Perinatal Depressive Symptoms, Human Immunodeficiency Virus (HIV) Suppression, and the Underlying Role of Antiretroviral Therapy Adherence: A Longitudinal Mediation Analysis in the IMPAACT P1025 Cohort

Florence Momplaisir, Mustafa Hussein, Deborah Kacanek, Kathleen Brady, Allison Agwu, Gwendolyn Scott, Ruth Tuomala, David Bennett, Florence Momplaisir, Mustafa Hussein, Deborah Kacanek, Kathleen Brady, Allison Agwu, Gwendolyn Scott, Ruth Tuomala, David Bennett

Abstract

Background: Women with HIV have higher risk of depressive symptoms in the perinatal period. Evidence on how perinatal depressive symptoms affect viral suppression (VS) and adherence to antiretroviral therapy (ART) remains limited.

Methods: Perinatal depressive symptoms were assessed using 6 items from the AIDS Clinical Trials Group (ACTG) Quality of Life questionnaire. VS (viral load <400 copies/mL) was the outcome. Adherence was defined as no missed dose in the past 1-4 weeks using the ACTG Adherence Questionnaire. Generalized mixed-effects structural equation models estimated the association of depressive symptoms on VS and the mediating role of ART adherence among women enrolled in the IMPAACT P1025 Perinatal Core Protocol (2002-2013).

Results: Among 1869 participants, 47.6% were 21-29 years, 57.6% non-Hispanic Black. In the third trimester, the mean depressive symptoms score was 14.0 (±5.2), 68.0% had consistent adherence, and 77.3% achieved VS. At 6 months postpartum, depressive symptoms declined while adherence and VS fell to 59.8% and 53.0%, respectively. In the fully adjusted model, a 1-SD increase in depressive symptoms was associated with a 3.8-percentage-point (95% CI: -5.7, -1.9) decline in VS. This effect is the sum of the indirect effect of depressive symptoms on VS via ART adherence (-0.4; 95% CI: -.7, -.2) and the direct effect through other pathways (-3.4; -5.2, -1.5). The decline in adherence driven by depressive symptoms accounted for ≥11% of the total negative effect of depressive symptoms on VS.

Conclusions: Perinatal depressive symptoms were associated with decreased adherence and VS, highlighting the need to screen for, diagnose, and treat perinatal depression to optimize maternal outcomes.

Clinical trials registration: NCT00028145.

Keywords: ART adherence; depressive symptoms; perinatal period; viral suppression; women with HIV.

© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America.

Figures

Figure 1.
Figure 1.
General longitudinal (random-effects) SEM approach for assessing mediation of the effects of depressive symptoms on viral suppression through ART adherence. C1, C2, and Cn are measured confounders; Alpha and Gamma (multilevel latent variables, with coefficients constrained to equal 1) are random intercepts for participants; arrows denote associations; ε in circles represent error terms for each of the outcome (vsp) and mediator (adh) regressions. Model constructed in Stata “gsem” builder for generalized structural equation models. Abbreviations: adh, adherence; ART, antiretroviral therapy; SEM, structural equation modeling; vsp, viral suppression; zdsm, depressive symptoms z score.
Figure 2.
Figure 2.
Observed changes in viral suppression, ART adherence, and depressive symptoms across the perinatal period in the study sample: IMPAACT P1025 cohort. (Respective numbers of participants with data for each variable by period are listed in Supplementary Table 3.) Abbreviations: ART, antiretroviral therapy; Dep., depressive; IMPAACT, International Maternal Pediatric Adolescent AIDS Clinical Trial Network; Sym., symptoms.

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