Factors associated with suicidal ideation among people with HIV engaged in care.

BACKGROUND: People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH. METHOD: We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models. RESULTS: Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI. LIMITATIONS: SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor. CONCLUSIONS: HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed.

AWARENESS: A cognitive behavioral intervention to reduce intersectional minority stress among sexual minority men living with HIV who use substances.

Introduction: The minority stress model is the primary explanatory model for disparities in substance use and other mental health problems among sexual minority men (SMM) compared to heterosexual men. This pilot randomized controlled trial tested the feasibility of AWARENESS, a novel 9-session cognitive-behavioral psychotherapeutic intervention that targets intersectional minority stress and stigma, among sexual minority men living with HIV who use substances. Methods: Feasibility was determined by the number of participants screened to obtain the target sample size, the percentage of eligible participants randomized, percentage of study intervention and assessment visits attended, time to complete study procedures, and percentage of data completeness of intervention assessments. Forty-two sexual minority men living with HIV with any illicit substance use or who reported at least one occasion of consuming five or more drinks in one setting in the last three months were randomized to AWARENESS (n = 22) or an attention control condition (n = 20). Results: Feasibility of the trial was supported, with adequate completion of study procedures and visits (73% completed all intervention sessions, 71% completed all study assessment sessions). This trial also demonstrated the feasibility of using AWARENESS skills and strategies in relation to multiple intersecting identities, with participants discussing an average of 5.7 identities (e.g., sexual orientation) or individual characteristics (e.g., socioeconomic status) in relation to intervention content. Conclusion: Our results support the feasibility of an AWARENESS trial to reduce intersectional minority stress related to multiple identities and characteristics among sexual minority men living with HIV who use substances.

Perfect Registration Leads to Imperfect Performance: A Randomized Trial of Multimodal Intraoperative Image Guidance.

OBJECTIVE: To compare surgical safety and efficiency of 2 image guidance modalities, perfect augmented reality (AR) and side-by-side unregistered image guidance (IG), against a no guidance control (NG), when performing a simulated laparoscopic cholecystectomy (LC). BACKGROUND: Image guidance using AR offers the potential to improve understanding of subsurface anatomy, with positive ramifications for surgical safety and efficiency. No intra-abdominal study has demonstrated any advantage for the technology. Perfect AR cannot be provided in the operative setting in a patient; however, it can be generated in the simulated setting. METHODS: Thirty-six experienced surgeons performed a baseline LC using the LapMentor simulator before randomization to 1 of 3 study arms: AR, IG, or NG. Each performed 3 further LC. Safety and efficiency-related simulator metrics, and task workload (SURG-TLX) were collected. RESULTS: The IG group had a shorter total instrument path length and fewer movements than NG and AR groups. Both IG and NG took a significantly shorter time than AR to complete dissection of Calot triangle. Use of IG and AR resulted in significantly fewer perforations and serious complications than the NG group. IG had significantly fewer perforations and serious complications than the AR group. Compared with IG, AR guidance was found to be significantly more distracting. CONCLUSION: Side-by-side unregistered image guidance (IG) improved safety and surgical efficiency in a simulated setting when compared with AR or NG. IG provides a more tangible opportunity for integrating image guidance into existing surgical workflow as well as delivering the safety and efficiency benefits desired.

Robotic Surgery Improves Technical Performance and Enhances Prefrontal Activation During High Temporal Demand.

Robotic surgery may improve technical performance and reduce mental demands compared to laparoscopic surgery. However, no studies have directly compared the impact of robotic and laparoscopic techniques on surgeons' brain function. This study aimed to assess the effect of the operative platform (robotic surgery or conventional laparoscopy) on prefrontal cortical activation during a suturing task performed under temporal demand. Eight surgeons (mean age ± SD = 34.5 ± 2.9 years, male:female ratio = 7:1) performed an intracorporeal suturing task in a self-paced manner and under a 2 min time restriction using conventional laparoscopic and robotic techniques. Prefrontal activation was assessed using near-infrared spectroscopy, subjective workload was captured using SURG-TLX questionnaires, and a continuous heart rate monitor measured systemic stress responses. Task progression scores (au), error scores (au), leak volumes (mL) and knot tensile strengths (N) provided objective assessment of technical performance. Under time pressure, robotic suturing led to improved technical performance (median task progression score: laparoscopic suturing = 4.5 vs. robotic suturing = 5.0; z = - 2.107, p = 0.035; median error score: laparoscopic suturing = 3.0 mm vs. robotic suturing = 2.1 mm; z = - 2.488, p = 0.013). Compared to laparoscopic suturing, greater prefrontal activation was identified in seven channels located primarily in lateral prefrontal regions. These results suggest that robotic surgery improves performance during high workload conditions and is associated with enhanced activation in regions of attention, concentration and task engagement.

