuals. Importantly, drug and alcohol-use disorders are frequently co-morbid with depression, anxiety and severe mental illness. Not only do these disorders increase the risk of contracting HIV, they have also been associated with decreased highly active antiretroviral therapy (HAART) utilisation, adherence and virological suppression. The literature evaluating the relationship between substance abuse and HIV outcomes has primarily focused on injection drug users, although there has been increasing interest in alcohol, cocaine and marijuana. Similarly, the mental health literature has focused largely on depression, with a lesser focus on severe mental illness or anxiety. To date, there is little literature evaluating the association between co-occurring HIV, substance abuse and mental illness on HAART uptake, adherence and virological suppression. Adherence interventions in these populations have demonstrated mixed efficacy. Both directly observed therapy and pharmacist-assisted interventions appear promising, as do integrated behavioural interventions. However, the current intervention literature has several limitations: few of these studies are randomised, controlled trials; the sample sizes have generally been small; and co-occurring substance abuse and mental illness has not specifically been targeted in these studies. Future studies examining individual substances of abuse, psychiatric disorders and co-occurring substance abuse and psychiatric disorders on HIV outcomes will inform targeted adherence interventions.

Individual, interpersonal, and structural correlates of effective HAART use among urban active injection drug users

Among individuals receiving highly active antiretroviral therapy (HAART), injection drug users (IDUs) are less likely to achieve HIV suppression. The present study examined individual-level, interpersonal, and structural factors associated with achieving undetectable plasma viral load (UVL) among US IDUs receiving recommended HAART. Data were from baseline assessments of the INSPIRE (Interventions for Seropositive Injectors-Research and Evaluation) study, a 4-site, secondary HIV prevention intervention for heterosexually active IDUs. Of 1113 study participants at baseline, 42% (n = 466) were currently taking recommended HAART (34% were female, 69% non-Hispanic black, 26% recently homeless; median age was 43 years), of whom 132 (28%) had a UVL. Logistic regression revealed that among those on recommended HAART, adjusted odds of UVL were at least 3 times higher among those with high social support, stable housing, and CD4 > 200; UVL was approximately 60% higher among those reporting better patient-provider communication. Outpatient drug treatment and non-Hispanic black race and an interaction between current drug use and social support were marginally negatively significant. Among those with high perceived support, noncurrent drug users compared with current drug users had a greater likelihood of UVL; current drug use was not associated with UVL among those with low support. Depressive symptoms (Brief Symptom Inventory) were not significant. Results suggest the major role of social support in facilitating effective HAART use in this population and suggest that active drug use may interfere with HAART use by adversely affecting social support. Interventions promoting social support functioning, patient-provider communication, stable housing, and drug abuse treatment may facilitate effective HAART use in this vulnerable population.

Interrater reliability of the Psychiatric Research Interview for Substance and Mental Disorders in an HIV-infected cohort: experience of the National NeuroAIDS Tissue Consortium

The interrater reliability of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) was assessed in a multicentre study. Four sites of the National NeuroAIDS Tissue Consortium performed blinded reratings of audiotaped PRISM interviews of 63 HIV-infected patients. Diagnostic modules for substance-use disorders and major depression were evaluated. Seventy-six per cent of the patient sample displayed one or more substance-use disorder diagnoses and 54% had major depression. Kappa coefficients for lifetime histories of substance abuse or dependence (cocaine, opiates, alcohol, cannabis, sedative, stimulant, hallucinogen) and major depression ranged from 0.66 to 1.00. Overall the PRISM was reliable in assessing both past and current disorders except for current cannabis disorders when patients had concomitant cannabinoid prescriptions for medical therapy. The reliability of substance-induced depression was poor to fair although there was a low prevalence of this diagnosis in our group. We conclude that the PRISM yields reliable diagnoses in a multicentre study of substance-experienced, HIV-infected individuals.

