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Prevalence and associated factors of depression among patients with HIV/AIDS in Hawassa, Ethiopia, cross-sectional study

Annals of General Psychiatry201817:45

https://doi.org/10.1186/s12991-018-0215-1

  • Received: 15 March 2018
  • Accepted: 21 October 2018
  • Published:

Abstract

Background

Globally, 350 million people are affected by depression and 800,000 people die due to suicide every year due to depression. People living with HIV/AIDS face different challenges, including HIV-related perceived stigma, lack of social support and also depression. This study aimed to assess prevalence and factors associated with depressive symptom among people living with HIV/AIDS attending Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia.

Methods

Hospital-based cross-sectional study was implemented in 2016. A total of 401 HIV-positive patients who had regular visit at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia were included in the study. Systematic random sampling technique was used to recruit study participants. Patient Health Questionnaire item nine (PHQ-9) was used to assess depressive symptoms. In addition to this, Oslo social support scale and HIV perceived stigma scale were used to assess social support and HIV-related perceived stigma, respectively.

Results

A total of 401 study participants were included in the study, giving a response rate of 96.2%. The mean age of the respondents was 38 years (SD ± 10.23). This study revealed that 48.6% of HIV-positive patients had depression. Patients who had poor social support [AOR = 2.53, (95% CI 1.70, 9.13)], HIV-related perceived stigma [AOR = 2.83, (95% CI 1.78, 4.48)] and CD4 cell count < 200 [AOR = 3.89, (95% CI 1.02, 14.83)] were more likely to have depression as compared to individuals who had good social support, no perceived HIV stigma and CD4 cell count > 200, respectively.

Conclusion

Having poor social support, HIV-related perceived stigma and low CD4 cell count (< 200) had statistically significant association with depressive symptom. Training of health workers in ART clinics and availing manuals on assessing mental health issues is useful to screen and treat depression among HIV patients.

Keywords

  • Depressive symptom
  • Perceived stigma
  • Social support
  • HIV
  • Ethiopia
  • Prevalence
  • Associated factors
  • Depression
  • Hawassa
  • South Ethiopia

Background

HIV/AIDS is one of a chronic disease which affects human immune systems and it increases vulnerability to infections and other immunological disorders [1]. Globally, different studies in 2013 revealed that an estimated 35 million people were living with HIV/AIDS, of which 24.7 million are living in Sub-Saharan Africa and 1.6 million people died related to HIV/AIDS [2]. In developing countries, 9.5 million people were receiving HIV treatment in 2012 [3].

According to the WHO 2015 report, 350 million people were affected by depression worldwide. Due to this problem, over 800,000 people die by suicide every year globally [4]. WHO estimated that the incidence of suicide related to depression will reach approximately 1.53 million people by the year 2020. Based on finding from general population study, the life-time risk of depression is one in five women and one in ten men in their lifetime [5].

Findings from different studies show that 121 million people living with HIV/ADIS are affected by depression globally [6]. Studies conducted in different countries on prevalence of depression among HIV patients showed 58.75% in Delhi (India) [7], 29.4% in Brazil [8], 54.4% in Italy [9], 37% in United States [10], 25.4% in South Africa [6, 11], 25.3% of women and 31.4% of men in Botswana [12], 47% in Uganda [13], 43.9% in Mekele, Ethiopia [14], 45.8% in Harar, Ethiopia [15] and 38.94% in Debrebirhan, Ethiopia [16].

Depressive symptom among HIV-positive clients is associated with low income, widowed, being female, non-adherence of ART, having frequent of schedule for clinical visit in a month, low educational status, being female, age category (40–49), and having stage III and Stage IV HIV-related symptom [16, 17].

Being mentally impaired has been linked with an impaired adherence to ART and poor treatment outcome, decrease in CD4 count and increase in viral load. In addition, depression has been associated with high-risk behaviors like engaging in unsafe sex [11, 15, 17].

