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Rulin C. Hechter 1 MD,PhD Jean Q. Wang 1 PhD Margo A. Sidell 1 ScD

Impact of Depression on Retention in Care and Viral Suppression in a Large Cohort of Insured HIV-infected Patients. Rulin C. Hechter 1 MD,PhD Jean Q. Wang 1 PhD Margo A. Sidell 1 ScD William J. Towner 2 MD 1 Dept. of Research and Evaluation

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Rulin C. Hechter 1 MD,PhD Jean Q. Wang 1 PhD Margo A. Sidell 1 ScD

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  1. Impact of Depression on Retention in Care and Viral Suppression in a Large Cohort of Insured HIV-infected Patients Rulin C. Hechter1MD,PhD Jean Q. Wang1 PhD Margo A. Sidell1ScD William J. Towner2 MD 1 Dept. of Research and Evaluation Kaiser Permanente Southern California 2 Infectious Disease Kaiser Los Angeles Medical Center July 27th, 2012 Disclosure:No potential conflict of interest

  2. Hypothesis poor retention in HIV Care • Depression less optimal viral control • Depressive symptoms are prevalent in HIV patients (~50%), affect adherence to ART Bing EG, et al, Arch Gen Psychiatry. 2001; HorbergMA, et al. J Acquir Immune DeficSyndr., 2008; Hartzell JD et al. J Acquir Immune DeficSyndr2007; • AIM1: To examine the impact of depression on retention in HIV primary care. • AIM2: To examine the impact of depression on viral suppression among patients on ART.

  3. Study Setting • Study Setting: Kaiser Permanente Southern California (KPSC)--3.49 million health plan members • Team-based integrated HIV primary care • Electronic HIV patient registry --- over 12,500 registered HIV patients in KPSC since 01/01/2000 • Inclusion criteria: • AIM1: HIV+ adults with at least 8 months health plan membership in 2010 • AIM2: 1) on ≥ 3 ARVs for≥ 6 months (≥ 2 refills), and 2) ≥ 1 HIV viral load test in 2010

  4. Sample size AIM 1 AIM 2

  5. measurements • Predictor: • Depressive symptoms (time-updated) • Major depression; Dysthymia; Anxiety and phobic disorders; Adjustment disorder with anxiety and depression. • Outcomes: • AIM1: Retention in 2010 • ≥2 CD4 and/or HIV-1 viral load tests at least 90 days apart • AIM2: Viral suppression at the last visit in 2010 • viral load <50 copies/mL

  6. Statistical analyses • Modeling: • AIM1: Poisson regression with robust error variances • AIM2: Logistic regression • Covariates (multivariable analyses): • age, gender, race/ethnicity, mode of HIV infection, ever AIDS diagnosis, medical center of care, and retention (AIM2 only) • Stratified analyses: • By gender (AIM1&2), and retention (AIM2)

  7. Results-AIM1 (baseline, 01/01/2010)

  8. Results-AIM1impact of depression on retention RR (95% CI) Adjusted Among Males Among Females 0.89 (0.86-0.91) 0.89 (0.87-0.92) 0.82 (0.75-0.89)

  9. Results-AIM2viral suppression at last test in 2010

  10. Results-AIM2impact on Maximal viral control Fig 2. Association between diagnosed depression and failure of viral suppression at the last test in 2010 OR (95% CI) 1.0

  11. Results-AIM2impact of depression on viral suppression Fig 3. Association between diagnosed depression and failure of viral suppression at the last test in 2010 Stratified by gender Stratified by retention Adjusted OR (95% CI) 1.0 1.0 2.65 (1.30-5.39)

  12. Limitations • Insured HIV patients • Small sample size of female patients (n= 628) • Potential misclassification • Potential residual confounding • Rx-antidepressant /counseling therapy • Illicit substance use • Adherence to ART

  13. conclusion • Depressive symptoms were prevalent (over 50%) • Depressive symptoms were negatively associated with retention in care in primary HIV care setting • Depressive symptoms may compromise viral control among patients on ART. • Clinical Implication: Early and regular screening for depression in HIV primary care setting Intervention / Referral for mental health services

  14. Acknowledgements • Drs. Jean Wang, Margo Sidell (Kaiser Permanente Southern California) • Dr. William Towner (Kaiser Los Angeles Medical Center) • Dr. Michael Horberg (Kaiser Permanente Mid-Atlantic States) • Dr. Michael Silverberg (Kaiser Permanente Northern California) • Dr. Chun Chao (Kaiser Permanente Southern California) • Beth Tang (Kaiser Permanente Southern California, HIV registry) • The International AIDS Society • Kaiser Permanente Southern California, Research and Evaluation Thank you! RulinHechter Kaiser Permanente Southern California Rulin.C.Hechter@kp.org

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