Drug Use Mediates the Relationship Between Depressive Symptoms and Adherence to ART Among Recently Incarcerated People Living with HIV

  • Lauren M. HillEmail author
  • Carol E. Golin
  • Nisha C. Gottfredson
  • Brian W. Pence
  • Bethany DiPrete
  • Jessica Carda-Auten
  • Jennifer S. Groves
  • Sonia Napravnik
  • David Wohl
  • Kevin Knight
  • Patrick M. Flynn
Original Paper


Depression is a known risk factor for antiretroviral therapy (ART) non-adherence, but little is known about the mechanisms explaining this relationship. Identifying these mechanisms among people living with HIV (PLHIV) after release from prison is particularly important, as individuals during this critical period are at high risk for both depression and poor ART adherence. 347 PLHIV recently released from prison in North Carolina and Texas were included in analyses to assess mediation of the relationship between depressive symptoms at 2 weeks post-release and ART adherence (assessed by unannounced telephone pill counts) at weeks 9–21 post-release by the hypothesized explanatory mechanisms of alcohol use, drug use, adherence self-efficacy, and adherence motivation (measured at weeks 6 and 14 post-release). Indirect effects were estimated using structural equation models with maximum likelihood estimation and bootstrapped confidence intervals. On average, participants achieved 79% ART adherence. The indirect effect of depression on adherence through drug use was statistically significant; greater symptoms of depression were associated with greater drug use, which was in turn associated with lower adherence. Lower adherence self-efficacy was associated with depressive symptoms, but not with adherence. Depression screening and targeted mental health and substance use services for depressed individuals at risk of substance use constitute important steps to promote adherence to ART after prison release.


Antiretroviral therapy Adherence Depression Drug use Incarceration Mediation 



This research was supported by the National Institute on Drug Abuse (R01 DA030793) and the UNC Center for AIDS Research (P30 AI50410). This research was partially supported by a National Research Service Award Post-Doctoral Traineeship from the Agency for Healthcare Research and Quality sponsored by The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill (T32 HS000032). Dr. Golin’s salary was partially supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K24 HD069204). Dr. Wohl’s salary (K24 DA037101) and Dr. Gottfredson’s salary (K01 DA035153) were partially supported by the National Institute on Drug Abuse. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Lauren M. Hill
    • 1
    • 2
    Email author
  • Carol E. Golin
    • 1
    • 2
    • 3
  • Nisha C. Gottfredson
    • 1
  • Brian W. Pence
    • 4
  • Bethany DiPrete
    • 4
  • Jessica Carda-Auten
    • 1
  • Jennifer S. Groves
    • 2
  • Sonia Napravnik
    • 3
    • 4
  • David Wohl
    • 3
  • Kevin Knight
    • 5
  • Patrick M. Flynn
    • 5
  1. 1.Department of Health BehaviorUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillUSA
  3. 3.Division of Infectious DiseasesUniversity of North Carolina at Chapel HillChapel HillUSA
  4. 4.Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillUSA
  5. 5.Department of PsychologyTexas Christian UniversityFort WorthUSA

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