Based on different study findings, the magnitude of depressive symptom among people living with HIV/AIDS is high. Though it has a great impact on their treatment outcome, it was not assessed at Hawassa University Comprehensive Specialized Hospital. Therefore, this study aims to assess the prevalence and factors of depressive symptom among people living with HIV attending Hawassa University Comprehensive Specialized Hospital, ART clinic, South Ethiopia.

Methods

Study setting and population

Hospital-based cross-sectional study design was implemented from April to May 2016 at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia. Among 1440 HIV patients who had regular follow-up at ART clinics, 417 study participants were recruited for the study; those unable to communicate because of their illness and those who need intensive care were excluded from the study. Study participants were included using systematic random sampling technique, K = 3. Sixteen patients were refused to participate in the study.

Data collection

Trained and experienced nurses had collected the data using pretested interviewer administered questionnaire. The data collection tool includes socio-demographic characteristics (age, education, occupation, marital status and others). Oslo 3-item social support scale has the sum score scale ranging from 3 to 14 with three broad categories: “poor support” 3–8, “moderate support” 9–11 and “strong support” 12–14 [18]. It was reliable in our study (Cronbach’s α = 0.88). HIV-related perceived stigma was collected by an 11-item HIV stigma scale. It consisted of four-point Likert scale (strongly disagree, disagree, agree, strongly agree) questions concerning perceived isolation, shame, guilt and disclosure of the HIV status. The item scores of the stigma questions were summed to construct a single stigma variable. Our study participants were classified as having or not having perceived stigma using the mean of the stigma variable as cutoff point [19, 20]. The instrument was adopted and translated to Amharic language and back to English and highly reliable in the study (Cronbach’s α = 0.92). The presence of depression was assessed by patient health questionnaires item nine (PHQ-9). It is a 9-item questionnaire, commonly used to screen for symptoms of depression in primary health care and in outpatients and validated in Ethiopia with sensitivity = 86% and specificity = 67%. The scales use a cutoff score for depression of greater than or equal to 5 [21].

Data processing and analyses

SPSS version 20 was used to analyze the data. The association of each independent variable with the outcome variable was seen by bivariate analysis. In order to identify potential confounders, binary logistic regression model was used. A p value of less than 0.05 was considered statistically significant and adjusted odds ratio with 95% CI was calculated to determine association.

Results

Socio-demographic characteristics of the study participants

A total of 401 study participants were included in the study, giving a response rate of 96.2%. The mean (± SD) age of the respondents was 38 years (± 10.228). Among the study participants, 149 (38.9%) were in age range between 35 and 44 years, 193 (50.4%) were orthodox religion followers, 178 (46.5%) were married, 138 (36%) were attended primary education, 96 (25.1%) were house wife, and 340 (88.8%) were living in urban. The median monthly income of the respondents was 875 Ethiopian birr (31.45 USD) (Table 1).
Table 1

Distribution of people living with HIV/AIDS at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia, 2016/2017

Characteristics

Category

Frequency

Percent (%)

Sex

Male

129

29

Female

272

71

Age

18–34

141

36.8

35–44

149

38.9

45–54

62

16.2

> 54

31

8.1

Residence

Urban

340

88.8

Rural

43

11.2

Religion

Protestant

160

41.8

Orthodox

193

50.4

Muslim

29

7.6

Educational level

Unable to write and read

68

17.8

Primary education (grade 1–8)

138

36

Secondary education (grade 9–12)

110

28.7

Tertiary education (college and above)

67

17.5

Ethnicity

Sidama

48

12.5

Oromo

88

23.0

Amhara

93

24.3

Wolaita

102

26.6

Gurage

32

8.4

Other

20

5.2

Marital status

Single

69

18.0

Married

178

46.5

Separated

19

5.0

Divorced

45

11.7

Widowed/widower

72

18.8

Occupation status

Merchant

76

19.8

Government employee

65

17.0

Privet employee

71

18.5

Day laborer

33

8.6

Student

17

4.4

House wife

96

25.1

Jobless

25

6.5

Monthly income

< 735ETB per month

199

52.0

735–1176ETBper month

49

12.8

> 1176ETB per month

135

35.2

Clinical and psychosocial characteristics of the study participants

Among respondents, the maximum CD4 cell count was 1622 with a mean of 541.08. 330 (86.2%) of the study participants had CD4 cell counts ranges between 200 and 1000. 357, (93.2%) of respondents were on ART, 162 (42.3%) were found in stage II HIV/AIDS, 259(67.6%) had poor social support, 168 (43.9%) had perceived stigma and 72 (18.8%) were current substance (khat, alcohol, cigarette) users (Table 2).
Table 2

