Transcript No Slide Title

Depression and PTSD Treatments Improve
HIV Treatment Outcome
Eric Avery, MD
Assistant Clinical Professor of Psychiatry
Director, HIV Psychiatry Services
The University of Texas Medical Branch
Galveston, Texas
Objectives
1. To understand the relationship between the increasing prevalence of
psychiatric disorders in HIV patients and the changing epidemiology of
the epidemic.
2. To review Depression and Post Traumatic Stress Disorder (PTSD):
Prevalence
Diagnosis
Impact on adherance and mortality
Treatment of Depression and PTSD
3. To review HIV and psychiatric drug/drug interactions.
HIV is a Psychiatric Epidemic
• Psychiatric illness increases risk for HIV.
• HIV increases risk for psychiatric illness.
• Effective treatment for psychiatric illness can improve
patient outcome.
• Effective treatment for psychiatric can decrease HIV
transmission.
Psychiatric Illness Increases Risk of HIV
Infection
• Substance Abuse.
• Mood Disorders (Major Depression, Bipolor D/O)
• Post Traumatic Stress Disorder (PTSD)
• Psychotic Disorders
• Impulsive behavior and personality factors
HIV Increases Risk for Psychiatric Illness
• Increased major depression.
• Increased mania.
• HIV dementia (AIDS Dementia Complex).
• Increased psychosocial stressors.
Depression
1. Prevalence
2. Diagnosis
3. Impact on ARV Treatment:
• Initiation
• Discontinuation
• Adherance
4. Impact on HIV Mortality
5. Treatment of Depression
100 Patients with HIV
How many are depressed?
Depressed Mood and HIV:
Name the 11 types:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Why is the diagnosis important?
Differential Diagnosis of Depressed Moods in HIV Patients
•Despondency/demoralization.
•Dysthymia (chronic low mood).
•Adjustment disorder/minor depression.
•Major depression, recurrent major depression.
•General anxiety disorder.
•Bipolar disorder -- depressed phase.
•Organic mood disorder “secondary depression” (infections, medication sideeffects, and mass lesions of CNS).
•Malnourishment/weight loss associated with HIV.
•Sleep disorder.
•Psychoactive substance abuse.
•Bereavement.
Depression: Multicenter AIDS Cohort Study
30
SYNDROMAL
CES - D>=22
CES-D-NS>=14
25
20
15
10
Time of
AIDS Onset
5
0
55-
49-
43-
37-
31-
25-
19-
13-
7-12
0-6
0-6
7-12
13-
19-
60
54
48
42
36
30
24
18
mo
mo
mo
mo
18
24
mo
mo
mo
mo
mo
mo
mo
mo
mo
mo
Percentages of Multicenter AIDS Cohort Study participants who met syndromal criteria for depression, or who had a
score of 22 or greater on the Center for Epidemiologic Studies Depression scale (CES-D) or 14 or greater on the CESD minus its “somatic” items (CES-D-NS), as AIDS developed.
Lyketos et al, Psych Ann 31: 1 Jan 01
Depression and Progression to AIDS – PreHAART
Lyketos, Hoover, Guccione et al
JAMA 1993
• MACS Cohort: 1718
participants
• 21% depressed at baseline
• Cox proportional hazards
analysis controlling for
sociodemographics, CD4, AIDS
related symptoms
• Depression did not predict
AIDS or death
Depression and Progression to Death – PreHAART
Burack, Barret, Stall, Chesney, Estrand, Coates
JAMA 1993
• San Francisco Men’s Health
Study: 277 participants
• 20% depressed at baseline
• Cox proportional hazards analysis
of progression to death
• Depression predicted ARV use but
not mortality
Depression and Progression to AIDS – PreHAART
Mayne, Vittinghoff, Chesney, Barrett, Coates
Arch Int Med 1996
•
•
•
•
•
SF Men’s Cohort: 1032 participants over 102 months
Cox proportional hazards with time dependent variables
58% had significant depressive symptoms (CES-D)
Longitudinal measurement of depression every 6 months
Predictors of Mortality
– CD4 cell count
– B2 microglobulin
– P24 antigen
– WHO HIV stage
– Depression (RR=1.67 P<0.05)
Depression and Progression to AIDS: Post-HAART
Ickovics, Hamburger, Vlahov et al
JAMA 2001
• HERS Cohort: 765
Participants
• Longitudinal depression
(CES-D)
– 42% chronic
– 35% intermittent
– 23% none
• Mortality predictors:
depression (RR=2), CD4,
HAART duration, age
Depression, Mortality by CD4 and Viral load:
Post-HAART
Ickovics, Hamburger, Vlahov et al
JAMA 2001
Why Does Depression Speed
Progression to AIDS and Death?