Increasing HIV Testing in Inpatient Psychiatry.

BACKGROUND: People with serious mental illness (SMI) are at elevated risk of HIV infection, but do not receive HIV tests regularly. Inpatient psychiatric admissions provide opportunities for HIV testing. OBJECTIVE: This study retrospectively examined the impact of three sequential interventions designed to increase HIV testing on an acute inpatient psychiatry service: (1) advocacy by an administrative champion, (2) an on-site HIV counselor, and (3) a clinician championing HIV testing. METHOD: Demographic and HIV testing data were extracted from hospital data systems for 11,360 admissions of HIV-negative patients to an inpatient psychiatry service between 2006 and 2012. Relationships among interventions, length of stay, patient demographics, and receipt of an HIV test were examined using general estimating equation methods. RESULTS: In the year prior to the intervention, 7.2% of psychiatric inpatients received HIV tests. After 1 year of administrative advocacy, 11.2% received tests. Following the HIV counseling intervention, 25.1% of patients were tested. After the counseling intervention ended, continued administrative and clinical advocacy was associated with further increases in testing. In the final year studied, 30.3% of patients received HIV tests. Patients with shorter inpatient stays and those of Black or Asian race/ethnicity were less likely to be tested. Further, 1.6% of HIV tests were positive. CONCLUSION: Three interventions of varying intensity were associated with a 5-fold increase in HIV testing on an acute inpatient psychiatry service. Nonetheless, 70% of inpatients were not tested. Continued efforts are needed to increase HIV testing in inpatient psychiatric settings.

A Doctor is in the House: Stakeholder Focus Groups About Expanded Scope of Practice of Community Psychiatrists.

We sought to understand stakeholder perspectives on barriers to metabolic screening for people with severe mental illness. We additionally assessed the feasibility of expanding psychiatrists' scope of practice to include treatment of cardiometabolic abnormalities. We conducted four focus groups among patients with severe mental illness, community psychiatrists, primary care providers, and public health administrators. Focus group transcripts were thematically analyzed. Three domains emerged: challenges with patient navigation of the complex health care system, problem list prioritization difficulties, and concern that treatment of cardiometabolic abnormalities were beyond the scope of practice of psychiatrists. Stakeholders agreed that navigating the health care system was challenging for this population and led to undertreatment of cardiometabolic risk factors. Expansion of psychiatrists' scope of practice within community mental health appears acceptable to patients and may be a mechanism to improve cardiometabolic care among people with severe mental illness.

Low Rates of HIV Testing Among Adults With Severe Mental Illness Receiving Care in Community Mental Health Settings.

OBJECTIVE: This research aimed to characterize HIV testing rates among Medicaid recipients with severe mental illness who received public specialty mental health services. METHODS: This retrospective cohort study examined California Medicaid records from October 1, 2010, to September 30, 2011 (N=56,895). Study participants were between age 18 and 67, utilized specialty mental health care services, were prescribed antipsychotic medications, and were not dually eligible for Medicare. Adjusted Poisson regression models were used to estimate the overall effects of predictor variables on HIV testing prevalence. RESULTS: During the study period, 6.7% of people with severe mental illness received HIV testing. Men were 32% less likely to be tested for HIV than women (p<.001). Compared with whites, Asians/Pacific Islanders were 53% less likely and blacks were 82% more likely to be tested (p<.001). Those with comorbid drug or alcohol use disorders were more likely to be tested than those without such disorders (p<.001). Utilization of nonpsychiatric medical care was the strongest predictor of HIV testing (p<.001). CONCLUSIONS: Most adults with severe mental illness receiving public specialty mental health services were not tested for HIV during a one-year period. Public health administrators must prioritize HIV testing for early identification of HIV infection and prevention of HIV transmission.

Does substance use compromise depression treatment in persons with HIV? Findings from a randomized controlled trial.

