HIV/AIDS  and Depression: When Two Conditions Coincide – Prevalence and Associated  Factors

Alvi Y

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OJHAS Vol. 21, Issue 3: (July-September 2022)

Original Article
HIV/AIDS and Depression: When Two Conditions Coincide – Prevalence and Associated Factors

Authors:
Yasir Alvi, Assistant Professor, Department of Community Medicine, Hamdard Institute of Medical Science and Research, Hamdard University, New Delhi, India,
Shamaila Sameen, Senior Resident, Department of Pathology, Hamdard Institute of Medical Science and Research, Hamdard University, New Delhi, India,
Najam Khalique, Professor, Department of Community Medicine, Jawaharlal Nehru Medical College & Hospital, Aligarh Muslim University (AMU), Aligarh, India.

Address for Correspondence
Yasir Alvi,
Department of Community Medicine,
Hamdard Institute of Medical Science and Research,
Hamdard University,
New Delhi, India
E-mail: yasiralvi13@gmail.com.

Citation
Alvi Y, Sameen S, Khalique N. HIV/AIDS and Depression: When Two Conditions Coincide – Prevalence and Associated Factors. Online J Health Allied Scs. 2022;21(3):7. Available at URL: https://www.ojhas.org/issue83/2022-3-7.html

Submitted: Aug 29, 2022; Accepted: Oct 4, 2022; Published: Nov 15, 2022

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This work is licensed under a Creative Commons Attribution-No Derivative Works 2.5 India License

Abstract: Introduction: Depression is the most common mental illness among people living with HIV/AIDS (PLHA). While depression is common among other chronic illnesses, it is expected to be more with HIV/AIDS, which is a more stressful state. Thus, in this study, we tried to estimate the prevalence of depression along with its associated factors in people with HIV/AIDS. Method: This cross-sectional study was done at one ART Centre in North India. Over a period of one year, HIV/AIDS patients taking antiretroviral therapy were interviewed, estimating depression with PHQ-9. Using multivariate logistic regression, we examined the association of various factors with depression among HIV patients. Results: We observed that 16% of PLHA suffered from depression, while 3% had moderate and moderately severe depression. Among the factors associated with depression, we found alcohol consumption [OR 2.553; 95%CI 1.180 - 5.526], lower CD4 cell counts [OR 2.630; 95%CI 1.297 - 5.330], side effects from ART [OR 2.442; 95%CI 1.302 - 4.577], unsatisfaction from family support [OR 2.683; 95%CI 1.334 - 5.394] and no improvement from ART [OR 0.412; 95%CI 0.190 - 0.896] to be individually and significantly associated. Conclusion: Higher prevalence of depression among HIV/AIDS patients and its association with various factors should worry policymakers, prompting them to take necessary action.
Key Words: Depression, PLHA, HIV/AIDS, Antiretroviral therapy

Introduction:

With 21.12 lacs patients, India has the world's third-largest population of people living with HIV/AIDS (PLHA) [1]. With the availability of free-of-cost Highly Active Antiretroviral Therapy (HAART) to every HIV/AIDS patient in India, the lifespan of PLHA has increased, transforming HIV into a manageable chronic disease. However, an unforeseen and unwelcome outcome of this is an increased experience of disorders said to be more among other chronic diseases, and depression is one of them.

In the spectrum of mental illness, depression tops as the most frequent mental health problem among PLHA [2], which is one of the leading causes of disease burden and the second most common cause of disability worldwide [3]. According to a nationwide survey in India, one out of every twenty suffers from depression [4]. Comorbidities, such as HIV/AIDS, raise the chance of developing depression [5]. The threat of depression among PLHA could arise due to psychosocial issues like the stress of illness, stigma/discrimination related to HIV/AIDS [6], maladjustment to challenging life events, and biological issues like viral and ART drug-mediated injury to the nervous system [7,8]. Additionally, the presence of psychiatric disorders, including depression, may lead a person more towards high-risk activities, increasing the transmission of HIV [9,10]. Studies have shown that depression is associated with poor quality of life and health [11], increased disease severity, and faster progression with early mortality [8,12]. Depression and HIV/AIDS are expected to be the significant causes of disability globally, and cohabitation may complicate disease management [5].

Prevalence estimates of depression in PLHA have shown wide variations, ranging from 8.1% in Uganda to 50% in central India [13,14], with higher rates among females and newly diagnosed cases. This prevalence of depression among PLHA is said to be about twice as high as their seronegative counterparts [15]. With the rising incidence among PLHA, depression is becoming a public health problem, leading to an additional burden on our country's already poor health care systems. Therefore, estimating the prevalence of depression among PLHA may help policymakers in designing health care services. Thus we undertook this research to estimate the prevalence of depression and its associated factors in the PLHA population.