• Stress alters cellular and humoral immune response
•
•
•
•
•
•
Kieclot-Glaser Proc Nat Acad Sci 1996
Vedhara Lancet 1999
Glaser Psychosom Med 1992
Jabaaij J Psychosom Res 1993
Glaser Ann NY Acad Sci 1998
Azciati Psychosomatics 2001
• Delay in HAART initiation
• Early HAART Discontinuation
• Sub-optimal adherence to HAART
Depression and Delay in HAART Initiation
Fairfield JGIM 1999
199 Patients New England Deaconnes with VL>10,000
Hazard
Factor
95% CI
p Value
CD4 cell count
<200
200-500
1.00
2.63
1.61, 4.17
<.001
>500
Tenfold increase in initial
elevated viral load
History of pneumocystis
11.11
3.57, 33.33
<.001
0.66
0.57
0.45, 0.98
0.37, 0.90
.038
.016
Depression (53%)
History of injection drug use
1.49
2.70
1.03, 2.13
1.35, 5.56
.032
.005
Model adjusted for calendar date of first elevated viral load.
What Degree of Adherence
Is Needed to Prevent Drug-Resistant Virus
Patients With HIV RNA <400 (%)
Adherence to a PI-Containing Regimen Correlates
With HIV RNA Response at 3 Months
100
80
60
40
20
0
<70
70-80
80-90
90-95
PI Adherence (%) (MEMScaps)
Paterson. 6th CROI; 1999; Chicago. Abstract 92.
>95
Depression Predicts Adherence to Non-HIV Treatment
Amiodarone
Irvine
Psychosom Med
1999
General medicine
Botelho
J Fam Pract
1992
Aspirin for angina
Carney
Behavioral Med
1998
Renal diet
De-Nour
Transplantation
1993
ESRD Diet
Katz
Psychol Reports
1998
ESRD Diet
Schnieder
Health psychol
1991
ESRD Medical Regimen
Brownbridge
Ped Neph
1994
Cyclosporine Renal Transplant
Kiley
Transplantation
1993
Cyclosporine Renal Transplant
Rodriguez
Trans Proc
1991
Rheum arthritis treatment plan
Taal
Pt Ed Counsel
1992
Oral cytoxan
Lebovits
Cancer
1990
Asthma
Cochrane
Drugs
1996
Depression and HIV Medication
Adherence
•
•
•
•
•
Singh AIDS Care 1996
Holzmer AIDS Patient Care STDs 1999
Peterson Annals Int Med 2000
Schulz 38th ICAAC 1998
Bangsberg #1721 41st ICAAC 2001
Depression is Under-Treated
• 475 HIV+ men
• 37% moderate-severe depressive symptoms
– 40% of depressed received mental health care (12 mo)
– 3.4% of depressed received antidepressant
medications (12 mo)
Katz et al AIDS Care 1996
Depression: Diagnosis
Simple Depression Assessment
1. During the past month, have
you often been bothered by
feeling down, depressed, or
hopeless?
Yes
No
2. During the past month, have you
often been bothered by having
little interest or pleasure in doing
things?
Yes
If “no” to both, patient is unlikely to have major
depression.
If “yes” to either, proceed with the follow-up clinical
interview.
Whooley MA, Simon GE. N Engl J Med, 2000.
No
Follow-up Interview for Diagnosis:
SIGECAPSS
S
I
G
E
C
A
P
S
S
Sleep
Disruption in sleep patterns nearly every day?
Interests
Decreased interest and pleasure in usual activities
Guilt
Feelings of worthlessness or guilt?
Energy
Decreased energy?
Concentration
Diminished ability to concentrate?
Appetite
Change in appetite or weight?
Psychomotor
Psychomoror retardation or agitation/irritable?
Suicidal
Recurrent thought of death or suicide?
Sex drive
Diminished sex drive?
