Nonadherence to Antiretroviral Therapy Among Men with HIV Linked to Depression, Substance Abuse

Researchers find interventions targeting mental health problems and substance abuse can improve treatment outcomes.

Adherence to antiretroviral therapy (ART) is negatively affected by depression and substance abuse in HIV-infected men who have sex with men (MSM), according to a recent study by a team of researchers at Harvard Medical School.

The study, published online June 6, 2014, in LGBT Health, examines the greatest challenges for medication adherence in the treatment of HIV. The study notes that more than 60% of incident HIV infections in the United States occur among gay, bisexual, and other MSM, who comprise just 2% of the total population.

To achieve an undetectable viral load, the study notes that patients need to maintain a high level of adherence, which involves taking at least 80% of medication as prescribed. Among the benefits of high adherence for HIV patients are an enhanced ability to suppress the virus, an increased CD4 lymphocyte count, a reduced likelihood of developing infections, and less chance of being hospitalized.

In order to cope with stress related to their HIV infection, MSM may employ avoidant coping strategies such as isolating themselves from others, sleeping more often, indulging in food, having sex, and working excessively. Avoidant coping was cited in the study as a potential mediator between depression and nonadherence to treatment. While using these escapist activities to relieve the stress of their illness, patients subsequently avoid doing activities needed to manage their illness, according to the study.

HIV-infected MSM have been found to have depression rates that are nearly double those of individuals not infected with the disease, the researchers note. Due to the fact that depression and substance abuse are highly prevalent among MSM, the link between these 2 problems and nonadherence is an issue health care providers need to address in the treatment of these individuals, according to the study.

Specifically, the use of alcohol and crystal methamphetamine poses a threat to adherence, with one study estimating use of methamphetamine to be 20 times higher among MSM than among the general population.

“HIV-infected individuals may use alcohol, meth, and other substances as a means of coping with substance-related withdrawal symptoms as well as HIV-related distress, creating a cyclical pattern of depression, use, and adherence failure,” the study authors write.

Substance abuse has a detrimental impact on adherence due to a number of related issues, which include impaired judgment, memory loss, and sleep cycle disruption.

In terms of treatment, the study recommends the use of cognitive behavioral therapy for adherence and depression with a trained therapist. Individuals who received this treatment were less depressed and were more likely to adhere to ART, and were generally found to maintain these results at 6- and 12-month follow-up visits, according to the study.

“Although few interventions have been developed that simultaneously aim to ameliorate psychosocial problems and improve antiretroviral adherence among MSM, those targeting such conditions have seen some preliminary success,” the authors write. “Continued efforts must be made to develop tailored interventions for MSM. Effective strategies tested via rigorous clinical trials must be translated into practice in order to improve adherence and secondary prevention outcomes among HIV-infected MSM and their sexual partners.”