BETHESDA, MD — In veterans with HIV, having post-traumatic stress disorder (PTSD) increased the likelihood of being nonadherent with their HIV treatment and requiring modification to their HIV treatment, according to a recent study.
The study published in the journal AIDS evaluated the associations between PTSD and antiretroviral therapy (ART) nonadherence, modifications and treatment failure (virologic, immunologic and clinical) in veterans with HIV. The authors also measured effect modification by number of deployments and combat exposure and examined how these associations vary over time among veterans of recent wars in Iraq and Afghanistan with HIV who are on ART and received care at the VA.1
The study authors are affiliated with Walter Reed Army Institute of Research, Henry M. Jackson Foundation for the Advancement of Military Medicine Inc. and the Uniformed Services University of the Health Sciences, each in Bethesda, MD, as well as the Rollins School of Public Health at Emory University in Atlanta.
With combination ART, HIV disease has become more manageable and chronic, improving life expectancy and quality of life. However, ART requires moderately high levels of adherence, and nonadherence rates of even 10 to 15% can significantly impact efficacy. Mental health plays a key role in ART adherence, and PTSD is among the strongest predictors of nonadherence. Previous studies have found that 95% of people with HIV report having at least one severe traumatic stressor, and more than half meet the criteria for PTSD, the researchers explained.
PTSD symptoms, including avoidant behaviors, intrusive thoughts and general hyperarousal, can affect a person’s cognitive capacity and their ability to remember medication instructions, dosing schedules and dietary requirements, which are important for ART efficacy. Less-than-optimal ART adherence could result in diminished viral suppression, poorer immunologic functioning, greater clinical decline, increased viral mutations and emergence of viral resistance, requiring the need for modifications to the ART regimen, the authors pointed out.
“PTSD is highly prevalent among military servicemembers and veterans and is known to affect HIV treatment; however, there hasn’t been much scientific inquiry into their association in this population,” Kartavya (Kurt) Vyas, PhD, a clinical-epidemiologic investigator at Walter Reed Army Institute of Research, told U.S. Medicine. “By understanding how PTSD affects HIV treatment in this population where it is so prevalent, we can better inform care for all people with HIV more broadly.”
This prospective cohort study included all veterans diagnosed with HIV who deployed to Iraq and Afghanistan (Operations Enduring Freedom, Iraqi Freedom and New Dawn [OEF/OIF/OND]), received care in the VA and had initiated ART prior to Dec. 31, 2020, a total of 3,206 patients. The participants entered the study at ART initiation and were censored in December 2022, totaling 22,261 person-years of follow-up. Data were generated and analyzed within the VA Informatics and Computing Infrastructure (VINCI), a secure analytic platform that hosts databases from select national VA data sources, including the Corporate Data Warehouse (CDW), DoD-VA Informatics and Computing Infrastructure (DaVINCI) and the U.S. Veterans Eligibility Trends and Statistics (USVETS) databases, the study reported.
“We found that veterans with PTSD were 6% more likely to be nonadherent with their HIV treatment than veterans without PTSD and that this association was elevated for those with multiple combat deployments,” Vyas said. “We also found that the rate at which their HIV treatment was modified was 38% higher among veterans with PTSD than those without PTSD, and that this association increased during the first decade after PTSD diagnosis.”
Overall, the researchers determined that PTSD negatively impacts HIV treatment adherence, and this impact can be observed up to a decade after PTSD diagnosis.
The analyses also found that PTSD increased the overall rates of virologic failure by 14%, immunologic failure by 5% and clinical failure by 89%, but none of these rates were statistically significant. The number of deployments or combat exposure didn’t modify these associations.
Regarding AIDS-defining illnesses, patients with PTSD were significantly more likely to have been diagnosed with candidiasis (esophageal), cryptococcosis (extrapulmonary), lymphoma (immunoblastic), mycobacterium avium complex or mycobacterium kansaii (disseminated or extrapulmonary), mycobacterium tuberculosis (any site, pulmonary or extrapulmonary) and progressive multifocal leukoencephalopathy than those without PTSD. Patients with PTSD were significantly less likely to have been diagnosed with Kaposi’s sarcoma, Pneumocystis jirovecii pneumonia, or toxoplasmosis (brain), than those without PTSD, the investigators pointed out.
“As HIV disease shifts to one that is more manageable and chronic, it is important that all providers recognize the role PTSD may play in HIV treatment nonadherence and its downstream effects on treatment failure and clinical decline,” Vyas said. “It is important that providers adopt a trauma-informed model of HIV care, refer patients to treatment advocacy programs and services, when indicated, and screen veterans for PTSD so that their unique trauma history can help guide medical decisions and treatment.”
The study authors suggested that attention should be paid to veterans with multiple combat deployments.
In this study, most patients were male (97.4%), Black (50.4%), never married (51.1%), high school educated (70.0%) and had an annual household income of $40,000 to $74,999 (36.7%). The median age at HIV diagnosis was 31.7 years. Most served in the Army (50.0%) and on active-duty (78.3%), were ranked as enlisted E5-E9 (53.8%), worked in service/supply (56.3%), deployed only once (78.6%), were unexposed to combat (76.8%), never sustained combat (97.3%) or noncombat (75.9%) injuries and were honorably discharged (97.0%). The median length of service was 6.6 years.
Patients with PTSD were significantly different only by age at HIV diagnosis and marital status in their sociodemographics and only by time to ART initiation, nadir CD4 count and first HIV viral load in their HIV clinical history compared to those without PTSD, according to the report. However, patients with PTSD were significantly different across all factors of military history assessed and all mental health disorders examined compared to those without PTSD, the authors explained.
Of the 3,206 patients in the study sample, 138 died (4.3%), 229 (7.1%) were lost to follow-up (LTFU), and 2,839 (88.6%) survived past the study period, according to the study.
The authors noted this study is one of the more comprehensive and robust analyses to estimate the associations between PTSD and ART in people with HIV, not just veterans with HIV. The results could help policymakers anticipate the potential long-term negative health consequences of war for veterans with HIV, the risk profiles of individuals who are most vulnerable and how to reduce those risks by supporting preventive measures.
This analysis also could enable providers to better identify those patients at highest risk for ART nonadherence and reduce this risk by referring patients to treatment advocacy programs and services. Lastly, the study could help modify ART regimens to improve adherence, reduce viral resistance and prevent treatment failure, as well as inform other medical decisions and treatment among people with HIV, the researchers suggested.
The investigators have completed two additional studies involving PTSD. The first study examines the association between PTSD and sexually transmitted infections among all OEF/OIF veterans receiving care in the VA. The second study evaluates PTSD and morbidity and mortality among all OEF/OIF veterans with HIV receiving care in the VA. Both studies are under peer review, Vyas said.
- Vyas KJ, Marconi VC, Agan BK, Sullivan PS, Lyles RH, Guest JL. Posttraumatic stress disorder and its associations with antiretroviral therapy among veterans with HIV. AIDS. 2025 Jan 3. doi: 10.1097/QAD.0000000000004105. Epub ahead of print. PMID: 39760706.
