Depressive symptoms and health services utilization in the HIV-Hepatitis C co-infected population in Canada


BACKGROUND: Depression is highly prevalent among people living with Hepatitis C (HCV) and HIV, which can contribute to high health services utilization (HSU). HCV cure have benefits in preventing liver disease and beyond, which could have an impact on HSU.Thus, we examined the relationship between depressive symptoms and HSU in the HIV-HCV co-infected population in Canada and how it was affected by sustained virologic response (SVR).
METHODS: We used data from the Canadian Co-infection Cohort, a multicentre prospective cohort, and its associated food security sub-study. We predicted Centre for Epidemiologic Studies Depression Scale-10 classes for depressive symptoms using a random forest classifier and corrected for misclassification.The HSU outcomes were number of self-reported inpatient visits (hospital stays, emergency room)and outpatient visits (general practitioner, HIV clinic, specialist, walk-ins) in the past 6 months. We restricted the analysis to the 2ndgeneration direct acting antiviral (DAA) era (post-November 2013). All HCV-RNA+ participants were followed until death, withdrawal or end of study period (July 2020). Participants achieved SVR if they had undetectable HCV-RNA at least 12-weeks after end of treatment. We used an adjusted zero-inflated negative binomial model accounting for overdispersion and excess zeroes.
RESULTS: We included 1,153 participants, of which 530 were treated for HCV and 504 (95%) achieved SVR. The median number of inpatient visits was 0 (IQR:0-1) and outpatient visits was 3 (IQR:1-6). Among those who had not achieved SVR, inpatient visits were 17% higher among those with depressive symptoms than those without; outpatient visits were 5% higher. Among those who achieved SVR, there was no evidence of an association between depressive symptoms and HSU. SVR was associated with 24% lower inpatient visits, however outpatient visits remained the same post-SVR.

Table 1: Effect of depressive symptoms and SVR on HSU

OutcomesSVRDepressive symptoms
- Among those who achieved SVR
Depressive symptoms
- Among those who did not achieve SVR
Incidence Rate Ratio (IRR)95% Confidence Interval (CI)IRR95% CIIRR95% CI
Inpatient visits0.760.70-0.841.030.89-
Outpatient visits1.000.97-

CONCLUSIONS: Depressive symptoms were associated with an increase in HSU, indicating depression contributes to poor health outcomes in the co-infected population. SVR was associated with a reduction in inpatient visits but not outpatient visits. SVR appears to attenuate the effect of depressive symptoms on HSU.

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