What is the relationship between Human Immunodeficiency Virus (HIV)-related depression and HIV-associated neurocognitive disorder (HAND), including HIV-associated dementia?

From the Guidelines

HIV-related depression and dementia should be managed with a comprehensive approach that includes optimizing antiretroviral therapy (ART) with good CNS penetration, treating depression with SSRIs, and providing symptomatic treatment for cognitive symptoms, as these conditions significantly impact medication adherence and quality of life. The management of HIV-related depression and dementia is crucial to improve medication adherence and quality of life.

• Depression affects approximately 20-45% of HIV patients and may result from both biological factors and psychological reactions to living with a chronic illness 1.
• For depression treatment, SSRIs like sertraline (50-200 mg daily) or escitalopram (10-20 mg daily) are first-line options, with careful monitoring for drug interactions with antiretroviral therapy (ART) 1.
• HIV-associated neurocognitive disorder (HAND) ranges from mild cognitive impairment to severe HIV-associated dementia, characterized by memory loss, concentration problems, motor difficulties, and behavioral changes 1.
• Optimizing ART with good CNS penetration is essential, using regimens containing drugs like dolutegravir, darunavir, or efavirenz 1.
• Symptomatic treatment may include memantine (5-20 mg daily) or psychostimulants like methylphenidate (5-60 mg daily) for cognitive symptoms.
• Regular neuropsychological assessments are recommended to monitor cognitive function, as cognitive impairment can be multifactorial, with a direct effect of HIV on the brain representing only one cause 1.
• The term HABI (HIV-associated brain injury) has been coined to refer to a degree of brain injury as a direct result of HIV, and distinguishing injury caused directly by HIV from indirect or combined effects is useful 1.
• A combination of investigations and clinical context can diagnose HABI, but no single imaging or CSF biomarker has been identified for all stages and types of HABI that is robust enough for clinical use 1.
• Early screening, diagnosis, and integrated treatment approaches combining pharmacological interventions with psychotherapy and support services are crucial for effective management of HIV-related depression and dementia, as these conditions significantly impact medication adherence and quality of life 1.

From the Research

HIV-Related Depression

• Depression is a common comorbid condition in individuals infected with HIV, and its treatment is crucial to lowering morbidity and mortality from HIV disease 2.
• Accurate diagnosis of major depression is complex and essential to preventing inappropriate exposure of patients to potentially harmful psychotropic medications 2.
• Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants appear to be effective in treating depressive symptoms in patients with HIV infection without affecting immune status 3.

Treatment of Depression in HIV-Infected Patients

• Antidepressant therapy may result in a greater improvement in depression compared to placebo in HIV-infected patients 4.
• SSRIs, such as fluoxetine, sertraline, and paroxetine, are effective in treating depression in HIV-infected patients 5, 3.
• Tricyclic antidepressants may also be effective, but their use is limited by anticholinergic adverse effects 4.
• Mirtazapine may result in a greater improvement in depression compared to an SSRI in some cases 4.

Adherence to Antiretroviral Therapy

• Depression is associated with decreased adherence to highly active antiretroviral therapy (HAART) and poorer clinical outcomes 6.
• Compliant use of selective serotonin reuptake inhibitors (SSRIs) is associated with improved HAART adherence and laboratory parameters in depressed HIV-infected patients 6.
• Depression without SSRI use is associated with significantly decreased odds of achieving > or =90% adherence to HAART 6.

Clinical Outcomes

• Depression is associated with significantly lower odds of an HIV RNA level <500 copies/mL 6.
• Depressed patients compliant with SSRI medication have HAART adherence and viral control statistically similar to nondepressed HIV-infected patients taking HAART 6.
• CD4 T-cell responses are statistically similar between depressed and nondepressed HIV-infected patients, but among depressed patients, those compliant with SSRI have statistically greater increases in CD4 cell responses 6.