Beck Depression Inventory
Date__________________
Name:__________________________________________________ Marital Status:_______ Age:____ Sex:___
Occupation:_____________________________________________ Education:___________________________
This questionnaire consists of 21 groups of statements. After reading each group of statements carefully, circle the number (0,1,2 or
3) next to the one statement in each group which best describes the way you have been feeling the past week, including today. If
several statements within a group seem to apply equally well, circle each one. Be sure to read all the statements in each group
before making your choice.
1
2
0 I do not feel sad.
8
0 I don’t feel I am any worse than anybody else.
1 I feel sad.
1 I am critical of myself for may weaknesses or mistakes.
2 I am sad all the time and I can’t snap out of it.
2 I blame myself all the time for my faults.
3 I am so sad or unhappy that I can’t stand it.
3 I blame myself for everything bad happens.
0 I am not particularly discouraged about the future.
9
0 I don’t have any thoughts of killing myself.
1 I have thoughts of killing myself, but I would not carry
1 I feel discouraged about the future.
them out.
2 I would like to kill myself.
3 I would kill myself if I had the chance.
2 I feel I have nothing to look forward to .
3 I feel that the future is hopeless and that things cannot
improve.
10
3
0 I do not feel like a failure.
0 I don’t cry any more than usual.
1 I cry more now than I used to.
2 I cry all the time now.
1 I feel I have failed more than the average person.
3 I used to be able to cry, but now I can’t cry even though I
2 As I look back on my life, all I can see is a lot of failures.
want to.
3 I feel I am a complete failure as a person.
To order forms: 1-800-228-0752
Depression: Treatment
Tricyclic Antidepressants Treatment of
Depression in HIV+ Individuals
Medication
Response
Author
Journal
Year
Imipramine
74%
Rabkin
Am J Psych
1994
Imipramine
87%
Elliot
Am J Psych
1998
Desipramine
50%
Schwartz
Dep and
Anxiety
1999
Treatment of Depression With Other Agents
in HIV+ Individuals
Drug
Response
Author
Journal
Year
Dextroamphetamine
73%
Wagner
J Clin Psych
1999
Testosterone
74%
Rabkin
2000
Testosterone
(Sx decrease)
Arch Gen
Psych
J Clin Endo
Metab
Grinspoon
Grinspoon 2000
2000
SSRI Treatment of Depression in HIV+
Individuals
Medication
Response
Author
Journal
Year
Fluoxetine
83%
Rabkin
J Clin Psych
1994
Fluoxetine
64%
Zisook
J Clin Psych
1998
Fluoxetine
67%
Elliot
Am J Psych
1998
Fluoxetine
90%
Ferrando
Gen Hosp Psych
1997
Fluoxetine
75%
Schwartz
Dep and Anxiety
1999
Fluoxetine/
Sertraline
78%
Ferrando
J Clin Psych
1999
Sertraline
86%
Ferrando
Gen Hosp Psyh
1997
Nefazodone
73%
Elliot
J Clin Psych
1999
Paroxetine
86%
Ferrando
Gen Hosp Psych
1997
Side Effect/Toxicity Profile
TCA vs SSRI
TCA
SSRI
• Narrow therapeutic window
• Mild side effects
– Requires drug monitoring
• Anticholinergic effects
– Dry mouth, Constipation,
dizziness, hypotension
– 41% discontinue at 6 months
• (Rabkin Amer J Psych 1994)
• Pill burden
– Anticholinergic,
agitation/sedation, sexual
dysfunction
• Drug interactions (Rx +
ritonavir)
• Bupropion - seizures
SSRI FDA Approvals
Paroxetine Citalopram
Fluoxetine
Sertraline*
Major
depression
OCD
+
+
+
+
+
+
+
-
Panic
Disorder
GAD
-
+
+
-
-
-
+
-
Social
Anxiety
Disorder
PTSD
-
Filed
with FDA
+
-
-
+
+
-
SSRI
* FDA approved to age 6 years;
Half Lives of 4 SSRIs
SSRI
Parent Drug
Metabolite
Fluoxetine
2 – 4 days
10 – 14 days – 100%
active
Sertraline
26 hours
62 – 104 hours –
20% active
Paroxetine
20 hours
None
Citalopram
35 hours
None
Serotonin Discontinuation Syndrome
• Somatic symptoms
–
–
–
–
–
Disequilibrium, dizziness, unsteadiness, vertigo
Feeling “spacey”, confusion, memory dysfunction
Flulike symptoms (myalgia, chills, fatigue, nausea)
Sensations of electric shocks, parethesia, tremor
