The Causal Effect of Effective Depression Treatment on HIV Outcomes in CNICS

描述（由申请人提供）：抑郁症是hiv感染者中非常常见的合并症。抑郁症与一系列不良健康行为和结果相关，包括抗逆转录病毒（ARV）药物依从性降低、艾滋病毒传播风险行为增加、病毒学失败增加和死亡率升高。抗抑郁药物和心理治疗对治疗艾滋病毒感染者的抑郁症是有效的。因此，艾滋病毒临床医生、研究人员和政策制定者面临的一个重要问题是，抑郁症治疗在多大程度上可以改善艾滋病毒行为、风险传播和临床结果，并帮助实现抗逆转录病毒治疗作为预防的全部潜力。通过投资于艾滋病毒患者的高质量抑郁症治疗，可以在人群层面上实现对传播和健康的影响，目前存在有限的真实有力证据。对抑郁症治疗对艾滋病结果的影响进行精确而有效的因果估计，特别是从大型和可推广的样本中，对于确定这种投资的艾滋病相关回报是必要的。少数随机对照试验表明，在强化以心理治疗为基础的抑郁症治疗干预后，抗逆转录病毒药物依从性得到改善，但这些试验是在小样本和不可推广的样本中进行的。一些观察性研究表明抗抑郁药治疗与抗逆转录病毒药物依从性呈正相关，但这些研究通常没有使用适当的因果推理统计方法来解释抑郁症状与治疗之间的动态关系。迄今为止的研究也普遍将所有抗抑郁治疗归为一类，而不是将适当的（最佳做法）治疗与临床惰性区分开来——临床惰性是非精神科医生未能滴定抗抑郁药的趋势

DESCRIPTION (provided by applicant): Depression is an exceedingly common comorbidity among HIV-infected patients. Depression has been associated with a range of adverse health behaviors and outcomes including reduced antiretroviral (ARV) medication adherence, increased HIV transmission risk behaviors, increased virologic failure, and higher mortality. Antidepressant medications and psychotherapy are effective in treating depression in HIV-infected patients. Consequently, an important question for HIV clinicians, researchers, and policy-makers is the extent to which depression treatment can improve HIV behavioral, risk transmission, and clinical outcomes and help realize the full potential of ARV treatment-as-prevention. Limited real-world, robust evidence exists about the population-level impact on transmission and health that could be achieved by investing in high-quality depression treatment for HIV patients. Precise and valid causal estimates of the effect of depression treatment on HIV outcomes, especially from large and generalizable samples, are necessary to define the HIV-related return on such investment. A small number of randomized controlled trials have demonstrated improvements in ARV adherence after intensive psychotherapy-based depression treatment interventions, but have been conducted in small and non-generalizable samples. Several observational studies have suggested a positive association of antidepressant treatment with ARV adherence, but these studies have generally not used appropriate causal inference statistical methods to account for the dynamic relationship between depressive symptoms and treatment. Studies to date have also generally grouped all antidepressant treatment together, rather than distinguish adequate (best-practices) treatment from clinical inertia - the tendency of non-psychiatric providers to fail to titrate antidepressant doses to address ongoing symptoms. In this project, we will draw on the rich information in the large and diverse CNICS observational cohort, encompassing 25,000 patients from 8 CFAR clinical sites across the US, to complete the following aims: (1) to characterize the frequency of adequate vs. inadequate antidepressant treatment provided within HIV clinical care; (2) to estimate the magnitude of the effect of antidepressant treatment, and specifically adequate antidepressant treatment, on HIV-related behavioral and health outcomes using state-of-the-art causal inference methods; and (3) to assess whether the effect of adequate depression treatment on HIV outcomes differs for certain subgroups, such as those with greater depressive severity, concurrent anxiety, or problematic alcohol or drug use. This scope of work is significant because we will (1) define the current "depression treatment gap" in HIV primary care, (2) define the population-level impact on HIV outcomes achievable by reducing that gap, and (3) define subpopulations for which the reduction of the treatment gap could be most beneficial. Our proposal is innovative in its use of advanced causal inference methods and its focus on distinguishing adequate from inadequate antidepressant treatment. The large and diverse patient population represented in CNICS will enhance the generalizability of this work's findings to the population of HIV-infected patients engaged in HIV primary care across the United States.