Mental health problems associated with worse clinical outcomes in HIV-positive US veterans

Over two-thirds of HIV-positive military veterans in the US have a mental health disorder, according to research published in the online edition of AIDS. The presence of certain mental health problems was associated with an increased risk of death and HIV disease progression. 

“Our results reflect ‘the real world’ of clinical practice, where challenging patients with complex comorbidities are much more common than in the clinical trial setting,” comment the investigators.

Improvements in treatment and care mean that many HIV-positive patients have a near-normal prognosis. However, the impact of mental health disorders on the outcomes of patients taking antiretroviral therapy is poorly understood.

Earlier research has shown that HIV-positive military veterans in the US have high rates of substance abuse and mental health problems. Therefore investigators from the Department of Veterans Affairs conducted a retrospective study to see if a number of psychiatric disorders hastened HIV disease progression and time to death.

A total of 9003 veterans who started HIV therapy between 2000 and 2006 were included in the analysis.

Most were male (98%), and African Americans were the largest racial group (43%). A quarter of patients were co-infected with hepatitis C virus, and the median age at baseline was 47 years.

Patients were followed for a median of three years. During follow-up there were 930 deaths and 712 patients developed an AIDS-defining condition.

Over two-thirds of patients (69%) had one or more mental health disorder. The most common were illicit drug use (50%), depression (41%), alcohol abuse (30%), anxiety (18%), bipolar disorder (7%) and schizophrenia (6%). Of the patients with a mental health disorder, 53% had two or more.

Individual with mental health problems were more likely to be women (3% vs. 2% no disorder, p = 0.029), white (30% vs. 25%, p < 0.0001), have other comorbid conditions (p < 0.0001), be co-infected with hepatitis C virus (29% vs. 16%, p < 0.001), have more clinic visits each quarter (6 vs. 3, p < 0.001) and have poorer adherence to their HIV therapy (p < 0.0001).

After taking into account other factors associated with disease progression and an increased risk of death such as age and CD4 cell count, the investigators found that the presence of any mental health disorder was associated with all cause mortality (HR = 1.17; 95% CI, 1.01-1.35). Individual conditions associated with faster time to death included schizophrenia (HR = 1.40; 95%, 1.11-1.77), bipolar disorder (HR = 1.32; 95% CI, 1.03-1.69) and substance abuse (HR = 1.23; 95% CI, 1.07-1.41).

In the unadjusted analysis, any mental health problem was associated with an increased risk of HIV disease progression. However, this association ceased to be significant in the analysis that controlled for potentially confounding factors. Nevertheless, patients with substance abuse disorders remained at increased risk of developing a new AIDS-defining illness (HR = 1.09; 95% CI, 1.02-1.39). Poor adherence to HIV therapy is offered by the authors as a likely explanation for this finding.

The investigators note that both bipolar disorders and schizophrenia have been associated with an increased risk of mortality in the general population. “To our knowledge,” they write, “this is the first study describing the increased risk of mortality associated with these disorders among HIV-infected persons.”

However, they were surprised that neither depression nor anxiety disorders were associated with poorer outcomes in their patients. They suggest that this was “due to unique factors in the VA [Veterans Affairs] healthcare system, including routine symptom monitoring, universal access to mental health services including collaborative care models, pharmacotherapy and co-morbid substance use programs.”

They conclude, “even in the VA medical system, where comprehensive mental health services are universally available and easily accessible, HIV-infected veterans with [mental illness] remain vulnerable to unfavourable outcomes.”