Insomnia, overactivity, vivid dreams
• Psychological symptoms
– Agitation, anxiety, irritability
– Mood lability, crying spells
– Cognitive fog
Hepatic Isoenzyme Inhibition of the SSRIs
(Cytochrome P450)
2D6
3A4
1A2
Fluoxetine
+++
+
-
Sertraline
+
-
-
Paroxetine
+++
-
-
Citalopram
-
-
-
HIV-Related Medications and Psychotropic Agents Involving the Cytochrome
P450 Isoenzyme
Cytochrome
P450
Isoenzyme
HIV
medications
Primarily
Metabolized
by Isoenzyme
Psychotropic
Medications
Primarily
Metabolized by
Isoenzyme
Common HIVRelated Medications
that Inhibit
Isoenzyme
Possible Clinical
Implications of
Isoenzyme Inhibition
Common HIVRelated Medications
that Induce
Isoenzyme
Possible
Clinical
Implications
of Isoenzyme
Induction
3A4
PI
Ritonovir
Amprenavir
Indinavir
Saquinavir
Benzodiazepines
Buspirone
Citalopram
Carbamazepine
Nefazodone
Trazodone
Sertraline
Risperdal (minor)
Protease inhibitors
(especially ritonavir)
Delavirdine
Clarithromycin
Erthromycin
Itraconazole
Ketoconazole
Macrolide antibiotics
Fluoxetine
Paroxetine (weak)
Valproic Acid (weak)
Increased plasma
levels and increased
side effects; for
benzodiazepines,
sedation & decreased
respiratory drive
Nivirapine
Efavirenz
Glucocorticoids
Rifampin
Rifabutin
Decreased
plasma levels
of
psychotropic
medications
& decreased
effectiveness
Mirtazapine
Fluoxetine
Paroxetine
Sertraline
Fluvoxamine
Tricyclic
antidepressants
Venlafaxine
Neuroleptics, typical
and atypical
Olonzepine (minor)
Risperidone
Protease inhibitors
(especially ritonavir
& nelfinavir)
Resperdal (weak)
Sertraline (weak)
Fluoxetine
Citaloprain (weak)
Paroxetine (weak)
Valproic Acid
Increased plasma
levels and increased
side effects; for
tricyclic
antidepressants,
potential increased
risk for cardiac
conduction delay
Efavirenz
NNRTI
Delavirdine
Efavirenz
Nevirapine
2D6
Ritonovir
Delavirdine
Efavirenz
Dose Ranges and Interactions With Human Immunodeficiency Virus (HIV)
Medications of Commonly Used Antidepressants*
Antidepressant
Usual Dosage Range
Interaction with HIV Medications
Nortriptyline
50-150 mg at bedtime (therapeutic serum level
50-150 mg ng/dL)
Fluconazole, lopinavir-ritonavir, and ritonavir increase
nortriptyline levels
Desipramine
50-300 mg at bedtime (therapeutic serum level
> 125 ng/dL)
Lopinavir-ritonavir and ritonavir increase desipramine
levels
Fluoxetine
10-30 mg in the morning
Fluoxetine increases amprenavir, delavirdine, efavirenz,
indinavir, lopinavir-ritonavir, ritonavir, nelfinavir, and
saquinavir level; nevirapine decreases fluoxetine levels
Sertraline
50-200 mg in the morning
Lopinavir-ritonavir and ritonavir increase sertraline levels
Paroxetine
10-40 mg at bedtime
Lopinavir-ritonavir and ritonavir increase paroxetine
levels
Citalopram
20-60 mg in the morning
Lopinavir-ritonavir and ritonavir increase citalopram
levels
Nefazodone
300-600 mg/d in divided doses
Nefazodone increases efavirenz and indinavir levels
Venlafaxine XR
75-300 mg in the morning
Lopinavir-ritonavir and ritonavir increase venlafaxine
levels
Mirtazepine
Bupropion SR
7.5-45 mg at bedtime
No known interactions
100-400 mg/d in divided doses
No known interactions
Staging HIV and Antidepressant Treatment:
Treat Depression First Whenever Possible
• Depression is common
• Depression is the strongest modifiable predictor of
adherence to all medical therapy
• Adherence is the strongest predictor of disease
progression and death after CD4 cell count
• Depression should be treated prior to starting
antiretroviral therapy
– Depression screen, CD4, VL
• Patients with severe HIV disease may need concurrent
initiation of antidepressant therapy and antiretroviral
therapy
Bangsberg JGIM 1999;14:446-8
Comorbid Mood and Anxiety Disorders
Panic Disorder
50% - 65%1
Generalized Anxiety
Disorder
8%- 39%1
Depression
Social Anxiety
Disorder
70%2
PTSD
48%4
OCD
67%3
1
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC;
American Psychiatric Press; 1994.