Description of clinical and psychosocial factors among people living with HIV/AIDS at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia, 2016/2017

Variables

Category

Frequency

Percent  %

CD4 cell count

< 200

33

8.6

200–1000

330

86.2

≥ 1000

20

5.2

Started ART taking

Yes

357

93.2

No

26

6.8

Perceived stigma

Yes

168

43.9

No

215

56.1

Current substance

Yes

72

18.8

No

311

81.2

HIV/AIDS stages

Stage I

150

39.2

Stage II

162

42.3

Stage III

58

15.1

Stage IV

13

3.4

Social support

Poor social support

259

67.6

Moderate social support

110

28.7

Strong social support

14

3.7

Prevalence of depressive symptom among the study participants

Depressive symptom was found using PHQ-9 scale. Based on the cutoff point ≥ 11, 48.6% of the HIV clients had depression.

Factors associated with depressive Symptoms

Binary logistic regression analysis revealed that poor social support, CD4 count (< 200) and perceived HIV stigma were associated with depressive symptom (Table 3).
Table 3

Factors associated with depression among people living with HIV/AIDS at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia, 2016/2017

Characteristics

Depression

COR (95% CI)

AOR (95% CI)

Yes

No

Sex

 Female

140

132

1.49 (0.96, 2.34)

1.44 (0.82, 2.52)

 Male

46

65

1

1

Age

 18–34

74

67

1.34 (0.61, 2.92)

1.31 (0.51,3.38)

 35–44

62

87

0.86 (0.397, 1.885)

0.86 (0.34,2.14)

 45–54

36

26

1.68 (0.71, 4.01)

1.59 (0.61, 4.18)

 > 54

14

17

1

1

Educational level

 Unable to read and write

34

34

1.23 (0.63, 2.43)

 

 Primary education

74

64

1.43 (0.79, 2.26)

 

 Secondary education

48

62

0.96 (0.52, 1.76)

 

 Tertiary education

30

37

1

1

Marital status

 Married

88

90

1.52 (0.86, 2.67)

1.76 (0.89, 3.46)

 Separated

7

12

0.91 (0.32, 2.59)

0.83 (0.24,2.87)

 Divorced

22

23

1.48 (0.69, 3.17)

1.28 (0.52, 3.15)

 Widowed/widower

42

30

2.17 (1.11, 4.27)

1.78 (0.72,4.38)

 Single

27

42

1

1

Monthly income

 < 735 ETB

105

94

1.67 (1.07, 2.60)

1.60 (0.95, 2.68)

 735–1176

27

22

1.84 (0.95, 3.56)

1.40 (0.67,2.95)

 > 1176

54

81

1

1

Substance use

 Yes

37

35

1.13 (0.68,1.92)

 

 No

149

162

1

1

ART taking

 Yes

173

184

0.940 (0.42, 2.08)

 

 No

13

13

1

1

HIV/AIDS stages

 Stage II

74

88

0.94 (0.59, 1.46)

0.77 (0.46, 1.29)

 Stage III

31

27

1.27 (0.69, 2.35)

1.02 (0.49, 2.10)

 Stage IV

10

3

3.71 (0.98, 14.02)

2.79 (0.64, 12.09)

 Stage I

71

79

1

1

Perceived stigma

 Yes

108

60

3.16 (2.08, 4.82)

2.83 (1.78, 4.48)**

 No

78

137

1

1

Social support

 Poor

104

155

1.21 (0.39, 3.71)

