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Letter to the Editor

Effect of Anxiety Symptoms on Adherence to Highly Active Antiretroviral Therapy in HIV-Infected Women

Perrine Roux, PharmD; M. Patrizia Carrieri, PhD; Laurent Michel, MD; Lionel Fugon, BSc, MSc; Fabienne Marcellin, BSc, MSc; Yolande Obadia, PhD, MD; and Bruno Spire, PhD, MD

Published: September 15, 2009

Effect of Anxiety Symptoms on Adherence to Highly Active Antiretroviral Therapy in HIV-Infected Women

To the Editor: Psychiatric comorbidities are known to impair adherence to highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV)-infected individuals1 and to affect women and men differently.2 To date, it is still controversial whether women are at higher risk of HIV progression3 or nonadherence to HAART.4 The VESPA survey, which enrolled a French representative sample of HIV-infected patients, was used here to assess whether psychiatric disorders affect HAART adherence differently in men and women.

Method. In this national cross-sectional survey (ANRS-EN12-VESPA study), conducted in 2003, 4,963 HIV-infected patients were recruited by random sampling in 102 French hospitals. We selected only participants receiving HAART with complete adherence and psychiatric disorders assessment (446 women and 1,363 men).

Adherence to HAART was measured by a validated indicator5 with a 100% cutoff to minimize social desirability bias.6 Nonadherence was reported by 42% of women and 39% of men. Anxiety and depression were assessed using the Hospital Anxiety and Depression (HAD) scale.7 The prevalence of anxiety and depressive symptoms was, respectively, 63% in women and 49% in men and 24% in women and 22% in men.

Results. In the multivariate logistic regression model, in both women and men, we identified known correlates of nonadherence to HAART: patients who were younger, were migrant,8 abused alcohol,9 reported side effects,10 and were employed were more likely to be nonadherent to HAART. Such factors have been commonly found as determinants of nonadherence to HAART in several contexts, particularly in disadvantaged populations whose adherence may be compromised by socioeconomic barriers and psychiatric comorbidities.11 Interestingly, anxiety symptoms remained associated with nonadherence to HAART in men who had (OR [95% CI]=1.5 [1.1-2.1]) and had not (OR [95% CI]=1.5 [1.2-2.0]) received anxiolytics, while women with anxiety symptoms who had received anxiolytics exhibited the same adherence as women with no anxiety symptoms. To test whether these results were attributable to the limited sample size of women, we performed a sensitivity analysis in men using a series of reduced samples (n=446) and computed OR estimations by bootstrap.12 This approach confirmed the results that were found in the whole male sample.

Co-occurring anxiety disorders are more frequently associated with major depression in women.13 Moreover, women are more sensitive than men to the pathogenic effects of low levels of social support at the onset of major depression,14 and it is possible that the social impact of HIV may contribute further to the onset of psychiatric disorders. Confirming results from a previous study,15 we found that women with alcohol abuse have a higher risk of nonadherence to HAART, and there is a significant linear trend (P<10-3) when men who abuse alcohol (OR [95% CI]=2.1 [1.5-2.9]) or women who abuse alcohol (OR [95% CI]=3.7 [2.0-7.1]) are compared with individuals who do not. Interventions to improve adherence in HIV-infected patients should be tailored according to gender; for HIV-infected women receiving HAART, such interventions should include women-oriented psychosocial counseling and improved screening and appropriate care for anxiety symptoms and alcohol abuse.


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2. Andreasen NC. Vulnerability to mental illnesses: gender makes a difference, and so does providing good psychiatric care. Am J Psychiatry. 2005;162(2):211-213. PubMed doi:10.1176/appi.ajp.162.12.2394

3. Farzadegan H, Hoover DR, Astemborski J, et al. Sex differences in HIV-1 viral load and progression to AIDS. Lancet. 1998;352(9139):1510-1514. PubMed doi:10.1016/S0140-6736(98)02372-1

4. Floridia M, Giuliano M, Palmisano L, et al. Gender differences in the treatment of HIV infection. Pharmacol Res. 2008;58(3-4):173-182. PubMed doi:10.1016/j.phrs.2008.07.007

5. Carrieri P, Cailleton V, Le Moing V, et al. The dynamic of adherence to highly active antiretroviral therapy: results from the French National APROCO cohort. J Acquir Immune Defic Syndr. 2001;28(3):232-239. PubMed

6. Wagner G, Miller LG. Is the influence of social desirability on patients’ self-reported adherence overrated? J Acquir Immune Defic Syndr. 2004;35(2):203-204. PubMed doi:10.1097/00126334-200402010-00016