2
Van Ameringen M et al. J Affect Disord. 1991;21:93-99.
3
Rasmussen SA, Eisen JL. J Clin Psychiatry. 1992;53(suppl):4-10.
4
Coryell W Et al. Am J Psychiatry 1988;155:895-898.
Post Traumatic Stress Disorder
• Prevalence
• Childhood abuse, PTSD and HIV risk behaviors
• Proposed association between PTSD and HIV treatment
nonadherance
• Treatment of PTSD
PTSD Prevalence
• Over half the U.S. population has been exposed to a severe trauma
• 10-20% of trauma survivors will develop PTSD
• Lifetime prevalence 8% overall. 12% in women
(Kessler 1995)
– Increased rates in HIV +, incarcerated
– Limited studies:
• HIV + 30% (1/3 after HIV dx) (Kelly 1998)
• Incarcerated women lifetime 33%, current 15-22%
(Hutton 2001)
• PTSD is the 5th most prevalent major psychiatric illness
Most Prevalent Anxiety Disorders in the
General Population
33
Lifetime Prevalence (%)
29
25
21
17
13
9
5
1
-3
Social Anxiety
Disorder
Males
Females
Hutton (2001) 177 Prison Women
Kelly (1998) 61 HIV+ Gay/Bi men
PTSD
GAD
Panic
OCD
Kessler et al, National
Comorbidity Survey, 1994
Comorbidity
• Comorbid psychiatric illness is about 80%
• Patients with PTSD are 2 - 4X more likely to have
depression, anxiety disorders or substance abuse
• They are 90X more likely to have a somatization disorder
Common Traumatic Events
• Witnessing injury/death
• Sexual molestation/rape
• Natural disaster/fire
• Physical attack or abuse/threatened with a weapon
• Life threatening accident
• Combat
PTSD - Clinical Course
• PTSD symptoms usually present within the first 3 months
following the trauma
• Less frequently, symptoms may be delayed for months or
years after the traumatic event
• Symptoms of PTSD may persist for months or years after
the trauma
• Approximately 50% of all cases of PTSD are chronic
Connection Between Childhood Abuse and HIV Infection
Reported Abuse & Survivor Characteristics (N= 52 HIV +Adults Atlanta Social Service Agency)
Survivor
Characteristics
Reported Abuse
Total
Nonsexual-Physical
Sexual
No Abuse
(N=52)
%
(N=12)
%
(N=22)
%
Revictimized
34
65
10
83
18
82
6
33
Sexually
compulsive
20
38
6
50
11
50
3
17
Chronically
depressed
29
56
6
50
17
77
6
33
Alcohol/drug
abusing
37
71
10
83
19
86
8
44
Note. Survivor characteristic categories are not independent.
Allers C. J Counsel Devel. 1991; 70: 309-13
(N=18)
%
Frequency of PTSD Disorders Among 177 Women
Prisoners in an HIV Risk Behavior Study
Women prisoners
Disorder
N
%
Percentage among
general population
Posttraumatic stress disorder 1
Lifetime
Current
59
27
33
15
1-14
<1
Compared with participants who did not have PTSD, those with lifetime diagnosis of
PTSD were 71% more likely to have engaged in anal sex and 56% more likely to have
engaged in prostitution. The association between lifetime PTSD and other HIV risk
behaviors were not significant in this study.
Hutton, Psych Services 2001, 52/4:508-13
PTSD Predicts Adherence to Non-HIV Treatment
Survivors of Myocardial Infarction
• 102 s/p MI
• 10% PTSD (intrusion/avoidance)
– significant association with decreased adherence
Shemesh Gen. Hosp. Psych 2000
PTSD is Under-Treated
47 HIV+ women
• 42% full, current PTSD
– 59% not receiving mental health care
• 22% partial PTSD
– 78% not receiving mental health care
Martinez AIDS Patient Care and STDs 2002
PTSD: Diagnosis
Screening questions
• Have you ever had anything happen to you where you
thought you would be seriously injured or might die?
