Falling through the cracks

Abstract

Depression is the most common mental health disorder among HIV patients, affecting 20–30% of those engaged in HIV medical care.1 In addition to being a serious, costly, and potentially fatal medical condition in its own right, depression poses challenging barriers to effective medical care at multiple points along the continuum of HIV medical care engagement and treatment,2 or what has become known as the “HIV treatment cascade.”3 The HIV treatment continuum shows that for an HIV-infected individual to achieve virologic suppression, the individual must be aware of his or her diagnosis, engage in HIV medical care, remain in care, start antiretroviral therapy (ART), and adhere to ART. Thus high population-level success rates in testing, linking and retaining in care, initiating ART, and maximizing adherence are essential to maximally reduce “community viral load.”4 However, with substantial attrition at each step along the HIV treatment continuum, a recent analysis estimated that only 19% of HIV-infected individuals in the US currently have suppressed virus.2 Attrition along the steps of the HIV treatment continuum is related to many factors, but in particular is strongly predicted by depression. Mounting evidence suggests that effectively treating depression in HIV patients may have benefits for their HIV treatment retention, ART adherence, and virologic suppression, and therefore for community viral load.5,6 However, the response to depression in HIV patients suffers from its own “treatment cascade.” Depression in HIV patients, while highly prevalent, is widely unrecognized.7 When clinically recognized, the condition often goes untreated.8 When treated, providers’ adherence to best-practices guidelines about dosing, duration, and monitoring of antidepressants is low, meaning that many patients fail to receive an adequate treatment course and therefore fail to benefit from treatment.9