Mediators of the Relationship Between Depression and HIV Medication Adherence

描述(由申请人提供)：高效抗逆转录病毒疗法(HAART)依从性差是艾滋病毒治疗和预防中的一个重要临床问题，因为极高水平的HAART依从性是维持病毒抑制所必需的。最近的证据表明，在全国范围内接受HAART治疗的患者中，只有19%的人表现出最佳的依从性并实现了完全的病毒抑制。努力更好地了解和改进HAART的遵守情况，对于控制艾滋病毒/艾滋病的流行至关重要。一个新的艾滋病毒感染负担不成比例的群体是生活在城市地区的低收入少数药物使用者。特别是在华盛顿特区，美国每年报告的新艾滋病毒/艾滋病病例比例最高，新感染人数最显著的增加是低收入、少数族裔吸毒者。在这一群体中，患者层面最显著和最普遍的坚持障碍之一是抑郁症状。抑郁症状，即使是亚临床水平，也预示着不坚持，超过了其他相关的心理社会因素，包括目前的药物使用。尽管人们关注抑郁症状，认为它是艾滋病毒吸毒者不遵守HAART的可靠而有力的预测指标，但很少有研究试图测试这种关系背后的潜在机制，这是推进我们对抑郁如何影响坚持的理解的重要一步，为这一群体的干预努力提供信息。使用基于强化的理论，我们专注于与抑郁和物质使用相关的两个关键的共同行为/环境因素，包括：(1)目标导向活动水平的减少和(2)环境中积极强化的减少。广泛的证据表明，这些因素与HAART的依从性有关；然而，它们尚未被测试为抑郁症状和HAART依从性之间关系的潜在中介。因此，该提案的目的是在低收入艾滋病毒阳性物质使用者的样本中测试目标导向的活动水平和积极强化在这种关系中的中介作用。我们将使用重复措施设计，评估自我报告和临床医生对抑郁症状、药物使用、目标导向的活动水平、阳性强化和HAART依从性的评估，以及在3个月期间的临床指标(病毒载量、CD4计数)。样本将包括从华盛顿特区一家大型艾滋病毒诊所招募的125名艾滋病毒阳性物质使用者。结果具有重要意义，因为它们将首次测试可能解释低收入少数药物使用者抑郁与遵守HAART之间关系的潜在机制，这是一个艾滋病毒结局极高风险的群体。正如Kazdin(2007)所指出的，确定调解人是至关重要的，以便最大限度地节约和优化干预措施的效力。目前的研究结果对于提高针对抑郁症和遵守HAART的综合干预措施的有效性和简洁性具有明确的意义，并对预防具有重要意义，因为更好地了解和改善坚持治疗可能会降低这一高危群体的传播风险。 公共卫生相关性：努力更好地了解和改善低收入少数艾滋病毒携带者接受高效抗逆转录病毒疗法(HAART)的情况，这对控制艾滋病毒/艾滋病的流行至关重要。在这一人群中，抑郁是不坚持的一个可靠而有力的预测因素，但到目前为止，还没有研究测试抑郁如何影响坚持。当前提案的目标是测试低收入HIV阳性药物使用者中抑郁症与HAART不依从性之间的潜在机制，这对提高现有预防和治疗干预的有效性和简洁性具有明显的意义。

DESCRIPTION (provided by applicant): Poor adherence to highly active antiretroviral therapy (HAART) is a significant clinical issue in the treatment and prevention of HIV, as extremely high levels of HAART adherence are necessary to maintain viral suppression. Recent evidence suggests only 19% of individuals on HAART nationwide show optimal adherence and achieve full viral suppression. Efforts to better understand and improve HAART adherence are crucial to managing the HIV/AIDS epidemic. A group that evidences a disproportionate burden of new HIV infection is low-income minority substance users living in urban areas. In D.C. specifically, where the highest rate of new HIV/AIDS cases in the U.S. are reported each year, the most notable increase in new infection has been among low-income, minority substance users. In this group, one of the most significant and prevalent patient-level barriers to adherence is depressive symptoms. Depressive symptoms, even at subclinical levels, predict nonadherence above and beyond other relevant psychosocial factors, including current substance use. Despite the focus on depressive symptoms as a reliable and powerful predictor of HAART nonadherence among substance users with HIV, few studies have sought to test potential mechanisms underlying this relationship, which is an important step to advance our understanding of how depression affects adherence to inform intervention efforts in this group. Using reinforcement-based theory, we focus on two key shared behavioral/environmental factors related to both depression and substance use that include: (1) reductions in goal-directed activity level and (2) reductions in positive reinforcement in one's environment. Extensive evidence suggests the relevance of these factors to HAART adherence; however, they have not been tested as potential mediators of the relationship between depressive symptoms and HAART adherence. Thus, the aim of the proposal is to test the mediating roles of goal-directed activity level and positive reinforcement in this relationship in a sample of low-income HIV positive substance users. We will use a repeated measures design assessing self-report and clinician rated measures of depressive symptoms, substance use, goal-directed activity level, positive reinforcement, and HAART adherence, as well as clinical indicators (Viral Load, CD4 count) over a 3-month period. The sample will include 125 HIV positive substance users recruited from a large HIV clinic in Washington, D.C. Results have important implications as they would provide the first test of potential mechanisms that may account for the relationship between depression and HAART adherence among low-income, minority substance users, a group at extremely high-risk for poor HIV outcomes. As Kazdin (2007) noted, it is crucial to identify mediators in order to maximize parsimony and optimize efficacy of interventions. Current findings have clear implications for increasing effectiveness and parsimony of integrated interventions to target depression and HAART adherence, as well as important implications for prevention, as better understanding and improving adherence may reduce the risk of transmission in this high-risk group. PUBLIC HEALTH RELEVANCE: Efforts to better understand and improve adherence to highly active antiretroviral therapy (HAART) among low- income, minority substance users living with HIV is crucial to managing the HIV/AIDS epidemic. One reliable and powerful predictor of nonadherence in this population is depression, yet to date no studies have tested how depression impacts adherence. The goal of the current proposal is to test potential mechanisms of the relationship between depression and HAART nonadherence among low-income HIV positive substance users, which has clear implications for increasing effectiveness and parsimony of existing prevention and treatment interventions.