Depression impacts more than just quality of life in HIV

  • The World Health Organisation considers depression to be the leading cause of disability globally, with anxiety rating 6th. 
  • 4.4% of the world’s population is thought to be living with depression, but estimates show that at least 50% of people living with HIV/AIDS (PLWHA) satisfy criteria for at least 1 mental or substance use disorder.
  • Risk-associated behaviour and poor health care adherence increases in people with depression particularly.
  • Depression is the most prevalent mental illness amongst PLWHA.
  • Mortality rates in PLWHA diagnosed with a Major Depressive Disorder (MDD) are double when compared with those not diagnosed with MDD.
  • Lengthier durations of MDD are associated with increased mortality, and this is thought to be due to chronic inflammation causing tryptophan deficiency and as a result serotonin deficiency.
  • Meta-analyses show adherence to the HIV model of care in PLWHA with depression is a significant barrier to treatment (15% adults, 25% in adolescents). 
  • Whilst multiple validated screening tools exist for mental illness and multiple modes of therapeutic intervention also exist these are not being employed reliably.

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Dr Robert Remien quotes that an estimated 70-85% of all mental health diagnoses around the world are not being treated, and the challenges lie in implementing support. People living with mental health issues experience a wide range of barriers with regard to HIV management, but there are also opportunities to screen for them at time points within the HIV model of care.

Cold screening tools such as the HEADSS assessment are useful in gaining a holistic view of overall functioning in adolescents and this can be used to guide screening for risk-associated behaviours such as condomless sex, drug use and present or emerging mental illness. The RACGP Preventive Activities in General Practice (red book) recommends annual STI screening in sexually active people between the ages of 16 and 29, providing another opportunity to screen for mental illness. 

Once a diagnosis of HIV is made, this is a key time to apply validated screening tools for mental illness, predominantly depression, anxiety and substance use disorders. Given combined anti-retrovial therapy (cART) is recommended to be lifelong, ongoing reviews can be used to re-screen for or monitor mental illness.

The real challenge, Dr Remien says, lies not necessarily with the detection of mental illness but rather in implementing meaningful support. Increasingly, there is a demand for brief intervention and whilst this shouldn’t be done away with, it’s likely that it isn’t enough to effect a significant clinical change. INDEPTH Uganda, an RCT looking at integrating and task-shifting management of depression in a sub-Saharan African HIV positive cohort hopes to identify productive models of care for PLWH who also have mental illnesses.

There is some evidence to suggest that more intensive and community-based interventions can actually translate to clinically measurable outcomes in surprising ways - the viral load and CD4 count. PATH+ is a RCT that included PLWHA who had serious mental illness (SMI), and assigned an advanced practice nurse to administer community based care as well as medical and mental health care coordination at least once per week and for a duration of 12 months. The effects were measured using readily available bio markers of HIV - the VL and CD4+ counts, as well as the SF-12 Mental and Physical Health measure of quality-of-life at 3, 6, 12 and 24 months (12 months after cessation of intervention). The PATH+ study found there was a statistically significant decline in VL, increase in CD4+ count and improvement in the SF-12 measure after 12 months which persisted to at least 24 months.

All in all, we have the ability to screen effectively for mental illness, and we have some interventions that are useful, however more tools are required to adequately support PLWHA and mental illness to bring their mortality back in line with the rest of their HIV+ cohort. What would this look like? Perhaps longer and more intense intervention, but certainly more tailored to the needs of the individual.


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