Depression and substance use are significant obstacles to effective HIV care. Using data derived from a randomized controlled trial of persons with HIV who are homeless or marginally housed, this study assesses the utility of antidepressant treatment among persons with HIV, depression, and active substance use. Participants were diagnosed with depressive disorders and randomly assigned to receive directly observed therapy with fluoxetine or a referral to community mental health treatment. Assessments, conducted at baseline and every 3 months over a 9-month period, included the Hamilton Rating Scale for Depression, the Beck Depression Inventory II, and self-report of alcohol, crack, cocaine, heroin, or methamphetamine use in the past 90 days. To investigate the effect of antidepressant treatment in the setting of active substance use, the authors fit mixed-effects linear regression models to estimate the effect of directly observed fluoxetine on depressive symptom severity after stratifying by any alcohol use or any illicit drug use. To investigate whether alcohol use or illicit drug use moderated the antidepressant treatment response, the authors examined the interaction terms. The effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant irrespective of alcohol use status. When stratified by illicit drug use status, the effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant only among persons who did not use illicit drugs. The interaction terms were not statistically significant. This study found a benefit of antidepressant treatment in persons with HIV, depression, and alcohol use. In addition, this study found no evidence that either alcohol use or illicit drug use moderates the antidepressant treatment response. Altogether, these findings support the use of antidepressant medication in this population. The public health impact of research in this area is significant given the known adverse effects of depression on HIV-related health outcomes. ClinicalTrials.gov Identifier: NCT00338767.

Sexual orientation and treatment-seeking for depression in a multilingual worldwide sample.

BACKGROUND: Prior research has found higher rates of mental health problems among sexual minority individuals. We examine treatment-seeking for depression, as well as its relationship with sexual orientation, in a large, multilingual, international sample. METHOD: Participants in an automated, quintilingual internet-based depression screening tool were screened for depression, and completed several background measures, including sexual orientation (with an option to decline to state) and past and current depression treatment seeking. RESULTS: 3695 participants screened positive for current or past depression and responded to the sexual orientation question. Those who declined to state their sexual orientation were far less likely to seek any treatment than individuals endorsing any orientation; they were especially unlikely to seek psychotherapy. Individuals identifying as bisexual sought both psychotherapy and alternative treatments at a higher rate than other groups. An interaction was observed between sexual orientation and gender, such that lesbian women were especially likely to have used psychotherapy. Other variables that emerged as significant predictors of treatment-seeking for depression included age and participant's language. LIMITATIONS: Limitations include possible misinterpretation of translated terms due to regional differences, and possible limits to generalizability due to this study being conducted on the internet. CONCLUSIONS: Our results suggest that individuals who decline to state their sexual orientation may be more likely to forgo effective treatments for depression. Further studies of depression service utilization should focus on developing treatment modalities that could better engage sexual minority individuals, especially those who are reluctant to disclose their orientation.

Substance use and drinking outcomes in Personalized Cognitive Counseling randomized trial for episodic substance-using men who have sex with men.

BACKGROUND: Non-dependent alcohol and substance use patterns are prevalent among men who have sex with men (MSM), yet few effective interventions to reduce their substance use are available for these men. We evaluated whether an adapted brief counseling intervention aimed at reducing HIV risk behavior was associated with secondary benefits of reducing substance use among episodic substance-using MSM (SUMSM). METHODS: 326 episodic SUMSM were randomized to brief Personalized Cognitive Counseling (PCC) intervention with rapid HIV testing or to rapid HIV testing only control. Both arms followed over 6 months. Trends in substance use were examined using GEE Poisson models with robust standard errors by arm. Reductions in frequency of use were examined using ordered logistic regression. RESULTS: In intent-to-treat analyses, compared to men who received rapid HIV testing only, we found men randomized to PCC with rapid HIV testing were more likely to report abstaining from alcohol consumption (RR=0.93; 95% CI=0.89-0.97), marijuana use (RR=0.84; 95% CI=0.73-0.98), and erectile dysfunction drug use (EDD; RR=0.51; 95% CI=0.33-0.79) over the 6-month follow-up. PCC was also significantly associated with reductions in frequency of alcohol intoxication (OR=0.58; 95% CI=0.36-0.90) over follow-up. Furthermore, we found PCC was associated with significant reductions in number of unprotected anal intercourse events while under the influence of methamphetamine (RR=0.26; 95% CI=0.08-0.84). CONCLUSION: The addition of adapted PCC to rapid HIV testing may have benefits in increasing abstinence from certain classes of substances previously associated with HIV risk, including alcohol and EDD; and reducing alcohol intoxication frequency and high-risk sexual behaviors concurrent with methamphetamine use.

Shame, self-acceptance and disclosure in the lives of gay men living with HIV: an interpretative phenomenological analysis approach.