Incidence and impact of posttraumatic stress disorder and comorbid depression on adherence to HAART and CD4+ counts in people living with HIV

Recent research suggests that the presence of posttraumatic stress disorder (PTSD) and depressive symptoms is independently related to abnormal hormone levels, inadequate medication adherence, and faster HIV disease progression. Although PTSD and depression occur comorbidly at high rates, the impact of both disorders on adherence and disease progression has not been examined. The present study examined the impact of PTSD and comorbid depression on CD4 cell counts and medication adherence in 58 male and 11 female (36% African American) HIV-positive individuals recruited from an AIDS service organization. Results revealed that participants high in depressive symptoms had lower CD4 cell counts and were less likely to adhere to their medication regimens than participants high in PTSD symptoms and those high in comorbid symptomatology. The present results suggest that the presence of depressive symptoms may be responsible for the observed impact of PTSD on people living with HIV (PLWH), and that failure to examine comorbid disorders may not adequately address the impact of clinical symptoms on people living with HIV.

Depressive symptoms, quality of life, and neuropsychological performance in HIV/AIDS: the impact of gender and injection drug use

Limited attention has been paid to the potential impact of gender and injection drug use (IDU) on mood, quality of life, and neuropsychological performance in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Several studies that describe the natural history of HIV/AIDS in terms of mental health and neuropsychological ability have focused solely on men or have excluded injection drug users. Women and injection drug users are two groups for whom the incidence of HIV infection is increasing. Additionally, the National Academy of Sciences recently recommended that studies concerned with health-related research include males and females, and that researchers analyze their data for gender differences. The goals of the current study were to investigate possible relationships between HIV and IDU status and depressive symptoms, quality of life, and neuropsychological performance in women and men matched for age, race, and education. Overall, women reported more depressive symptoms than men, and this gender difference was most evident in women who were both infected with HIV and who were also injection drug users. Women and HIV-infected individuals reported the poorest quality of life scores. Women outperformed men on a measure of verbal memory and HIV(-) participants outperformed HIV(+) participants on a measure of perceptual speed. Finally, gender and HIV status interacted such that uninfected women performed the best, and infected men performed the worst, on a test of verbal memory. A better understanding of how men and women with different drug use profiles respond to HIV/AIDS may substantially improve survival, as well as aspects of daily functioning, of affected individuals. Thus, further study and development of treatment protocols targeted at including women and IDU are needed.

Mood disorders in the medically ill: scientific review and recommendations

OBJECTIVE

The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research.

DATA SOURCES

Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors.

STUDY SELECTION/DATA EXTRACTION

Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed.

CONCLUSIONS

A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.

Self-care strategies for depressive symptoms in people with HIV disease

AIM

This paper reports a study with people living with HIV to examine the experience of depressive symptoms, self-care symptom management strategies, symptom outcomes in response to those strategies, and sources from which the strategies were learned.

BACKGROUND

Depressive symptoms are common, under-diagnosed and under-treated in people living with HIV. These symptoms have been associated with lower medication adherence, risky behaviours and poorer health outcomes.

METHODS

The study was based on the model of symptom management developed by the University of California San Francisco School of Nursing Symptom Management Faculty. Thirty-four HIV+ men and women from a larger study of symptom self-care strategies (n = 422) reported experiencing depressive symptoms. Data were collected from this subset on the Web, by mail and in-person using the critical incident technique.

RESULTS

Depressive symptoms were described using 80 words and phrases clustered into eight categories: futility, sadness, loneliness/isolation, fatigue, fear/worry, lack of motivation, suicidal thoughts and other. A total of 111 self-care strategies were coded into six categories: practising complementary/alternative therapies, talking to others, using distraction techniques, using antidepressants, engaging in physical activity, and using denial/avoidant coping. Sources of information for strategies used were trial and error (31%), healthcare providers (28%), family and friends (20%), classes/reading (8%), clergy (8%), support groups (4%) and other (3%). Overall, 92% of the self-care strategies used were reported as helpful, 4% were sometimes helpful and 4% were not helpful.

