Assessing longitudinal patterns of depressive symptoms and the influence of symptom trajectories on PrEP persistence among adolescent girls in HPTN 082


BACKGROUND: African adolescent girls and young women (AGYW) who may benefit from HIV pre-exposure prophylaxis (PrEP) face high levels of depression and related psychosocial issues, including PrEP stigma and intimate partner violence (IPV). Depressive symptoms at PrEP initiation may reduce PrEP adherence. However, the proportion of AGYW initiating PrEP with persistent depressive symptoms, the relationship between symptoms and other psychosocial factors, and the impact of persistent symptoms on PrEP adherence have not been studied.
METHODS: HPTN 082 was an open-label PrEP study among AGYW (ages 16-24) in Harare, Zimbabwe and Cape Town and Johannesburg, South Africa from 2016-2018. Depressive symptoms were measured at enrollment and months 3, 6, and 12, using the 10-item Center for Epidemiologic Studies scale; a score >10 is correlated with clinical depression. PrEP stigma, IPV, sexual behavior, and PrEP adherence were also assessed at these visits. High PrEP adherence was defined as tenofovir diphosphate levels >=700 fmol/DBS punch. Group-based trajectory modeling was used to model longitudinal patterns of depressive symptoms, assigning participants to a trajectory (e.g., persistent, sporadic, no symptoms). We assessed psychosocial predictors of trajectories to understand factors associated with symptom patterns and used generalized estimating equations to model associations between group trajectory membership and 12-month PrEP adherence.
RESULTS: At enrollment, 179 (41.9%) of 427 participants had elevated depressive symptoms consistent with clinical depression. 33.0%, 36.7%, and 36.9% had elevated symptoms at months 3, 6, and 12, respectively. Group-based trajectory models revealed persistent elevated symptoms in 49.2%, declining symptoms in 13.5%, and steady low/no symptoms in 37.3%. AGYW who engaged in transactional sex, reported IPV, or had traumatic stress symptoms were more likely to be assigned to the persistent elevated symptom group compared with the steady low/no symptom group (Wald test p-value all <0.01). Participants assigned to the persistent depressive symptom trajectory had significantly lower odds of high PrEP adherence than those in the low/no symptom trajectory (aOR=0.73; 95% CI: 0.56-0.96).
CONCLUSIONS: Depressive symptoms were common and persistent among AGYW seeking PrEP in sub-Saharan Africa. Integration of depression screening and treatment into HIV prevention programs may improve PrEP effectiveness among African women.