7. Snaith RP, Zigmond AS. The Hospital Anxiety and Depression scale. Br Med J (Clin Res Ed). 1986;292(6516):344. PubMed doi:10.1136/bmj.292.6516.344

8. Bouhnik AD, Chesney M, Carrieri P, et al. Nonadherence among HIV-infected injecting drug users: the impact of social instability. J Acquir Immune Defic Syndr. 2002;31(suppl 3):S149-S153. PubMed

9. Palepu A, Horton NJ, Tibbetts N, et al. Uptake and adherence to highly active antiretroviral therapy among HIV-infected people with alcohol and other substance use problems: the impact of substance abuse treatment. Addiction. 2004;99(3):361-368. PubMed doi:10.1111/j.1360-0443.2003.00670.x

10. Carrieri MP, Leport C, Protopopescu C, et al. Factors associated with nonadherence to highly active antiretroviral therapy: a 5-year follow-up analysis with correction for the bias induced by missing data in the treatment maintenance phase. J Acquir Immune Defic Syndr. 2006;41(4):477-485. PubMed doi:10.1097/01.qai.0000186364.27587.0e

11. Gordillo V, del Amo J, Soriano V, et al. Sociodemographic and psychological variables influencing adherence to antiretroviral therapy. AIDS. 1999;13(13):1763-1769. PubMed doi:10.1097/00002030-199909100-00021

12. Efron B, Halloran E, Holmes S. Bootstrap confidence levels for phylogenetic trees. Proc Natl Acad Sci U S A. 1996;93(23):13429-13434. PubMed doi:10.1073/pnas.93.23.13429

13. Marcus SM, Kerber KB, Rush AJ, et al. Sex differences in depression symptoms in treatment-seeking adults: confirmatory analyses from the Sequenced Treatment Alternatives to Relieve Depression study. Compr Psychiatry. 2008;49(3):238-246. PubMed doi:10.1016/j.comppsych.2007.06.012

14. Kendler KS, Myers J, Prescott CA. Sex differences in the relationship between social support and risk for major depression: a longitudinal study of opposite-sex twin pairs. Am J Psychiatry. 2005;162(2):250-256. PubMed doi:10.1176/appi.ajp.162.2.250

15. Lazo M, Gange SJ, Wilson TE, et al. Patterns and predictors of changes in adherence to highly active antiretroviral therapy: longitudinal study of men and women. Clin Infect Dis. 2007;45(10):1377-1385. PubMed doi:10.1086/522762

Perrine Roux, PharmD

M. Patrizia Carrieri, PhD

Laurent Michel, MD

Lionel Fugon, BSc, MSc

Fabienne Marcellin, BSc, MSc

Yolande Obadia, PhD, MD

Bruno Spire, PhD, MD

Author affiliations: INSERM, U912 (SE4S); ORS PACA (Observatoire Régional de la Santé Provence Alpes Côte d’ Azur); and Université Aix Marseille, IRD, UMR-S912, Marseille (Drs Roux, Carrieri, Obadia, and Spire; Mr Fugon; and Ms Marcellin); and Université Paris-Sud, Université Paris Descartes, UMR-S0669, Paris; and Centre de Traitement des Addictions, Hôpital Emile Roux, Limeil-Brévannes (Dr Michel), France. Financial disclosure: None reported. Funding/support: This study was supported by the French National Agency of AIDS and Hepatitis Research (ANRS, France). Acknowledgment: Special thanks to the members of the VESPA Group: C. Afsa (INSEE), A. Bonnet (UFR Psychopathologie, Université de Provence), A. D. Bouhnik (INSERM U912/ORS PACA), V. Di Paola (LEST), R. Dray-Spira (INSERM U88), J. Fagnani (CNRS-UMR Matisse), L. Fernandez (UFR Psychopathologie, Université de Provence), I. Heard (INSERM U430), F. Lert (INSERM U88), Y. Obadia (ORS PACA/INSERM U912), J. L. Pedinielli (UFR Psychopathologie, Université de Provence), P. Peretti-Watel (ORS PACA/INSERM U912), J. Pierret (CERMES-INSERM U504-UMR 8559), B. Riandey (INED), M. A. Schiltz (CERMES-INSERM U504-UMR 8559), R. Sitta (INSERM U88), and B. Spire (INSERM U912/ORS PACA). We especially thank all physicians and patients who took part in this study. We also thank Jude Sweeney for the English revision and editing of the manuscript. Mr Sweeney’s assistance was funded by INSERM; he reports no conflict of interest.


© Copyright 2009 Physicians Postgraduate Press, Inc.

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