CONCLUSIONS

People living with HIV use numerous effective self-care strategies to manage depressive symptoms. Further study is needed to validate the use of these strategies across populations, to standardize dose, duration and frequency, and to measure their effectiveness.

Mental disorders and drug abuse in persons living with HIV/AIDS

This article reviews the literature on the prevalence of mental and substance use disorders among persons living with HIV/AIDS. Drug use, both injection and non-injection, substantially increases the risk for HIV infection. While injection drug users have the highest prevalence rates for HIV, substantially elevated rates of HIV infection are also present among crack cocaine users and individuals with substance use disorders generally. Persons with HIV/AIDS and a mental and/or substance use disorder have highly variable patterns of accessing services. Persons with HIV/AIDS who have a serious mental illness are more highly involved with services than other groups. Most individuals with co-occurring disorders report some involvement with outpatient primary medical care, although ancillary services such as mental health and substance abuse treatment, transportation assistance, and case management improve involvement in medical care. Women with HIV/AIDS and co-occurring mental and substance use disorders experience unique vulnerabilities, particularly those related to exposure to traumatic events. Given the complexity of needs with which triply or multiply diagnosed individuals present, effective treatment programmes are likely to be those that provide some degree of integrated care.

Stress, appraisal, and coping: a comparison of HIV-infected women in the pre-HAART and HAART eras

BACKGROUND

It has been widely suggested that highly active antiretroviral therapy (HAART) has improved the psychosocial aspects of living with HIV/AIDS.

METHOD

A sample of 79 women living with HIV/AIDS in the pre-HAART era (1994-1996) were compared with a matched sample of 79 women with HIV/AIDS from the HAART era (2000-2003) on measures of stress, illness appraisals, and coping strategies.

RESULTS

Contrary to expectations, HIV-infected women in the HAART era were significantly more likely than women in the pre-HAART era to report health-related stress, to report stress from stigma and disclosure, to view HIV as having caused them harm, to report that their health is due to chance, and to report more use of maladaptive forms of coping (e.g., escape-avoidant coping).

CONCLUSION

Although HAART may have extended survival for many HIV-infected individuals, they have not resulted in equivalent psychosocial improvements. Thus, efforts are needed to address the psychosocial difficulties that HIV-infected women in the HAART era continue to experience.

A brief mental health and substance abuse screener for persons with HIV

Mental illness and substance abuse are common among HIV-infected individuals and are associated with negative outcomes, including poor medication adherence. Therefore, quick and effective methods for detecting these co-occurring disorders are necessary for health care practitioners. This article reports on the creation and preliminary testing of a brief screening tool, the Substance Abuse and Mental Illness Symptoms Screener (SAMISS). The 13-item screener was developed primarily from existing scales and administered to HIV-infected individuals receiving care at infectious diseases clinics in the Southeast. To assess the validity of the SAMISS, a subset of those who screened positive for both mental illness symptoms and substance use problems (n = 207) were administered the Structured Clinical Interview for DSMIV Disorders (SCID). The positive predictive value of the screener in comparison to the SCID was 98.6% for mental disorders and 98.6% for substance use disorders. The agreement between specific screener symptoms and their corresponding SCID diagnoses was relatively high for alcohol dependence (kappa = 0.50, p < 0.001), drug dependence (kappa = 0.30, p < 0.001), and drug abuse (kappa = 0.42, p <0.001). The finding that the screener is highly predictive of having a general mental disorder and substance use disorder among those screening positive for mental illness symptoms and substance use problems, as well as its brevity and ease of administration, make it a useful tool to detect symptoms of co-occurring disorders so that patients can be referred to mental health and substance abuse specialists. The screener is not a diagnostic instrument and has limited value in predicting specific psychiatric diagnoses.