Materials and Methods

Study design and setting
This was a cross-sectional study done at one of the ART Centre situated in North India over a period of one year. All adult HIV/AIDS patients registered at Anti-Retroviral Treatment (ART) centre, Aligarh, were included in the study. This ART Centre and its attached two Link ART centres serve a large population of PLHA patients from nearby regions.

Study Population and design
All the adult patients (> 18 years) registered at the ART centre for more than six months and taking ART were eligible for the study. Patients were selected after receiving written consent and were excluded if they had: 1. Any acute medical condition 2. Any past or family history of mental illness, and 3. Any bereavement, severe loss of property, or illness/death of loved ones during the previous three months.

The eligible population was sampled by systematic random sampling. Anticipating prevalence of 50% [14], and absolute precision as 10%, the sample size was determined using the formula n = 4p(1-p)/d2. Considering non-response rate of 10% , the sample size was calculated to be 440.

Study instruments
We conducted the face-to-face interview in the local language (Hindi) using a pre-designed and pre-tested questionnaire. This questionnaire elicited information regarding selected socio-demographics, clinical and social factors. We selected the Physical Health Questionnaire- (PHQ-9) as our tool for assessing depression since it was designed specifically for screening and diagnosing depression in primary care settings. Furthermore, PHQ-9 takes a few minutes -acceptance by patients will be more- and would be easily prescribed by the counselor at HIV clinics. The PHQ-9 is a set of nine measures based on the DSM-IV to diagnose depressive disorders [16]. The total score runs from 0 to 27, and depression severity is divided into four categories: none (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27). The sensitivity and specificity of PHQ-9 in diagnosing depression vary from 87%-99% and 88%-90%, respectively [17,18], including the local (Hindi) version of the questionnaire.

Data Management and Statistics
Statistical Package for Social Sciences (SPSS) Version 20 was used to enter and analyze the data. Statistical significance was tested first by the Chi-square test during univariate unadjusted analysis. Variables that were significant during univariate analysis (p<0.05), were included in a multivariate logistic regression model with selection of variables was carried out using enter method.

Ethics
The JN Medical College's Institutional Ethics and Research Advisory Committee approved the study. All patients gave written informed consent. Individual rapport-building sessions were undertaken before the interview's commencement to explain the research's objective and its consequences while maintaining confidentiality. After the interview, all patients received appropriate health information, counseling, and referrals.

Results

Out of the 440 patients who were approached during the study period, only 434 participants finished the interview.

Socio-demographic and clinical characteristics
During the study period, we interviewed 434 patients, including 262 males, 170 females and 2 transgender. The mean age was 39.02 ±9.82 years, ranging from 18 to 76 years. The majority were married (65.4%), resided in rural areas (73.7%), and in a nuclear family (62.7%). Only about two-thirds of patients were literate, and the same proportion were employed. About two-thirds of participants (66.4%) belonged to a lower social-economical class, while about one-third (33.9%) were economically dependent. With a mean CD4 count of 384.57 ±179.54 cu. mm, most individuals (249/434) were asymptomatic (WHO stage I). In the past month, 48 patients had consumed alcohol, while 45 patients gave the history of smoking. Antiretroviral side effects were reported by 18.7% of the individuals in the past 30 days. The majority of patients (388/434) considered ART beneficial. (Table 1)

Table 1: Socio demographic characteristics of patients taking ART.
Pattern of Depression		Frequency	Percentage	95% CI
Age	18-30	93	21.4	17.8-25.5
	31-40	169	38.9	34.5-43.6
	41-50	119	27.4	23.4-31.8
	51 and above	53	12.2	9.4-15.7
Sex	Male	262	60.4	55.7-64.9
	Female	170	39.2	34.7-43.8
	Intersex	2	0.5	0.1-1.7
Religion	Hindu	386	88.9	85.6-91.6
	Non Hindu	48	11.1	8.4-14.4
Residence	Urban	114	26.3	22.3-30.6
	Rural	320	73.7	69.4-77.7
Marital Status	Never married	32	7.4	5.2-10.3
	Married	284	65.4	60.8-69.8
	Widowed, separated, divorced	118	27.2	23.2-31.6
Education	Illiterate	140	32.3	28.0-36.8
	Primary	130	30.0	25.8-34.4
	Secondary	125	28.8	24.7-33.2
	Graduation and above	39	9.0	6.6-12.1
Present occupation	Unemployed	144	33.2	28.9-37.7
	Employed	290	66.8	62.3-71.1
Socioeconomic status*	I	23	5.3	3.5-7.9
Socioeconomic status*	II	48	11.1	8.4-14.4
	III	66	15.2	12.1-18.9
	IV	158	36.4	32.0-41.0
	V	139	32.0	27.8-36.6
Economic dependency	Independent	287	66.1	61.6-70.4
Economic dependency	Dependent	147	33.9	29.6-38.4
Type of family	Nuclear	272	62.7	58.0-67.1
	Joint	162	37.3	32.9-42.0
Alcohol use (within one month)	Yes	48	11.1	8.4-14.4
Alcohol use (within one month)	No	386	88.9	85.6-91.6
Smoking (within one month)	Yes	45	10.4	7.8-13.6
Smoking (within one month)	No	389	89.6	86.4-92.2
* Mod BG Prasad Classification

