标题：Directly Observed Antidepressant Medication Treatment and HIV Outcomes Among Homeless and Marginally Housed HIV-Positive Adults: A Randomized Controlled Trial
摘要：Objectives. We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008. Methods. We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL). Results. The intervention reduced depression symptom severity (b = −1.97; 95% confidence interval [CI] = −0.85, −3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes. Conclusions. Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence. Depressive, pain, and substance use disorders are highly prevalent among persons living with HIV/AIDS 1,2 and among the homeless and marginally housed. 3–5 The triple diagnosis of depression, HIV, and substance use poses unique treatment challenges for clinicians: successful management of one condition is often dependent on successful management of the others, and the optimal sequencing of depression treatment, substance use treatment, and stabilization of psychosocial comorbidities remains unclear. Adherence to the entire continuum of HIV care is often hampered by depression 6–8 and substance use. 9,10 For homeless persons, the need to address subsistence concerns such as obtaining food and shelter may not only adversely affect mental well-being 11 but may also divert attention away from medication adherence and regular clinic attendance. 12 Timely and effective depression treatment is critical for HIV-positive persons, because depression has been associated with CD4+ T-lymphocyte cell count decline, 13 progression to AIDS, 14 and AIDS-related mortality. 15 Yet depression remains pervasively underdiagnosed and undertreated among the homeless 16–18 and among HIV-positive persons. 19,20 Depression treatment might be expected to improve virological or immunologic outcomes through improved adherence, but this has not been conclusively demonstrated. 21–23 We therefore sought to determine whether treatment with once-weekly fluoxetine reduced depression symptom severity among homeless and marginally housed persons with comorbid depression and HIV. Because this population faces many psychosocial barriers to successful medication adherence, 12,24 in addition to depression, 25 we employed a directly observed treatment strategy similar to that used for treatment and management of patients with tuberculosis and HIV. 26 This strategy reduced the potential for incomplete adherence to reduce the effectiveness of antidepressant treatment. A secondary aim was to determine whether depression treatment improved antiretroviral therapy (ART) uptake among persons eligible for treatment and ART adherence and viral suppression among treated persons.
