Does Effective Depression Treatment Alone Reduce Secondary HIV Transmission Risk? Equivocal Findings from a Randomized Controlled Trial

Abstract

Depressed mood has been associated with HIV transmission risk behavior. To determine whether effective depression treatment could reduce the frequency of sexual risk behavior, we analyzed secondary outcome data from a 36-week, two-arm, parallel-design, randomized controlled trial, in which homeless and marginally housed, HIV-infected persons with comorbid depressive disorders were randomized to receive either: (a) directly observed treatment with the antidepressant medication fluoxetine, or (b) referral to a local public mental health clinic. Self-reported sexual risk outcomes, which were measured at 3, 6, and 9 months, included: total number of sexual partners, unprotected sexual intercourse, unprotected sexual intercourse with an HIV-uninfected partner or a partner of unknown serostatus, and transactional sex. Estimates from generalized estimating equations regression models did not suggest consistent reductions in sexual risk behaviors resulting from treatment. Mental health interventions may need to combine depression treatment with specific skills training in order to achieve durable impacts on HIV prevention outcomes.

Changes in Sexual Behavior of HIV-Infected Older Adults Enrolled in a Clinical Trial of Standalone Group Psychotherapies Targeting Depression

“…Accordingly, results may not generalize to HIV-positive younger adults or those living in rural areas or metropolitan areas in other regions of the United States. Our null treatment findings do, however, converge with those of Tsai and colleagues [16] who enrolled a sample that is demographically and geographically distinct from participants in the current study. Second, as noted previously, this was not a sexual risk reduction trial, and these secondary data analyses were not powered to detect treatment effects on sexual behavior outcomes.…”

“…Consistent with the current study, Tsai and colleagues [16] identified no differential reductions in sexual risk behavior by treatment condition in a randomized controlled trial of fluoxetine versus community mental health referral for HIV-positive homeless and marginally housed middle-aged adults in San Francisco, despite fluoxetine demonstrating superiority to community mental health referral in reducing depressive symptoms, with large treatment effects. Participants in this trial, however, also reported low rates of sexual risk behavior at baseline.…”

“…It is possible that among depressed HIV-positive persons who engage in risky sex, amelioration of depressive symptoms is a necessary, albeit insufficient, condition to promote safer sex and that sexual risk reduction components combined with treatments for depression may yield positive outcomes in both mental health and sexual behavior indices [16]. Somewhat contrary to this hypothesis are findings from a standalone sexual risk reduction intervention for HIV-positive men who have sex with men that was efficacious only for participants who met criteria for clinical depression at baseline [26], suggesting that integrating depression treatment with risk reduction interventions may not be necessary to achieve desired sexual behavior outcomes.…”

“…Recently, Tsai and colleagues [16] examined the efficacy of a standalone psychopharmacological treatment for depression (i.e., fluoxetine) to reduce sexual risk behavior in homeless and marginally housed HIV-positive middle-aged adults. This trial demonstrated the superiority of fluoxetine to community mental health referral in reducing depressive symptoms over nine months of follow-up [17].…”

“…This trial demonstrated the superiority of fluoxetine to community mental health referral in reducing depressive symptoms over nine months of follow-up [17]. Secondary analyses, however, found no differential changes in sexual risk behavior between the two conditions [16]. …”