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.

Agency
National Institute of Health (NIH)
Institute
National Institute on Drug Abuse (NIDA)
Type
Dissertation Award (R36)
Project #
1R36DA034513-01
Application #
8408869
Study Section
Behavioral and Social Consequences of HIV/AIDS Study Section (BSCH)
Program Officer
Kahana, Shoshana Y
Project Start
2012-07-15
Project End
2013-06-30
Budget Start
2012-07-15
Budget End
2013-06-30
Support Year
1
Fiscal Year
2012
Total Cost
$53,025
Indirect Cost
$3,913
Name
University of Maryland College Park
Department
Psychology
Type
Schools of Arts and Sciences
DUNS #
790934285
City
College Park
State
MD
Country
United States
Zip Code
20742
Magidson, Jessica F; Listhaus, Alyson; Seitz-Brown, C J et al. (2015) Can behavioral theory inform the understanding of depression and medication nonadherence among HIV-positive substance users? J Behav Med 38:337-47
Magidson, Jessica F; Blashill, Aaron J; Safren, Steven A et al. (2015) Depressive symptoms, lifestyle structure, and ART adherence among HIV-infected individuals: a longitudinal mediation analysis. AIDS Behav 19:34-40
Magidson, Jessica F; Blashill, Aaron J; Wall, Melanie M et al. (2014) Relationship between psychiatric disorders and sexually transmitted diseases in a nationally representative sample. J Psychosom Res 76:322-8
Magidson, Jessica F; Seitz-Brown, C J; Safren, Steven A et al. (2014) Implementing Behavioral Activation and Life-Steps for Depression and HIV Medication Adherence in a Community Health Center. Cogn Behav Pract 21:386-403
Magidson, Jessica F; Seitz-Brown, C J; Listhaus, Alyson et al. (2013) Distress tolerance and use of antiretroviral therapy among HIV-infected individuals in substance abuse treatment. AIDS Patient Care STDS 27:518-23
Magidson, Jessica F; Wang, Shuai; Lejuez, C W et al. (2013) Prospective study of substance-induced and independent major depressive disorder among individuals with substance use disorders in a nationally representative sample. Depress Anxiety 30:538-45