Prevalence of Depression
In our study population, 16.1% [95% CI 13.0-19.9] (70/434) were depressed. The prevalence of current depression among ART patients is depicted in Table 2. Furthermore, it was observed that the majority of them had only mild depression (57/70), while some were categorized as moderate and moderately severe depression (10/70 and 3/70, respectively) (Table 2).

Table 2: The pattern of Depression in the study population (n=434)
Pattern	Frequency	Percentage	95% CI
No Depression	364	83.9%	80.1-87.0
Depression	70	16.1%	13.0-19.9
Mild*	57 (81.4%)	13.1%	10.3-16.7
Moderate*	10 (14.3%)	2.3%	2.3-12.0
Severe*	3 (4.3%)	0.7%	0.06-1.36
* Proportion among those who were depressed

Determinants of depression
The younger population (35 years or less), in comparison to than in the older, was observed to be depressed more (20.3% vs. 13.2%), but this relationship was not statistically significant in multivariate analysis (p=0.302). Similarly, most of the socio-demographic variables were found to be not associated with depression. Unemployed and asymptomatic patients were depressed significantly more in univariate analysis, but came out to be non-significant in multiple logistic regression after adjustment. The patients who consumed alcohol were 2.6 times more depressed than those who did not. Among clinical factors, we found CD4 cells counts less than 200 cu.mm [OR 2.630; 95%CI 1.297 - 5.330] and side effects [OR 2.442; 95%CI 1.302 - 4.577] to be significantly higher among the depressed. Depression was significantly lower who perceived benefits from the treatment [OR 0.412; 95%CI 0.190 - 0.896] and higher among those satisfied with the support they got from their family [OR 2.683; 95%CI 1.334 - 5.394]. Depression was not found to be associated with the patient's gender, residence, marital status, family type, literacy, socioeconomic class, economic dependency, smoking, duration of treatment, HAART regimen, social support, positive status of spouse, and HIV status discloser. Association between depression and various variables has been illustrated in Table 3 and Table 4.