• Have you ever been in a life threatening accident? Fire?
Disaster?
• Have you ever been attacked or raped?
• Have you ever seen these things happen to someone else?
If the answer to any of these questions is “yes”
• Do you ever have nightmares about the event, or sometimes feel
the same feelings you had when you were in the trauma?
• Do you startle easily?
• Do you try hard to avoid situations which remind you of the
trauma?
• How do you feel about your future?
HOW CAN I TELL IF I HAVE PTSD?
PTSD is a serious, yet treatable medical disorder. It is not a sign of personal weakness. If you
think you may have PTSD, answer the following questions and show this checklist to your health
care professional
Yes or No?



 Problems concentrating?
Yes No
Have you experienced or witnessed a lifethreatening event that caused intense fear


Do you re-experience the event in at least one of
the following ways?
Yes No

Yes No
Yes No


Yes No

 Feeling “on guard”?

Yes No

Repeated, distressing memories and/or
dreams?

Acting or feeling as if the event were
happening again (flashbacks or a sense of
reliving it)?
Intense physical and/or emotional distress
when you are exposed to things that remind
you of the event?
Do you avoid reminders of the event and feel numb, compared to
the way you felt before, in three or more of the following ways?
 An exaggerated startle response?
 Do your symptoms interfere with your daily life?
Yes No

 Have you symptoms lasted at least 1 month?
Yes No
Having more than one illness at the same time can make it more
difficult to diagnose and treat the different conditions. Illnesses
that sometimes complicate PTSD include depression and
substance abuse. To see if you have other problems that may
need treatment, please complete the following questions.
Consensus Guidelines: J Clin Psych 1999
PTSD: Treatment
Psychotherapeutic Interventions
• Acute PTSD
– mild:
– severe:
Psychotherapy
Psycho therapy and medication
• Chronic PTSD
– mild:
– severe:
Psychotherapy first or + medication
Psychotherapy first or + medication
If comorbid (eg: depression / bipolor / other anxiety DO)
– medication plus psychotherapy
• Most effective: cognitive behavioral therapy (CBT) and exposure therapy
• Patients are encouraged to confront anxiety provoking triggers, decrease
avoidance, and practice stress reducing strategies
• When referring patients, seek therapists with expertise in CBT and BT
Consensus Guidelines J. Clin. Psychiatry 1999
Pharmacological Interventions:
Antidepressants
Positive Controlled Trials:
TCAs
• amitryptaline (Elavil)
• imipramine ((Tofranil)
MAOIs
• phenelzine (Nardil)
SSRIs
• fluoxetine (Prozac): civilians only
• sertraline (Zoloft): (Paxil): FDA indication
• paroxetine (Paxil)
Benzodiazepines
• Should NOT be first line
• May exacerbate
– Dissociation
– Substance abuse
– Disinhibition
• Best used as an augment
Pharmacological Steps for PTSD
• Start with and SSRI
• Initiate with a low dose, half of what would start for depression
• Titrate to a high dose
• Once patient improves, maintain dosage for at least a year
Pharmacotherapy Steps for PTSD
• If no response or intolerant to SSRI:
– Venlafaxine
– Nefazadone
– A tricyclic antidepressant
• If all else fails, consider a monoamine oxidase inhibitor
Reasonable augmentations
• Anticonvulsants: for dissociation, explosiveness, mood lability
• Autonomic blockers: for SNS overactivity
• Benzodiazepines or Buspirone: for excessive anxiety
• Neuroleptics: for poor impulse control
• Sedating antidepressants (Trazadone): for insomnia
Summary
1.
Psychiatric disorders, especially depression and PTSD are
common in HIV patients.
2. Depression is the strongest modifiable predictor of adherence to
all medical therapy.
3. Adherence is the strongest predictor of disease progression and
death after CD4 count.
4. Depression should be treated prior to starting antiretroviral
therapy. When in doubt, treat.
5. The behavioral manifestations of PTSD contribute to problems of
HIV treatment adherance.
•
•
•
•
Difficulty recognizing harm
Difficulty developing self protective mechanism
Compulsive need to repeat the trauma
Sense of foreshortened future