Photo Credit: Kateryna Kovarzh

Many patients with HIV have untreated anxiety symptoms, and findings show that viral suppression is worst in patients with untreated moderate-to-severe anxiety.

“In 2019, [one in five] adults with a HIV diagnosis had symptoms of generalized anxiety disorder,” researchers wrote in AIDS. “Yet we know little about the anxiety care continuum among people with HIV. We have limited information about how often anxiety symptoms are diagnosed and treated, and how effective those treatments are at resolving anxiety symptoms among people with HIV.”

Investigators used data from the Johns Hopkins HIV Clinical Cohort of 1,967 people with HIV who received routine care in one HIV clinic to examine cross-sectional associations with viral suppression.

At almost all clinic visits (98.7%), a current ART prescription was listed in the medical record. Participants mostly self-rated ART adherence as “excellent” (62.6%) or “very good” (19.2%).

Most (76.1%) patient-reported outcome surveys reported minimal anxiety symptoms; mild symptoms were reported on 8.1%, moderate symptoms on 8.2%, and severe symptoms on 7.7%. Viral suppression prevalence ranged from 87% to 89% across the anxiety care continuum, with one exception: 81% among patients with untreated moderate-to-severe anxiety. Among the 43% of participants with anxiety in remission and comorbid depression, viral suppression prevalence was 84%.

Physician’s Weekly (PW) talked with two experts not involved in the study about its importance and implications for patient care.

PW: For clinicians, what are the study’s key takeaways?

Christine Horvat Davey, PhD, BSPS, RN: This study underscores the essential need for comprehensive mental healthcare in HIV care management. Prior research demonstrates a link between poor mental health and poor HIV health outcomes. Yet, the degree to which untreated moderate-to-severe anxiety symptoms impact viral suppression is noteworthy, highlighting the need to integrate routine mental healthcare for people with HIV. Viral suppression is vital to preventing transmission of HIV and promoting healthy aging in people with HIV.

Brian Pence, PhD: Many patients with HIV have current anxiety symptoms, but few of them currently receive any anxiety treatment. Patients with untreated moderate-to-severe anxiety have the worst HIV viral suppression rates. Further, there is substantial overlap in anxiety and depressive symptoms, and viral suppression was especially low among those with both untreated anxiety and depressive symptoms.

We know that untreated mental illness continues to be a major unmet need for people with HIV and that those with untreated mental illness consistently have worse HIV care outcomes. Although most work in this area has been on depression, exploring anxiety symptoms is quite important.

How may the results affect patient care?

Dr. Horvat Davey: Much research has focused on depression and substance use related to viral suppression in people with HIV; however, the impact of anxiety in relation to viral suppression is understudied. By characterizing the anxiety care continuum, this study can inform targeted interventions aimed at improving mental health, viral suppression, and HIV treatment outcomes in this patient population.

Promoting anxiety screening at routine clinic appointments may lead to identifying patients who need mental healthcare. Identifying patients with anxiety could lead to improved viral suppression rates, especially among patients with moderate-to-severe anxiety. The key is to address any barriers to viral suppression and promote healthy aging in this vulnerable population.

Dr. Pence: While most of the mental illness and HIV work has investigated depression or trauma history, generalized anxiety disorder and anxiety symptoms are also highly prevalent in people with HIV. In fact, symptoms overlap quite a bit with depression and trauma history. This study gives us a more complete picture of the range of mental health needs in this population and their impact on viral suppression.

Non-mental-health professionals are increasingly expected to be comfortable with completing routine depression assessments with the Patient Health Questionnaire-9 or similar tools and even with prescribing first-line antidepressants. This study argues for HIV clinics to pair a depression screen with an anxiety screen and to integrate depression and anxiety medication management and counseling into their services through models like collaborative care and measurement-based care.

What novel interventions show promise?

Dr. Horvat Davey: Results from this study demonstrate a need for addressing anxiety, predominantly moderate-to-severe anxiety in adults with HIV to potentially mitigate rates of viral non-suppression. Interventions that address mental healthcare, specifically anxiety, such as pharmacotherapy (e.g., anxiolytics, antidepressants), psychotherapy (e.g., cognitive behavioral therapy), or a combination therapy may help manage anxiety and in turn viral suppression in people with HIV. It is important to note that anxiety symptoms are treatable and people with HIV can respond well to treatment.

What strengths or limitations of the study are noteworthy?

Dr. Horvat Davey: A large, well-characterized cohort is an important strength of this study as it provides strong evidence for the association between untreated moderate-to-severe anxiety symptoms with viral non-suppression in this population. An important limitation is its cross-sectional design that did not account for longitudinal anxiety symptom trajectories. Identifying anxiety symptoms in relation to mental healthcare treatment and alterations in viral suppression status is crucial. Understanding changes in anxiety symptoms over time enables us to recognize potential subsets of individuals at highest risk for poor mental and physical health outcomes.

Dr. Pence: This study used ten years of data from a large academic HIV treatment center that has integrated routine depression and anxiety PROs into an electronic health system, so the sample is large and high quality. This study didn’t use diagnoses of mental disorders but rather patient-reported scales, which has pros and cons. Scales aren’t a diagnosis; on the other hand, mental disorders are widely underdiagnosed. So, getting routine, systematic patient self-reports likely better reflects the actual mental health burden than looking for diagnosis codes.

What further research might you recommend?

Dr. Horvat Davey: Future research should explore the long-term effects of untreated anxiety on HIV outcomes, including viral non-suppression. Such research could provide a comprehensive understanding of the impact of anxiety over time on HIV management, leading to improved health outcomes in this patient population.

Is there anything else you’d like to mention?

Dr. Horvat Davey: To promote mental and physical health in their patients with HIV, clinicians need to be vigilant for the potential consequences of comorbid mental health symptoms. Clinicians should consider including comprehensive routine mental health screenings in clinic visits.

Dr. Pence: The prevalence of anxiety and depression is very high in people with HIV and has a big impact on their HIV care success. If your practice isn’t already doing this, think about how you can integrate routine anxiety and depression screening into the care you provide, paired with next steps for those who screen positive, using models like collaborative care and measurement-based care.