Table 3: Univariate analysis of various factors with presence of depression among HIV patients.
Variables		Depressed Freq. (%)	Not depressed Freq. (%)	Total N=434	P value
Age (in years)	35 or less	36 (20.3%)	141 (79.7%)	177	0.048
Age (in years)	> 35	34 (13.2%)	223 (86.8%)	257
Sex	Male	42 (16.0%)	220 (84.0%)	262	0.426
	Intersex	1 (50.0%)	1 (50.0%)	2
	Female	27 (15.9%)	143 (84.1%)	170
Residence	Rural	50 (15.6%)	270 (84.4%)	320	0.632
Residence	Urban	20 (17.5%)	94 (82.5%)	114
Martial Status	Married	48 (16.9%)	236 (83.1%)	284	0.547
Martial Status	Currently Unmarried	22 (14.7%)	128 (85.3%)	150
Family type	Nuclear	49 (18.0%)	223 (82.0%)	272	0.166
Family type	Joint	21 (13.0%)	141 (87.0%)	162
Literacy	Literate	48 (16.3%)	246 (83.7%)	294	0.871
Literacy	Illiterate	22 (15.7%)	118 (84.3%)	140
Employment	Unemployed	12 (32.4%)	25 (67.6%)	37	0.005
Employment	Employed	58 (14.6%)	339 (85.4%)	397
Socioeconomic status*	I, II & II	18 (13.1%)	119 (86.9%)	137	0.250
Socioeconomic status*	IV &V	52 (17.5%)	245 (82.5%)	297
Economic dependency	Independent	46 (16.0%)	241 (84.0%)	287	0.936
Economic dependency	Dependent	24 (16.3%)	123 (83.7%)	147
Alcohol consumption	Yes	14 (29.2%)	34 (70.8%)	48	0.009
Alcohol consumption	No	56 (14.5%)	330 (85.5%)	386
Smoking	Yes	9 (20.0%)	36 (80.0%)	45	0.456
Smoking	No	61 (15.7%)	328 (84.3%)	389
Current WHO staging	I (Asymptomatic)	30 (12.0%)	219 (88.0%)	249	0.007
Current WHO staging	II, III & IV	40 (21.6%)	145 (78.4%)	185
Current CD4 cells count	200 or less	20 (32.3%)	42 (67.7%)	62	<0.001
Current CD4 cells count	> 200	50 (14.2%)	301 (85.8%)	351
Drug regimen	TLE & ZLE	43 (18.1%)	194 (81.9%)	237	0.211
Drug regimen	ZLN and others	27 (13.7%)	170 (86.3%)	197
Side effects	Yes	25 (30.9%)	56 (69.1%)	81	<0.001
Side effects	No	45 (12.7%)	308 (87.3%)	353
Time since diagnosis	< 5 years	55 (18.7%)	239 (81.3%)	294	0.034
Time since diagnosis	> 5 years	15 (10.7%)	125 (89.3%)	140
Time since treatment	< 5 years	56 (17.4%)	265 (82.6%)	321	0.209
Time since treatment	> 5 years	14 (12.4%)	99 (87.6%)	113
Social Support	Present	19 (18.4%)	84 (81.6%)	103	0.464
Social Support	Absent	51 (15.4%)	280 (84.6%)	331
Family support	Satisfied	52 (14.0%)	320 (86.0%)	372	0.003
Family support	Not satisfied	18 (29.0%)	44 (71.0%)	62
ART centre support	Satisfied	65 (16.2%)	336 (83.8%)	401	0.874
ART centre support	Not satisfied	5 (15.2%)	28 (84.8%)	33
HIV status discloser	Yes	66 (16.1%)	343 (83.9%)	409	0.986
HIV status discloser	No	4 (16.0%)	21 (84.0%)	25
Positive Family member	Yes	37 (15.3%)	205 (84.7%)	242	0.593
Positive Family member	No	33 (17.2%)	159 (82.8%)	192
Benefits from ART	Improved	55 (14.2%)	333 (85.8%)	388	0.001
Benefits from ART	Not improved	15 (32.6%)	31 (67.4%)	46
* Mod BG Prasad

Table 4: Multivariate analysis of factors associated with depression among HIV patients.
Variable		Adjusted OR	95% CI	p value
Age (in years)	35 or less	1.368	0.754 – 2.482	0.302
Age (in years)	> 35	Ref
Employment	Unemployed	2.005	0.846 – 4.753	0.114
Employment	Employed	Ref
Alcohol consumption	Yes	2.553	1.180- 5.526	0.017
Alcohol consumption	No	Ref
Current WHO staging	I	0.598	0.320 – 1.118	0.107
Current WHO staging	II, III & IV	Ref
Current CD4 count	200 or less	2.630	1.297- 5.330	0.007
Current CD4 count	> 200	Ref
Side effects	Yes	2.442	1.302-4.577	0.005
Side effects	No	Ref
Time since diagnosis	< 5 years	1.657	0.849-3.237	0.139
Time since diagnosis	> 5 years	Ref
Family support	Absent	2.683	1.334 – 5.394	0.006
Family support	Present	Ref
Perceived change in health status	Improved	0.412	0.190 – 0.896	0.025
Perceived change in health status	Not improved	Ref

Discussion

This study was done to determine the prevalence of depression among PLHA and its association with various variables. The depression was 16.1% (70/434), with 57/70 (81.4%) suffering from mild, 10 patients had moderate and 3 patients suffering from severe depression. Among the factors associated with depression, we found alcohol consumption, lower CD4 cell counts, side effects from ART, non-satisfaction with family support, and no improvement from ART were found to be significantly associated.

