Journal Article Annotations
2022, 1st Quarter
Annotations by John A R Grimaldi MD, Mary Ann Cohen MD, FAPM, Kelly Cozza MD, DFAPA, FACLP and Luis Pereira MD
January, 2022
The finding:
Baseline and 3-month follow-up quantitative measures were used to determine chang-es in the mental health of People Living with HIV (PWH) related to the COVID-19 pandemic. This study was a secondar analysis using a sub-cohort of participants in a longitudinal study of the long-term health effects of marijuana on PWH . Reasons for changes were explored using qualitative information obtained from open-ended questions. Thirty-one percent of participants re-ported worsened mental health, 8% reported improved mental health, and 61% reported no change. Frequently given reasons for worsened mental health included worry about acquiring and having no control over preventing COVID-19. Participants also worried about the effect of HIV on vul-nerability to becoming infected with and complications of COVID-19. Finances, staying in, man-aging pre-existing psychiatric disorders and stress of having school-age children at home were also reasons for worsened mental health. The most common reasons for improved mental health were increased health awareness and activity followed by increased health care access and adherence, change in life perspective and staying in and away from others. Having mild, moderate, or severe depression significantly increased the odds of worsened mental health, when compared to persons with minimal or no depression.
Strength and weaknesses:
Previous studies have explored the effect of the COVID-19 pandemic on PWH. This study confirms existing knowledge and is unique in adding lived examples of COVID-19-related changes in mental well-being. This granular look at the pandemic’s effect pro-vides potential targets for therapeutic interventions. Inquiring about reasons for improved mental health expands our understanding of resilience among PWH and offer clues about preventive strat-egies for buffering stress. The study sample was drawn from PWH in a clinical setting and there-fore limits generalizability to PWH in the general population or those not in regular care. The ques-tionnaires used were developed prior to the availability of COVID-19 vaccines, and therefore is-sues related to vaccine uptake and hesitancy were not included. Standardized questionnaires were not used to determine either changes or reasons for changes in mental health. Lack of available measures beyond 3 months limits observation of changes in responses over time, at different stages in the evolution of the pandemic, and pre- and post-vaccine availability.
Relevance:
There is a growing body of knowledge related to risk of COVID-19-related morbidity and mortality in PWH compared to HIV-negative persons. The availability of an effective vaccine against COVID-19 has significantly reduced the risk of COVID-related serious illness and hospi-talization among both PWH and HIV-negative persons. This study confirms the possible role of depression in decreasing mental well-being in PWH and offers insight into actionable targets for therapeutic interventions. Findings from the study may be generalizable to the HIV-negative popu-lation and useful in developing strategies for overcoming COVID-19 vaccine hesitancy. Future studies should explore the effects of vaccination status on COVID-related worries and mental health among PWH.
The finding:
This population-based study used a nationally representative dataset from the UK to compare the incidence of composite mental illness comprising depression, anxiety, and severe mental illness as well as the incidence of depression, anxiety, and severe mental illness individually among PWH and matched, HIV-negative controls. PWH were at significantly greater risk of developing mental illness compared to person without HIV, with an adjusted hazard ratio of 1.63. Similarly, incident depression, anxiety, and severe mental illness were significantly higher among PWH compared to HIV-negative controls, with adjusted hazard ratios of 1.94, 1.38, and 2.18, respectively. Men with HIV were at 2 times greater risk, compared to HIV-negative men, of developing any disorder, a rate that was significantly higher than the risk for women living with HIV.
Strength and weaknesses:
This study of people with HIV was population-based and used a dataset representative of the UK with a matched control group of persons without HIV. It spanned a long follow-up period and was the first of its kind to determine rates of mental illness in PWH without a prior history of psychiatric disorders. The study was not able to determine sexual orientation among subjects, a variable that may be a confounder. The study also did not include data on antiretroviral medications, CD4 cell count, or viral load. It is possible that efavirenz, known for its associated neuropsychiatric adverse effects, may have contributed to elevated risk of psychiatric morbidity in the HIV group. Findings may not be generalizable to countries that are not comparable to the UK in terms of income, quality and access to healthcare and other resources, and cultural and societal determinants of health.
