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Effect of Depression on Adherence to Oral PrEP Among Men and Women in East Africa

Velloza, Jennifer, MPH*,†; Baeten, Jared M., MD, PhD*,†,‡; Haberer, Jessica, MD, MS§; Ngure, Kenneth, MPH, PhD║,¶; Irungu, Elizabeth, MBChB, MPH; Mugo, Nelly R., MBChB, MMed, MPH#; Celum, Connie, MD, MPH*,†,‡; Heffron, Renee, MPH, PhD*,† for the Partners Demonstration Project Team

JAIDS Journal of Acquired Immune Deficiency Syndromes: November 1, 2018 - Volume 79 - Issue 3 - p 330–338
doi: 10.1097/QAI.0000000000001821
Prevention Research

Background: Low adherence can undermine the efficacy of daily oral pre-exposure prophylaxis (PrEP). Mental health conditions, particularly depression, could be associated with low PrEP adherence, especially for women.

Setting: We analyzed data from 1013 Kenyan and Ugandan HIV-uninfected participants in the Partners Demonstration Project, an open-label study of PrEP delivered to HIV-uninfected members of serodiscordant couples.

Methods: Participants completed quarterly visits over 2 years and were encouraged to use PrEP until their partners living with HIV had ≥6 months of antiretroviral therapy use (when viral suppression was expected). PrEP adherence was measured daily with electronic medication event monitoring system caps and dichotomized into low (<80% of expected bottle openings) and high adherence. Depression was assessed annually using the 16-item Hopkins Symptom Checklist screening tool; scores >1.75 indicate “probable depression.” The association between probable depression and PrEP adherence was assessed separately for men and women using generalized estimating equations and marginal structural models.

Results: At enrollment, 39 (11.7% of 334) women and 64 (9.4% of 679) men reported symptoms indicating probable depression, and these proportions decreased during follow-up (P < 0.001 for women and men). Probable depression was significantly associated with low PrEP adherence among women (adjusted risk ratio = 1.77; 95% confidence interval: 1.14 to 2.77; P = 0.01); there was no association between depression and adherence among men (P = 0.50). Marginal structural models and sensitivity analyses confirmed these findings.

Conclusions: Depression was relatively uncommon in this population and was an independent risk factor for low PrEP adherence among women. For PrEP programs targeting African women, integration of depression screening may improve PrEP effectiveness.

Departments of *Global Health;

Epidemiology; and

Medicine, University of Washington, Seattle, WA;

§Massachusetts General Hospital, Boston, MA;

Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya;

Partners in Health and Research Development, Nairobi, Kenya; and

#Kenya Medical Research Institute, Nairobi, Kenya.

Correspondence to: Renee Heffron, MPH, PhD, International Clinical Research Center, University of Washington, Box 359927, 325 Ninth Avenue, Seattle, WA 98104 (e-mail:

Supported by the National Institute of Mental Health of the US National Institutes of Health (Grant R01 MH095507), the Bill & Melinda Gates Foundation (Grant OPP1056051), and through the US Agency for International Development (cooperative agreement AID-OAA-A-12-00023). J.V. was supported by the National Institute of Mental Health of the US National Institutes of Health (Grant F31 MH113420). Gilead Sciences donated the PrEP medication but had no role in data collection or analysis. The results and interpretation presented here do not necessarily reflect the views of the study funders.

Presented in part at the Conference on Retroviruses and Opportunistic Infections 2018 (CROI); March 4–7, 2018; Boston, MA.

The authors have no funding or conflicts of interest to disclose.

Partners Demonstration Project Team members are listed in Appendix 1.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Received March 12, 2018

Accepted July 09, 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.