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  13th International Workshop on
HIV and Aging
13-14 October 2022

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Depression Tied to Noncommunicable
Disease Rate in People With HIV

  International Workshop on HIV and Aging, October 13-14, 2022
By Mark Mascolini for NATAP and Virology Education
A depression diagnosis independently boosted odds of more noncommunicable diseases (NCDs) in a study of almost 5000 US people with HIV [1]. This cross-sectional analysis did not find a link between "community mental distress"-a county-wide calculation of average number of mentally unwell days-and NCDs. But race/ethnicity modified the association between community mental distress and NCDs.
Estimates of depression prevalence in people with HIV range from as low as 12% to as high as 67%. Research links mood disorders like major depressive disorder and bipolar affective disorder to higher risk of NCD in people with HIV, including cardiovascular disease, cerebrovascular disease, diabetes, and multimorbidity. Frequent association of depression and HIV infection with social determinants of health can cause population disparities in NCDs and complicate analysis of how depression and HIV affect NCD risk. Until this study by Vanderbilt University researchers, no one had analyzed whether community mental distress affects an HIV-positive individual's NCD risk.
To address these issues, the Vanderbilt team in Nashville, Tennessee conducted a cross-sectional study of associations between depression diagnosis, community mental distress, and number of NCDs in individuals seen at a university clinic between January 2009 and December 2019. Community mental distress meant the average monthly number of mentally unwell days within 2 years in a county resident determined by the Behavioral Risk Factor Surveillance System (BRFSS, an annual national phone survey about mental health, including the question "For how many days during the past 30 days was your mental health not good?")
The main study question was, "Independent of individual depression, is community mental distress associated with NCD in people with HIV?"
In this study depression meant all mood disorder diagnoses within 6 months of the study visit. NCDs included cardiovascular disease (hypertension, coronary artery disease, peripheral vascular disease, cerebrovascular disease), liver disease (cirrhosis, chronic liver disease, steatosis), metabolic disease (diabetes, dyslipidemia), chronic kidney disease (stage 3 or worse), and non-AIDS defining cancers.
The researchers used multivariable logistic regression to probe for associations between depression and community mental distress. They used multivariable proportional odds models to explore associations between number of NCDs with either individual depression or community mental distress. These models adjusted for age, gender, race/ethnicity, HIV acquisition risk factor, substance use, antiretroviral therapy, year, hepatitis C virus coinfection, time since HIV diagnosis, CD4 count, viral load, body mass index, and depression.
The study group included 4798 adults with HIV with a median age of 40.8 years, 59% cisgender men who have sex with men (MSM), 21% cisgender women, 13% heterosexual cisgender men, and the rest "cisgender men, other," transgender (n = 50), and other. Half of the group was non-Hispanic white, 41% non-Hispanic black, and 10% other. Median CD4 count stood at 490, one third of participants had a viral load below 48 copies, 57% had no NCDs, 24% had 1 NCD, and 19% had 2 or more. A little more than one quarter, 28%, reported depression.
People with versus without depression were slightly but significantly older (median 42 vs 40 years, P < 0.001), disproportionately non-Hispanic white (64% vs 45%, P < 0.001), and more likely to be cisgender women (26% vs 19%, P < 0.001), have a longer time since HIV diagnosis (median 6.95 vs 4.45 years, P < 0.001), have a higher body mass index (median 26.5 vs 25.8 kg/m2, P < 0.001), and have 2 or more NCDs (22% vs 17%, P < 0.001).
Among people with versus without depression, a higher proportion had hyperlipidemia (about 34% vs 24%). But hypertension prevalence was lower in people with versus without depression (about 27% vs 33%). NCD prevalence did not differ much by depression status for chronic kidney disease, chronic liver disease, cardiovascular disease, diabetes, or non-AIDS cancer.
People with and without depression had the same median monthly mentally unwell days for county of residence (3.00, P = 0.4). Multivariable logistic regression found no association between BRFSS-determined community mental distress and individual depression (overall P = 0.1638). But multivariable proportional odds models saw a strong association between individual depression and higher number of NCDs (adjusted odds ratio [aOR] 1.21, 95% confidence interval [CI] 1.11 to 1.31, P < 0.001).
More average days of community mental distress meant a higher number of NCDs, but this association lacked statistical significance (aOR comparing 25th to 75th percentiles [4.2 vs 2.9 days] 1.09, 95% CI 0.96 to 1.24, P = 0.076). Race modified the relationship between community mental distress and NCD prevalence in an adjusted analysis: (1) For non-Hispanic blacks there was a null association between community mental distress and number of NCDs. (2) For non-Hispanic whites there was a modest positive association and between community mental distress and NCD burden. (3) For other racial/ethnic groups combined there was an inverse correlation between community mental distress and NCD burden, but this last association had a very wide confidence interval spanning the null.
The Vanderbilt investigators cautioned that the study population came from a single clinic, and 24% of participants lived in a single county in central Tennessee; so these findings may not apply to other populations with HIV. Also, the study was cross-sectional, representing a single slice of time for individual participants. A longitudinal study could give a clearer picture of evolving associations between individual depression, community mental distress, and number of NCDs.
With these caveats in mind, the researchers concluded that a depression diagnosis in an individual is significantly linked to a higher NCD burden in people with HIV. An area-level measure of community mental distress was not statistically linked to NCD burden; but race/ethnicity modified this association, a result "suggesting heterogeneity in the association and other social determinants of health affect the relationship."
1. Castilho J, Bian A, Rebeiro P, et al. Individual and community measures of depression and risk of non-communicable disease among adults with HIV. International Workshop on HIV and Aging, October 13-14, 2022. Abstract 5.