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, in 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.

Objectives: To evaluate the prevalence of and factors associated with depression among HIV‐infected homeless and marginally housed men. Design: Cross‐sectional study. Participants and Setting: Homeless and marginally housed men living with HIV in San Francisco identified from the Research on Access to Care in the Homeless (REACH) Cohort. Measurements: The primary outcome was symptoms of depression, as measured by the Beck Depression Inventory (BDI). Multivariate logistic regression was used to identify associations of sociodemographic characteristics, drug and alcohol use, housing status, jail status, having a representative payee, health care utilization, and CD4 T lymphocyte counts. Results: Among 239 men, 134 (56%) respondents screened positive for depression. Variables associated with depression in multivariate analysis included white race (adjusted odds ratio [AOR]=2.2, confidence interval [CI]=1.3 to 3.9), having a representative payee (AOR=2.4, CI=1.3 to 4.2), heavy alcohol consumption (AOR=4.7, CI=1.3 to 17.1), and recently missed medical appointments (AOR=2.6, CI=1.4 to 4.8). Conclusions: Depression is a major comorbidity among the HIV‐infected urban poor. Given that missed medical appointments and alcohol use are likely indicators of depression and contributors to continued depression, alternate points of contact are necessary with many homeless individuals. Providers may consider partnering with payees to improve follow‐up with individuals who are HIV‐positive, homeless, and depressed.

The absence of new HCV infections in this sample supports the hypothesis that the risk of sexual transmission of HCV is low.