Leveraging A Low-Intensity Behavioral Intervention for HIV Care to Target Depressive Symptoms in People Living with HIV

University Of Pennsylvania, Philadelphia PA

Investigators

Abstract

PROJECT SUMMARY People living with HIV (PLWH) experience depression at nearly two times the rate of the general population, leading to decreased quality of life,1 more rapid HIV disease progression,2 increased suicide risk,3 and increased mortality.4 In the United States, PLWH are disproportionately Black or Latinx, LGBTQ+, and living in poverty. Access to mental health services among this population is limited by myriad contextual barriers related to individual and structural factors (e.g., stigma,5 discrimination,6 poverty,7 food insecurity,8) and implementation factors (e.g., provider burnout, insufficient public funding). These challenges in accessing mental health treatment exacerbate existing inequities within this population. There is an urgent need for effective, feasible, and scalable treatment for depression in PLWH that overcomes existing access barriers. Managed Problem Solving Therapy (MAPS), a low-intensity behavioral intervention to increase medication adherence in PLWH, is an evidence-based practice endorsed by the CDC. Although MAPS was designed to specifically target medication adherence, when tested in a randomized-controlled trial, depressed PLWH receiving this treatment were twice as likely to experience depression remission compared to those receiving usual care.9,10 MAPS+, an adapted version of MAPS that focuses on medication adherence and care retention, will be delivered by community health workers (CHWs) in Philadelphia HIV clinics in an R01-funded trial (NR 019753; Momplaisir, Beidas, Gross). My proposed project builds upon the R01 project, adding a behavioral health component by 1) prospectively testing the effect of MAPS+ on depressive symptoms; 2) examining the mechanism by which MAPS+ affects depressive symptoms; 3) addressing crucial implementation questions related to mental health and health equity that are relevant to scaling up this intervention. Quantitative data will be collected from ~100 PLWH across 4 clinics over one year and will be compared to a cohort of similar patients from the same clinics from an earlier time using propensity score matching. The hypothesized mechanism of action, that MAPS+ decreases depressive symptoms by increasing self-efficacy, will be tested using mediation modeling. The proposed project also includes a qualitative aim involving multi-level stakeholders. Thirty qualitative interviews with patients, CHWs, and clinic leaders will capture perspectives on contextual barriers and facilitators to MAPS+ implementation to inform future implementation efforts in Philadelphia and beyond and to advance health equity goals. This fellowship opportunity will provide the applicant with advanced training in implementation science and statistical methods through didactics and formal mentorship. Further, carrying out the proposed research project will provide the applicant with an opportunity to develop independent research skills that will prepare her to carry out her long-term career goal of improving access to mental health care in resource-limited settings by leveraging low-intensity interventions. 1. Sherbourne CD, Hays RD, Fleishman JA, et al. Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. Am J Psychiatry. 2000;157(2):248-254. doi:10.1176/appi.ajp.157.2.248 2. Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70(5):539-545. doi:10.1097/PSY.0b013e3181777a5f 3. Carrico AW, Johnson MO, Morin SF, et al. Correlates of suicidal ideation among HIV-positive persons. AIDS. 2007;21(9):1199-1203. doi:10.1097/QAD.0b013e3281532c96 4. Villes V, Spire B, Lewden C, et al. The effect of depressive symptoms at ART initiation on HIV clinical progression and mortality: Implications in clinical practice. Antivir Ther. 2007;12(7):1067-1074. 5. Goodin BR, Owens MA, White DM, et al. Intersectional health-related stigma in persons living with HIV and chronic pain: implications for depressive symptoms. AIDS Care - Psychol Socio-Medical Asp AIDS/HIV. 2018;30(sup2):66- 73. doi:10.1080/09540121.2018.1468012 6. Logie C, James L, Tharao W, Loutfy M. Associations between HIV-Related stigma, racial discrimination, gender discrimination, and depression among hiv-positive african, caribbean, and black women in Ontario, Canada. AIDS Patient Care STDS. 2013;27(2):114-122. doi:10.1089/apc.2012.0296 7. Oldenburg CE, Perez-Brumer AG, Reisner SL. Poverty matters: Contextualizing the syndemic condition of psychological factors and newly diagnosed HIV infection in the United States. AIDS. 2014;28(18):2763-2769. 8. Turan JM, Elafros MA, Logie CH, et al. Challenges and opportunities in examining and addressing intersectional stigma and health. BMC Med. 2019;17(1):1-15. doi:10.1186/s12916-018-1246-9 9. Gross R, Bellamy SL, Chapman J, et al. The effects of a problem solving-based intervention on depressive symptoms and HIV medication adherence are independent. PLoS One. 2014;9(1):84952. 10. Gross R, Bellamy SL, Chapman J, et al. Managed problem solving for antiretroviral therapy adherence: A randomized trial. JAMA Intern Med. 2013;173(4):300-306. doi:10.1001/jamainternmed.2013.2152