Jon C Mills1, Brian W Pence2, Andrew Edmonds2, Adebola Adedimeji3, Rebecca M Schwartz4, Seble Kassaye5, Jennifer Cocohoba6, Mardge H Cohen7, Gretchen Neigh8, Margaret A Fischl9, Mirjam-Colette Kempf10, Adaora A Adimora1. 1. Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC. 2. Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC. 3. Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY. 4. Department of Occupational Medicine, Epidemiology and Prevention, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY. 5. Department of Infectious Diseases, Georgetown University Medical Center, Georgetown University, Washington, DC. 6. Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, CA. 7. Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL. 8. Department of Anatomy and Neurobiology, School of Medicine, Virginia Commonwealth University, Richmond, VA. 9. Department of Medicine/Infectious Diseases, Miami Center for AIDS Research, University of Miami, Miller School of Medicine, Miami, FL. 10. Schools of Nursing, Public Health and Medicine, University of Alabama at Birmingham, Birmingham, AL.
Abstract
BACKGROUND: Data are limited on cumulative impacts of depression on engagement in care and HIV outcomes in women living with HIV (WLWH) during the era of universal antiretroviral therapy (ART). Understanding the relationship of accumulated depression with HIV disease management may help identify benefits of interventions to reduce severity and duration of depressive episodes. SETTING: A cohort of WLWH (N = 1491) from the Women's Interagency HIV Study at 9 sites across the US. METHODS: This longitudinal observational cohort study (2013-2017) followed WLWH for a maximum of 9 semiannual visits. Depression was quantified as a time-updated measure of percent of days depressed (PDD) created from repeated assessments using the Center for Epidemiologic Studies Depression scale. Marginal structural Poisson regression models were used to estimate the effects of PDD on the risks of missing an HIV care appointment, <95% ART adherence, and virological failure (≥200 copies/mL). RESULTS: The risk of missing an HIV care appointment [risk ratio (RR) = 1.16, 95% confidence interval = 0.93 to 1.45; risk difference (RD) = 0.01, -0.01 to 0.03], being <95% ART adherent (RR = 1.27, 1.06-1.52; RD = 0.04, -0.01 to 0.07), and virological failure (RR = 1.09, 1.01-1.18; RD = 0.01, -0.01 to 0.03) increased monotonically with increasing PDD (comparing those with 25 to those with 0 PDD). The total effect of PDD on virological failure was fully (%100) mediated by being <95% ART adherent. CONCLUSIONS: Time spent depressed increases the risk of virological failure through ART adherence, even in the era of universal ART regimes forgiving of imperfect adherence.
BACKGROUND: Data are limited on cumulative impacts of depression on engagement in care and HIV outcomes in women living with HIV (WLWH) during the era of universal antiretroviral therapy (ART). Understanding the relationship of accumulated depression with HIV disease management may help identify benefits of interventions to reduce severity and duration of depressive episodes. SETTING: A cohort of WLWH (N = 1491) from the Women's Interagency HIV Study at 9 sites across the US. METHODS: This longitudinal observational cohort study (2013-2017) followed WLWH for a maximum of 9 semiannual visits. Depression was quantified as a time-updated measure of percent of days depressed (PDD) created from repeated assessments using the Center for Epidemiologic Studies Depression scale. Marginal structural Poisson regression models were used to estimate the effects of PDD on the risks of missing an HIV care appointment, <95% ART adherence, and virological failure (≥200 copies/mL). RESULTS: The risk of missing an HIV care appointment [risk ratio (RR) = 1.16, 95% confidence interval = 0.93 to 1.45; risk difference (RD) = 0.01, -0.01 to 0.03], being <95% ART adherent (RR = 1.27, 1.06-1.52; RD = 0.04, -0.01 to 0.07), and virological failure (RR = 1.09, 1.01-1.18; RD = 0.01, -0.01 to 0.03) increased monotonically with increasing PDD (comparing those with 25 to those with 0 PDD). The total effect of PDD on virological failure was fully (%100) mediated by being <95% ART adherent. CONCLUSIONS: Time spent depressed increases the risk of virological failure through ART adherence, even in the era of universal ART regimes forgiving of imperfect adherence.
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