OBJECTIVE: HIV-related stigma is a major driver of poor prognosis for the treatment and reduced spread of HIV. The present article provides a qualitative analysis surrounding various themes related to stigma and shame as a result HIV. DESIGN: Eight gay men recruited from a community HIV clinic contacted the researchers in response to a study involving participation in a structured, eight-week group intervention for HIV-related stigma. Following this group, three men took part in open-ended interviews about their thoughts and experiences. METHODS: Interpretative phenomenological analysis was used to examine the participants' experiences surrounding shame and stigma related to living with HIV. RESULTS: Three superordinate themes were identified: social support and the disclosure of serostatus, stigma associated with serosorting and attempts to negotiate a spoiled identity. CONCLUSION: In San Francisco, a city with a great deal of acceptance surrounding HIV and a large, politically active community of persons living with HIV, gay men continue to struggle with disclosure and stigma. This stigma may be an unexpected result of a high degree of HIV testing and attempts by both HIV-positive and negative gay men to practise serosorting.

A roadmap for adapting an evidence-based HIV prevention intervention: personal cognitive counseling (PCC) for episodic substance-using men who have sex with men.

Episodic (less than weekly) drug use and binge drinking increase HIV-related sexual risk behaviors among men who have sex with men (MSM), yet no evidence-based interventions exist for these men. We describe an adaptation process of the Personalized Cognitive Counseling (PCC) intervention for utilization with high-risk, HIV-negative episodic, substance-using MSM. Participants (N = 59) were racially diverse, and reported unprotected anal intercourse and concurrent binge drinking (85%), use of poppers (36%), methamphetamine (20%) and cocaine (12%). Semi-structured interviews with 20 episodic, substance-using MSM elicited sexual narratives for engaging in unprotected anal intercourse while using alcohol or drugs. Emergent qualitative themes were translated into self-justifications and included in a revised PCC self-justification elicitation instrument (SJEI). The adapted SJEI was pretested with 19 episodic, substance-using MSM, and the final adapted PCC was pilot-tested for acceptability and feasibility with 20 episodic, substance-using MSM. This process can be used as a roadmap for adapting PCC for other high-risk populations of MSM.

Does effective depression treatment alone reduce secondary HIV transmission risk? Equivocal findings from a randomized controlled trial.

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.

Primary care providers' views on metabolic monitoring of outpatients taking antipsychotic medication.

OBJECTIVE: The purpose of this study was to evaluate attitudes of primary care providers toward barriers to metabolic monitoring and to characterize their beliefs about providers' responsibility for monitoring and reducing cardiovascular risk for people with severe mental illness. METHODS: An anonymous survey was administered to 214 primary care providers working in 23 public community health clinics in San Francisco. RESULTS: The response rate was 77% (164 of 214). Nearly 40% of primary care providers were unaware of consensus guidelines for metabolic monitoring of people who take second-generation antipsychotic medications. Responses showed variation in providers' beliefs about who should monitor patients' metabolic risk. The major barriers to metabolic monitoring were severity of psychiatric illness, difficulty collaborating with psychiatrists, and difficulty arranging psychiatric follow-up. CONCLUSIONS: Primary care providers believed that better communication between primary care providers and psychiatrists would facilitate metabolic monitoring and promote better treatment for patients with severe mental illness who are taking antipsychotic medications.

Dose-response associations between number and frequency of substance use and high-risk sexual behaviors among HIV-negative substance-using men who have sex with men (SUMSM) in San Francisco.

We evaluated the relationship between frequency and number of substances used and HIV risk [ie, serodiscordant unprotected anal intercourse (SDUAI)] among 3173 HIV-negative substance-using MSM. Compared with nonusers, the adjusted odds ratio (AOR) for SDUAI among episodic and at least weekly users, respectively, was 3.31 [95% confidence interval (CI), 2.55 to 4.28] and 5.46 (95% CI, 3.80 to 7.84) for methamphetamine, 1.86 (95% CI, 1.51 to 2.29) and 3.13 (95% CI, 2.12 to 4.63) for cocaine, and 2.08 (95% CI, 1.68 to 2.56) and 2.54 (95% CI, 1.85 to 3.48) for poppers. Heavy alcohol drinkers reported more SDUAI than moderate drinkers [AOR, 1.90 (95% CI, 1.43 to 2.51)]. Compared with nonusers, AORs for using 1, 2, and ≥3 substances were 16.81 (95% CI, 12.25 to 23.08), 27.31 (95% CI, 18.93 to 39.39), and 46.38 (95% CI, 30.65 to 70.19), respectively. High-risk sexual behaviors were strongly associated with frequency and number of substances used.

A randomized clinical trial of smoking cessation treatments provided in HIV clinical care settings.