Relevance:
This study fills a significant gap in knowledge about the risk of developing new onset psychiatric conditions during the course of HIV disease. The majority of existing prevalence studies have not used HIV-negative control groups and did not distinguish between pre-existing and newly diagnosed psychiatric disorders following an HIV diagnosis. Findings suggest underlying biological causes of depression in HIV and the need for pharmacologic approaches to treatment. They also confirm the importance of HIV-related stigma and psychosocial factors associated with mental illness in HIV and suggest changes in economic and social policies that may be required to prevent psychiatric comorbidity. Research has demonstrated the negative effect of depression on adherence to antiretroviral therapy, virologic suppression, and retention in HIV care—all of which are critically important in preventing secondary transmission of HIV. This study brings renewed attention to the importance of regular screening and referral for treatment of mental health conditions in people with HIV.
The finding:
Data from the HIV Medical Monitoring Project 2015-2018 was used to compare people with HIV (PWH) who inject drugs with PWH who use drugs but do not inject, across several HIV health outcomes, social and structural, mental health, and substance use treatment services access measures. PWH who use drugs by any route are more likely to have worse HIV clinical outcomes, experience homelessness and incarceration, and engage in high HIV-acquisition behaviors. Methamphetamine use was especially prevalent among PWH who inject drugs; nearly half of PWH who use only non-injection drugs, compared to 1 in 3 PWH who use injection drugs, reported using cocaine and crack cocaine in the past 12 months. Almost half of the PWH who inject drugs and 3 out of 4 PWH who use only non-injection drugs reported not needing and not receiving substance use treatment services, suggesting the need for targeted education about risks associated with drug use. Symptoms of depression and anxiety were more prevalent among PWH who use drugs by any route when compared to all adults diagnosed with HIV. Recent homelessness and incarceration were more prevalent in PWH who injected drugs compared to those who used only non-injection drugs. PWH who injected drugs were also less likely than non-injection drug users to have sustained HIV viral suppression. Sexual behaviors associated with HIV acquisition, such as drugs before and during sex, were more prevalent among PWH who use drugs than among all adults diagnosed with HIV. PWH who inject drugs were more likely than non-injection drug users to engage in high-risk sexual behaviors and to use drugs before and during sex.
Strength and weaknesses:
This study provides the first nationally representative estimates that behavioral characteristics, clinical outcomes, and social, structural, and mental health variables between PWH who inject drugs and PWH who use only non-injection drugs. A limitation of the study was that most of the measures used were self-reported and thus subject to social desirability and recall bias. The study did not account for potentially confounding variables such as age and race/ethnicity.
Relevance:
The proportion of HIV acquired through injection drug use and sharing of needles and drug-related paraphernalia has fallen significantly since the beginning of the epidemic. This decrease is likely due in part to the availability of clean needles and syringes. Recent local outbreaks of new HIV infections attributable to injection drug use suggest that more needs to be done to better understand behavioral characteristics of this group of at-risk individuals and existing gaps in treatment and prevention efforts. The large proportions of PWH who inject methamphetamine and those who use cocaine and crack cocaine through non-injection routes point to the need for more aggressive implementation of evidence-based interventions for these disorders, such as cognitive-behavioral therapy, contingency management, and syringe service programs. Both substances are known to impair immune functioning, contribute to CNS injury, and correlate with worse clinical outcomes. The greater prevalence of depressive and anxiety symptoms in PWH who use drugs, compared to the general non-HIV population and general population of PWH, draws attention to an important gap in treatment. The adverse health effects of unstable housing, and greater prevalence of homelessness among PWH who inject drugs, compared to non-injection drug users, is relevant for C-L psychiatrists. C-L psychiatrists are likely to consult on PWH hospitalized for cardiac and soft tissue complications of injection drug use, when C-L psychiatrists can advocate for behavioral health treatment, housing resources, and supported care transitions upon discharge. A principal goal of the federal HIV National Strategic Plan and End the HIV Epidemic initiative includes achieving sustained viral suppression for most PWH. This study demonstrates that reaching this goal is less likely in PWH who use drugs, especially injection drugs. In light of this study’s findings, models of HIV care that integrate substance use and mental health treatment with care management that addresses housing and social needs could greatly improve HIV prevention and outcomes.