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Co-occurring Mental Health and Substance Use Disorders Among HIV+ Women: Impact On Antiretroviral Therapy Use, Adherence, and Immune health

Judith A. Cook1, Mardge H. Cohen2, Rebecca Schwartz3, Pamela Steigman1, Dennis D. Grey1, Nancy Hessol4, Elizabeth T. Golub5, Kathryn Anastos6, Daniel Merenstein7, Joel Milam8

1University of Illinois at Chicago, 2Hektoen Institute of Medicine, 3SUNY Downstate, 4University of California, San Francisco, 5Johns Hopkins University, 6Montefiore Medical Center, 7Georgetown University, 8University of Southern California

Introduction

HIV+ women have high rates of co-morbid mental health and substance use disorders (MH/SUD)1-2 but little epidemiological evidence exists regarding these disorders in large, well-characterized cohorts.3 Considerable research evidence suggests that MH/SUD co-morbidities lower the likelihood of medical care, including initiation of highly active antiretroviral therapy (HAART), continued use of HAART, and adherence to HAART regimens.1,4 Other studies suggest that MH/SUD are significantly associated with more rapid HIV disease progression, as well as morbidity and mortality.5,6 However, the nature of these influences remains poorly understood. This study assessed the prevalence of co-occurring MH/SUD in a multi-site cohort of HIV+ women in the Women’s Interagency HIV Study (WIHS).

Study Hypotheses:

Methods

889 HIV+ WIHS participants completed the World Mental Health Composite International Diagnostic Interview (WMH-CIDI).

Prevalence of mood, anxiety, alcohol, and drug use disorders was calculated. Results were matched to 12-month data regarding receipt of HAART, ARV adherence (95% or better and 100%), plasma HIV-RNA (>1,000), and CD4 (<200 copies/ml). Outcomes were analyzed using logistic regression with multivariate models controlling for age, race/ethnicity, and education.

Subject Demographics (N=889)

Results

Of those assessed (N=889), lifetime prevalence of co-occurring MH/SUD is 44%; 12-month prevalence is 7%. Figure 1 displays the most frequently co-occurring conditions among those with 12-month MH/SUD. Tables 1 and 2 show the likelihood of HAART use, adherence, and poor immune health among those with 12-month MH/SUD. Women with 12-month MH/SUD were less likely to be on HAART, and less likely to be ARV adherent at 95%+ and 100% levels. They were also more likely to have poor immune health (CD4<200) even controlling for age, race/ethnicity, education, HAART use, ARV adherence, and viral load.

Figure 1: Type and Prevalence of Co-Occurring Conditions Among 12-Month MH/SUD

Figure 1: Type and Prevalence of Co-Occurring Conditions Among 12-Month MH/SUD. Co-Occuring Conditions were: Anxiety/Drug, 29%; Anxiety/Mood/Drug, 23%; Anxiety/Alcohol, 14%; Anxiety/Mood/Drug/Alcohol, 11%; Other, 23%.

Table 1: Logistic Regression Models Predicting Likelihood of HAART Use and Adherence Among HIV+ Women with 12-Month MH/SUD
 

USING HAART95%

ARV ADHERENT

100% ARV ADHERENT

Variables

O.R.

C.I.

O.R.

C.I.

O.R.

C.I.

12-Month MH/SUD

0.480*

.26-.89

.483*

.26-.89

0.475*

.25-.89

Age

1.05***

1.02-1.07

1.02*

1.01-1.05

1.01

.99-1.03

Race/Ethnicity

0.45*

.21-.96

0.83

.48-1.43

1.21

.78-1.88

HS Education

0.91

.20-4.22

0.73

.16-3.38

.69

.22-2.20

O.R.=Odds Ratio; C.I.=Confidence Interval; * p<.05; **p<.01; ***p<.000

 

POOR IMMUNE HEALTH (CD4&lt;200)

Variables

O.R.

C.I.

12-Month MH/SUD

2.33*

1.10-4.95

Age

0.98

.95-1.02

Race/Ethnicity

1.20

.54-2.69

HS Education

1.40

.78-2.18

HAART Use

0.27

.06-1.22

95% ARV Adherence

0.53*

.31-.91

HIV-1 RNA

1.00***

1.00-1.00

O.R.=Odds Ratio; C.I.=Confidence Interval; * p<.05; **p<.01; ***p<.000

 

Conclusion

Co-occurring MH/SUD is associated with women’s lower likelihood of HAART use and being adherent at the 95% and 100% levels, even when controlling for age, race/ethnicity, and education. As well, co-occurring MH/SUD is also associated with greater likelihood of having poor immune health as indicated by a CD4 of less than 200. Even controlling for HAART use and adherence, women with co-occurring MH/SUD have poorer immune health. This suggests the need for treatment approaches that address these conditions in combination, in order to reduce morbidity and mortality of this population.

References

  1. Cook, J.A., Grey, D.D., Burke-Miller, J.K. et al., (2007). Illicit drug use, depression, and their association with highly active antiretroviral therapy in HIV-positive women. Drug & Alcohol Dependence, 89, 74-81.
  2. Whetten, K., Reif, S., Napravnik, S. et al., (2005). Substance abuse and mental illness among HIV-positive persons in the Southeast. Southern Medical Journal, 98, 9-14.
  3. Bing, E.G., Burnam, A., Longshore, D. et al. (2001). Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Archives of General Psychiatry, 58, 721-728.
  4. Chandler, G., Himelhoch, S., Moore, R.D. (2006). Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy . Drugs, 66(6), 769-789.
  5. Ickovics, J.R., Hamburger, M.E., Vlahov, D. et al. (2001). Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: Longitudinal analysis from the HIV epidemiology research study. JAMA, 285, 1466-1474.
  6. Cook, J.A., Burke-Miller, J.K., Cohen, M.H. et al., (2008). Crack cocaine, disease progression, and mortality in a multicenter cohort of HIV-1 positive women. AIDS, 22(11), 1355-1363.

Funded by grant number 1R01MH089830 from the National Institute of Mental Health (NIMH, P.I. J. Cook); and by grants to the Women's Interagency HIV Study Collaborative Study group from the National Institute of Allergy and Infectious Diseases (UO1-AI-35004, UO1-AI-31834, UO1-AI-34994, UO1-AI-34989, UO1-AI-34993, and UO1-AI-42590). Contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

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