INTRODUCTION: Identifying successful smoking treatment interventions and methods of delivery is critical given the smoking rates among HIV-positive populations and the medical implications of smoking in this population. This study compared the efficacy of 3 smoking cessation interventions provided in HIV clinical treatment settings. METHODS: Following a baseline assessment, 209 HIV-positive smokers were randomly assigned to 1 of 3 conditions in a parallel group design. Treatment conditions were individual counseling plus nicotine replacement treatment (NRT), a computer-based Internet smoking treatment plus NRT, and self-help plus NRT. Smoking status was determined at follow-up assessments completed at 12, 24, 36, and 52 weeks following treatment initiation. RESULTS: Cessation rates ranged from 15% to 29%; however, no statistically significant differences in abstinence were found among the treatment conditions over time. Those employed, those who reported a greater desire to quit, or those with lower mood disturbance scores were more likely to achieve abstinence (p < .01). The number of cigarettes participants reported smoking in the 24hr prior to each assessment significantly declined over time (p < .001). CONCLUSIONS: Although we found no differences in abstinence rates across groups, the results indicate that integration of smoking cessation interventions is feasible in HIV clinical treatment settings, and cessation results are promising. The overall abstinence rates we report are comparable to those found in similar treatment studies across multiple populations. Further research is warranted.

Descriptive analysis of a novel health care approach: reverse colocation-primary care in a community mental health "home".

OBJECTIVE: Persons with serious mental illness have increased rates of chronic medical conditions, have limited access to primary care, and incur significant health care expenditures. Few studies have explored providing medical care for these patients in the ambulatory mental health setting. This study describes a real-world population of mental health patients receiving primary care services in a community mental health clinic to better understand how limited primary care resources are being utilized. METHOD: Chart review was performed on patients receiving colocated primary care (colocation group, N = 143) and randomly chosen patients receiving mental health care only (mental-health group, N = 156) from January 2006 through June 2011. Demographic and mental and physical health variables were assessed. RESULTS: Compared to the mental-health group, the colocation patients had more psychiatric hospitalizations (mean = 1.07 vs 0.23, P < .01), were more likely to be homeless (P < .01), and were more likely to require intensive case management (P < .01). Interestingly, the colocation group was not more medically ill than the mental-health group on key metabolic measures, including mean body mass index (colocation = 27.8 vs mental-health = 28.7, P = .392), low-density liprotein (colocation = 110.0 vs mental-health = 104.4, P = .480), and glucose (colocation = 94.1 vs mental-health = 109.2, P = .059). The most common medical disorders in the colocation group were related to metabolic syndrome. CONCLUSIONS: Colocated primary care services were allocated on the basis of severity of psychiatric impairment rather than severity of medical illness. This program serves as a model for other systems to employ for integrated primary and behavioral health services for patients with serious mental illness.

A randomized control trial of personalized cognitive counseling to reduce sexual risk among HIV-infected men who have sex with men.

The increased life expectancy and well-being of HIV-infected persons presents the need for effective prevention methods in this population. Personalized cognitive counseling (PCC) has been shown to reduce unprotected anal intercourse (UAI) with a partner of unknown or different serostatus among HIV-uninfected men who have sex with men (MSM). We adapted PCC for use among HIV-infected MSM and tested its efficacy against standard risk-reduction counseling in a randomized clinical trial in San Francisco. Between November 2006 and April 2010, a total of 374 HIV-infected MSM who reported UAI with two or more men of negative or unknown HIV serostatus in the previous 6 months were randomized to two sessions of PCC or standard counseling 6 months apart. The primary outcome was the number of episodes of UAI with a non-primary male partner of different or unknown serostatus in the past 90 days, measured at baseline, 6, and 12 months. Surveys assessed participant satisfaction with the counseling. The mean number of episodes of UAI at baseline did not differ between PCC and control groups (2.97 and 3.14, respectively; p=0.82). The mean number of UAI episodes declined in both groups at 6 months, declined further in the PCC group at 12 months, while increasing to baseline levels among controls; these differences were not statistically significant. Episode mean ratios were 0.76 (95% confidence interval [CI] 0.25-2.19, p=0.71) at 6 months and 0.48 (95% CI 0.12-1.84, p=0.34) at 12 months. Participants in both groups reported a high degree of satisfaction with the counseling. The findings from this randomized trial do not support the efficacy of a two-session PCC intervention at reducing UAI among HIV-infected MSM and indicate the continued need to identify and implement effective prevention methods in this population.

Directly observed antidepressant medication treatment and HIV outcomes among homeless and marginally housed HIV-positive adults: a randomized controlled trial.

OBJECTIVES: We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008. METHODS: We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL). RESULTS: The intervention reduced depression symptom severity (b = -1.97; 95% confidence interval [CI] = -0.85, -3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes. CONCLUSIONS: Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.