Research in context
Evidence before this study
Clinical depression is highly prevalent (approximately 37%) in individuals living with HIV and is associated with non-adherence to antiretroviral therapy. Cognitive behavioural therapy is a well studied non-pharmacological therapy treatment for depression. However, there is a general scarcity of efficacy studies on psychosocial treatments for depression and adherence in individuals living with HIV. We searched PubMed and PsycINFO, with the search terms “HIV and depression treatment”, “HIV and CBT”, “HIV and behaviour therapy”, and “HIV and psychological treatment” for papers published until about January, 2008, and at various timepoints during the study planning phases, and also monitored emerging studies during this trial.
Added value of this study
In this study, we found that for people living with HIV who have a clinical diagnosis of depression, 12 sessions of counselling integrating cognitive behavioural therapy for depression with a cognitive behavioural approach to enhance antiretroviral medication adherence (Life-Steps), was more effective than a single session of adherence counselling and a letter to the patient's treatment provider documenting the patient's depression. These gains were evident at the end of treatment (roughly 4 months), and over 8 months and 12 months of follow-up. This approach was not superior, however, to another manualised 12 session treatment for depression (information with supportive psychotherapy) that also integrated the same cognitive behavioural approach to adherence counselling. The findings in this study support the integration of cognitive behavioural adherence counselling (Life-Steps) into evidenced-based psychosocial treatments for depression. Accordingly, mental health-care providers who treat patients living with HIV might wish to integrate this counselling into their treatment to improve adherence to antiretroviral therapy, which might, in turn, improve HIV outcomes. These results support the preliminary findings from our group and extend them through a full-scale efficacy trial of HIV-positive individuals with depression in HIV care.
Implications of all the available evidence
Mental health-care providers should consider adding adherence counselling into their psychiatric treatment of patients with HIV who have comorbid depression and poor HIV medication adherence. Cost-effectiveness analyses are needed for policy implications because this study showed that a more intensive treatment for adherence and depression was more effective than a less intensive approach. Implementation and effectiveness trials are also needed.