Importance Depression commonly affects adults with HIV and complicates the management of HIV. Depression among individuals with HIV tends to be chronic and cyclical, but the association of this chronicity with HIV outcomes (and the related potential for screening and intervention to shorten depressive episodes) has received little attention.

Objective To examine the association between increased chronicity of depression and multiple HIV care continuum indicators (HIV appointment attendance, treatment failure, and mortality).

Design, Setting, and Participants The study comprised an observational clinical cohort of 5927 patients with 2 or more assessments of depressive severity who were receiving HIV primary care at 6 geographically dispersed US academic medical centers from September 22, 2005, to August 6, 2015.

Main Outcomes and Measures Missing a scheduled HIV primary care visit, detectable HIV RNA viral load (≥75 copies/mL), and all-cause mortality. Consecutive depressive severity measures were converted into a time-updated measure: percentage of days with depression (PDD), following established methods for determining depression-free days.

Results During 10 767 person-years of follow-up, the 5927 participants (5000 men, 926 women, and 1 intersex individual; median age, 44 years [range, 35-50 years]) had a median PDD of 14% (interquartile range, 0%-48%). During follow-up, 10 361 of 55 040 scheduled visits (18.8%) were missed, 6191 of 28 455 viral loads (21.8%) were detectable, and the mortality rate was 1.5 deaths per 100 person-years. Percentage of days with depression showed a dose-response relationship with each outcome. Each 25% increase in PDD led to an 8% increase in the risk of missing a scheduled appointment (risk ratio, 1.08; 95% CI, 1.05-1.11), a 5% increase in the risk of a detectable viral load (risk ratio, 1.05; 95% CI, 1.01-1.09), and a 19% increase in the mortality hazard (hazard ratio, 1.19; 95% CI, 1.05-1.36). These estimates imply that, compared with patients who spent no follow-up time with depression (PDD, 0%), those who spent the entire follow-up time with depression (PDD, 100%) faced a 37% increased risk of missing appointments (risk ratio, 1.37; 95% CI, 1.22-1.53), a 23% increased risk of a detectable viral load (risk ratio, 1.23; 95% CI, 1.06-1.43), and a doubled mortality rate (hazard ratio, 2.02; 95% CI, 1.20-3.42).

Conclusions and Relevance Greater chronicity of depression increased the likelihood of failure at multiple points along the HIV care continuum. Even modest increases in the proportion of time spent with depression led to clinically meaningful increases in negative outcomes. Clinic-level trials of protocols to promptly identify and appropriately treat depression among adults living with HIV should be conducted to understand the effect of such protocols on shortening the course and preventing the recurrence of depressive illness and improving clinical outcomes.

重要性 抑郁症通常会影响成年人的艾滋病毒感染，并使艾滋病毒的管理复杂化。艾滋病毒感染者的抑郁症往往是慢性的和周期性的，但是这种慢性病与艾滋病毒预后的关系（以及相关的筛查和干预措施可能缩短抑郁症发作的可能性）却很少受到关注。

目的 探讨抑郁症的慢性病增加与多个艾滋病毒护理连续性指标（艾滋病毒预约人数，治疗失败和死亡率）之间的关系。

设计，背景和参与者 该研究包括5927名患者的观察性临床队列，他们于2005年9月22日至2015年8月6日在6个地理位置分散的美国学术医学中心接受了HIV初级保健的2次或更多次抑郁严重程度评估。

主要结果和措施 缺少计划的HIV初级保健就诊，可检测到的HIV RNA病毒载量（≥75拷贝/ mL）和全因死亡率。遵循确定无忧郁症天数的既定方法，将连续性忧郁症严重程度的度量标准转换为时间更新度量：患有抑郁症的天数百分比（PDD）。

结果 在10 767人-年的随访期间，5927名参与者（5000名男性，926名女性和1名双性恋者；中位年龄为44岁[范围，35-50岁]）的PDD中位数为14％（四分位间距） ，0％-48％）。在随访期间，错过了55 040次例行检查中的10 361次（18.8％），可检测到28 455次病毒载量中的6191次（21.8％），死亡率为每100人年1.5例死亡。抑郁症天数百分比与每种结局均呈剂量反应关系。PDD每增加25％，错过预定约会的风险就会增加8％（风险比，1.08； 95％CI，1.05-1.11），可检测病毒载量的风险增加5％（风险比） ，1.05； 95％CI，1.01-1.09），死亡率危险增加19％（危险比，1.19； 95％CI，1.05-1.36）。这些估计表明，

结论和相关性 抑郁症的长期慢性病增加了艾滋病护理连续性过程中多个部位失败的可能性。即使在抑郁症上花费的时间比例适度增加，也会导致负面结果在临床上有意义的增加。应进行临床方案试验，以迅速识别和适当治疗艾滋病毒携带者成年人的抑郁症，以了解此类方案在缩短病程，预防抑郁症复发和改善临床结果方面的作用。