Regarding the prevalence of depression, our study finding of 16.1% reiterates the rates of previous studies from India and various parts of the world [7,13,19,20]. However, there have been studies showing higher rates of depression among PLHA. [14,21-25]. We observed a relatively lower prevalence, maybe since it was conducted on chronic cases of HIV, ruling out acute episodes of depression often seen in recently diagnosed with HIV. Further deduction and comparison of prevalence among various studies are difficult to examine due to methodological differences, differences in the study population, and the use of different instruments in diagnosing depression. Nevertheless, PHQ-9, which we used to estimate depression among PLHA, revealed good internal consistency (r= 0.87) and has been used previously in India and globally among PLWHA [10,11,16,19,24]. Therefore, PHQ-9 is a reliable tool not only for estimating depression but also for the classification of its severity. This prevalence of depression among PLHA is twice that of the general population [4], corresponding to the findings of earlier studies [15]. The higher depression prevalence among PLHA might be due to an amalgamation of the various factors since they may aid in coping with the situation [26]. Encouragingly, most patients diagnosed with depression were mildly depressed- 57/70 (81.9%), proving a good value for money in the periodic screening of HIV patients for depression and its early management. Data suggests that screening and early intervention for depression in chronic diseases improve quality of life [27], and some have advocated for the same as part of standard HIV care [12].

Regarding factors associated with depression, we found consumption of alcohol within 30 days to be significantly and independently associated with depression. Our findings mirror a recent study conducted in Vietnam [28], which discovered that alcohol use is an independent factor for depression in PLHA, despite a few studies failing to find the same [21]. HIV infection is a stressful condition; in order to cope, patients may land up into alcoholism and further into depression. We also found a negative association between depression and satisfaction with family support. The patients who were not satisfied with the family support were 2.7 times more depressed than those who were satisfied. Earlier studies have shown similar findings [21,29]. In a family-oriented society in India, the family plays a significant role in the dispersion of stress and sharing of responsibility, thus being the primary source of support for all the members [29]. Those PLHA who do not receive family support might become stressed by the present HIV management and might be worried about their future, leading to depression. However, depression was associated with family support but not with social support. In our study, few people (less than one-fourth) had a history of receiving social support, and even those who were attached to these social support groups were because of some incentives.

We also found that those who perceived improved health from ART were less likely to get depressed (AOR 0.412). Being on lifetime therapy, which could be ineffective to some, can lead to pessimism, despair, and depression. We also found that patients with lower CD4 cell counts (<200 cells ml) were 2.6 times more depressed than those with higher CD4 counts. Lower CD4 cell counts in HIV patients frequently indicate a compromised immune status due to elevated viral titers. This state has been linked to various opportunistic infections and cancers, resulting in a great deal of stress and discomfort, which may eventually manifest as depressive symptoms. Previous studies have shown a positive relationship between disease severity -in terms of CD4 cell count and WHO staging- to be significantly associated with depression [23,24]. However, in their study, Deshmukh et al. [14] failed to find any relationship between these two variables. There was no relation between the class of ART drugs and depression in our study population, endorsing the results of earlier research [24]. Instead, depression was 2.4 times more in those who reported side effects due to these drugs within 30 days. Side effects may make a life of HIV miserable who is already overburdened with many stresses. These side effects have a substantial public health impact and may result in drug discontinuation. In previous reports, we could not demonstrate correlations between depression and demographic variables [21,30]. Recent observational studies, however, show a link between depression and younger age [23,24], employment status [14,23,24], and who staging [22,29]. Remarkably all these factors were significant in univariate analysis but became insignificant after adjusting for confounding in multivariate analysis.

We had a few limitations in our study. To begin with, being a cross-sectional study conducted in a hospital setup limits its generalizability, though most PLHA in India are managed at these ART centres only. Second, due to the study design, we refrained from making any causal associations as the temporality could not be established. Finally, because we only interviewed the patients who reported to the ART centre, selection bias was possible.

Conclusion

The prevalence of depression among HIV/AIDS patients was found to be substantially greater than in the general population. Alcohol intake, lower CD4 cell counts, ART side effects, lack of family support, and denial of ART improvement were all significantly and independently linked with depression. Along with constant pressure to take ART for the rest of their lives, multiple conditions put PLHA in a stressful condition. Therefore, detecting depression as early as possible is vital for them since it can worsen the disease's prognosis. Consequently, regular screening and psychosocial interventions as part of standard HIV should be considered by the National AIDS Control Programme.

Statement of Ethics: The study was approved by the JN Medical College's Institutional Ethics and Research Advisory Committee – 14/FM/PG/30 dated 23.02.2015. All patients gave written informed consent. Individual rapport-building sessions were undertaken before the interview's commencement to explain the research's objective and its consequences while maintaining confidentiality. After the interview, all patients received appropriate health information, counseling, and referrals.

Conflict of Interest Statement: The authors have no conflicts of interest to declare.

Funding Sources: None

Data Availability Statement: The data supporting this study's findings are available on request from the corresponding author. The data are not publicly available due to privacy restrictions

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