SLAM DUNC: Improving HAART Adherence

Depression is a serious concern in the clinical management of HIV infection, affecting 20-25% of people living with HIV/AIDS (PLWHA) and predicting a range of negative HIV-related behavioral and clinical health outcomes, including greater sexual risk behavior, worse antiretroviral medication adherence, poor response to antiretroviral therapy (ART), faster immune system decline, and higher mortality.

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Standard depression treatment strategies are effective for PLWHA, and psychotherapy-based depression interventions in PLWHA have tended to lead to improved ART adherence. Much less attention has focused on antidepressant treatment interventions, which have a greater potential than psychotherapy-based interventions to address the resource constraints and lack of psychiatric

This project will integrate a depression treatment and brief medication adherence counseling intervention into clinical care at three HIV clinics and will use a randomized controlled trial to assess whether, relative to usual care, the intervention leads to improved HIV medication adherence. The depression treatment intervention uses a model known as Measurement-Based Care which equips Care Coordinators with systematic measurement tools, a decision algorithm, and psychiatric backup and trains them to provide decision support to HIV clinicians to implement, monitor, and adjust antidepressant therapy.expertise that define most HIV care settings. A combination of antidepressant therapy with brief adherence counseling in a model that could be integrated into routine clinical practice settings may have great potential to improve adherence in depressed HIV patients.

Our goal in this R01 proposal is to conduct a randomized controlled trial of an evidence-based depression treatment intervention known as Measurement-Based Care (MBC), combined with brief Motivational Interviewing (MI) adherence counseling, in depressed PLWHA to assess its impact on ART adherence and clinical outcomes. MBC employs clinical coordinators (CCs) with expertise in depression management to screen for depression and help non-psychiatric physicians implement guideline-concordant, algorithm-driven antidepressant treatment. The CC uses standardized metrics (depressive symptoms, side effects) and an algorithm to monitor treatment response and recommend changes. Weekly supervision from a psychiatrist ensures quality care. Biweekly contact between patients and the CC will include brief MI adherence counseling. We will recruit 390 PLWHA on ART with confirmed depression, and will conduct a provider-randomized trial of the MBC intervention versus enhanced usual care. Our 3 HIV clinical sites in North Carolina have a long history of collaboration on HIV behavioral health research.

Our aims are:

  • to test whether MBC improves ART adherence and HIV clinical outcomes;
  • to assess the cost-effectiveness of MBC;
  • to collect process measures concerning MBC implementation to inform replication at other sites. Since the CC role can be effectively filled by a behavioral health provider or nurse given appropriate training and supervision and the intervention has limited time requirements, this model is potentially replicable to a wide range of resource-constrained HIV treatment settings.
  • Duke University Center for Health Policy and Infectious Diseases Clinic, Durham, NC
  • University of North Carolina at Chapel Hill
  • Department of Psychiatry and Infectious Diseases Clinic, Chapel Hill, NC
  • Northern Outreach Clinic, Henderson, NC
  • University of Alabama at Birmingham, 1917 Clinic, Birmingham, AL

Principal Investigators

  • Brian Pence, PI, bpence@unc.edu
  • Bradley Gaynes, Co-PI
  • Evelyn Byrd Quinlivan, UNC site PI
  • Michael Mugavero, UAB site PI
  • Kristen Shirey, Duke site PI

Investigators

  • Amy Heine
  • Nathan Thielman
  • Chris Conover
  • Julie Adams
  • James Willig
  • James Raper
  • Teena McGuinness

Staff

  • Quinn Williams, Project Director, qwilliams@unc.edu
  • Katya Roytburd, UNC coordinator
  • Elise Nelson, Duke coordinator and interviewer
  • Riddhi Modi, UAB coordinator
  • Marcus Hawley, Interviewer Malaika Edwards
  • Depression Care Manager Scotty Elliott
  • Depression Care Manager Sally Shurbaji
  • Depression Care Manager Anne Zinski
  • Depression Care Manager Charita Montgomery
  • Research assistant Julie O’Donnell
  • Research assistant Jennifer Lee
  • Research assistant Melonie Walcott
  • Research assistant Donna Safley, Data manager
  • Grant Number: R01 MH086362
  • Effective Dates: September 2009-August 2014
  • ClinicalTrials.gov ID: NCT01372605
  • Pence BW, Gaynes BN, Williams Q, Modi R, Adams J, Quinlivan EB, Heine A, Thielman N, Mugavero MJ. Assessing the effect of Measurement-Based Care depression treatment on HIV medication adherence and health outcomes: Rationale and design of the SLAM DUNC Study. Contemporary Clinical Trials, 2012 Jul;33(4):828-38. PMCID: PMC3361555. [Abstract in Pubmed] [Free PMC article]
  • Pence BW, O’Donnell J, Gaynes BN. Falling through the cracks: The gaps between depression prevalence, diagnosis, treatment, and response in HIV care. AIDS 2012 Mar 13;26(5):656-8. PMC submission in progress; NIHMSID 478846. [Abstract in Pubmed] [Free PMC article]
  • Pence BW, O’Donnell JK, Gaynes BN. The depression treatment cascade in primary care: A public health perspective. Current Psychiatry Reports:14(4):328-35, 2012. PMCID: PMC3410049. [Abstract in Pubmed] [Free PMC article]
  • Adams JL, Gaynes BN, McGuinness T, Modi R, Willig J, Pence BW. Treating depression within the HIV “medical home”: A guided algorithm for antidepressant management by HIV clinicians. AIDS Patient Care and STDs 26(11):647-54, 2012. PMCID: PMC3495111. [Abstract in Pubmed] [Free PMC article]
  • Bess K, Adams JL, Watt MH, O’Donnell JK, Gaynes BN, Thielman NM, Heine A, Zinski A, Raper JL, Pence BW. Providers’ Attitudes Towards Treating Depression and Self-Reported Depression Treatment Practices in HIV Outpatient Care. AIDS Patient Care & STDs 27(3):171-180, 2013. PMCID PMC3595951. [Abstract in Pubmed] [Free PMC article]
  • Edwards M, Quinlivan E, Bess K, Gaynes BN, Heine A, Zinski A, Modi R, Pence BW. Implementation of PHQ-9 Depression Screening for HIV-Infected Patients in a Real-World Setting. J Assoc Nurses AIDS Care. Published ahead of print, 2013. [Abstract in Pubmed]