2.53 (1.70, 9.13)**

 Moderate

77

33

4.20 (1.31,13.48)

7.09 (1.91, 26.29)*

 Strong

5

9

1

1

CD4

 < 200

23

10

2.30 (0.73, 7.25)

3.89 (1.02, 14.83)*

 200–1000

153

177

0.86 (0.35, 2.13)

1.27 (0.47, 3.47)

 ≥ 1000

10

10

1

1

Depression (Yes)-PHQ ≥ 11, * significant association (p-value < 0.05) ** significant association (p-value < 0.01)

Italic values represent references of the variable

Discussion

Institution-based cross-sectional study was conducted to assess the prevalence and factors associated with depression among patients HIV/AIDS at Hawassa University Comprehensive specialized hospital using PHQ9. The finding of this study (48.6%) was higher than studies in rural South Africa 42.4% [6, 11], in Malawi 18.9% [22], and in Ethiopia 43.9%, 45.8%, 38.94% in Mekele, Harar and Debreberihan, respectively [1416]. On the other side, the study finding was lower than studies done in Delhi (India) 58.75% [7], North Central Nigeria 56.7% [23], in Cameroon 63% [24] and in Ethiopia [25]. The difference might be related to study design, data collection tool, sample size and study participant’s variation.

HIV-related perceived stigma had significant association with depressive symptom. The finding is similar to the study done in Botswana [12], in Ethiopia [1416, 25]. Having HIV, which is one of the chronic life-long diseases and which is prone to high levels of stigma, they may find it easier to be alone to avoid stigma or discrimination, or they may not have the energy to be socially engaged [26].

Clients who had poor social support were 2.5 times more likely to have depressive symptom when compared to clients who had strong social support (AOR = 2.53, 95% CI 1.70, 9.13). The finding was similar to the study conducted in Delhi (India) [7], in Nigeria in 2008 [27], and in North Central Nigeria in 2013 [23]. This might be due to the fact that social isolation reduces social support, which can have a negative impact on mental and physical well-being [28].

Individuals who had < 200 CD4 cell count had significant association with depressive symptom. This was similar to the study conducted in Malawi [22], and Debrebirhan, Ethiopia [16]. This might be due to severe immune depression and HIV illness is underlining causes of depression [29].

Unlike other study, being female sex, being divorced and unmarried and those using substance had no statistically significant association with depression.

Conclusion

Depressive symptom was high (48.6%) among the current study population. Perceived HIV-related stigma, poor social support and CD4 count (< 200) had significant association with depressive symptom. Hence, depression is highly prevalent among HIV-positive patients, still underdiagnosed and undertreated but it needs further research. Therefore, Ministry of Health should give more emphasis to those clients with depressive symptoms. Further research on risk factors of depression should be conducted to strengthen and broaden the current findings.

Limitation of the study

We did not do detailed validation study for perceived HIV-related stigma scale and Oslo 3-item social support scale.

Declarations

Authors’ contributions

BD conceived the study and was involved in the study design, reviewed the article, analysis, report writing and drafted the manuscript. EG, MZ and SM were involved in the study design and analysis. All authors read and approved the final manuscript.

Acknowledgements

The authors appreciate the respective study institution for their help and the study participants for their cooperation in providing all necessary information.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

All relevant data are within the paper.

Consent for publication

Not applicable.

Ethical approval and consent to participate

Ethical clearance for this study was obtained from the Research and Ethics Review Committee of College of Medicine and Health Sciences, Hawassa University. Permission letter was obtained and submitted to Hawassa University Comprehensive Specialized Hospital. Study participants were informed about their rights to interrupt the interview at any time and written informed consent was obtained from each study participants. Confidentiality was maintained at all levels of the study. HIV-positive subjects who were found to have moderate to severe depressive symptoms had poor social support and perceived HIV-related stigma was referred to psychiatry clinics for further investigations.

Funding

No funding source.

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Authors’ Affiliations

(1)
Faculty of Health Sciences, College of Medicine and Health Sciences, Hawassa University, P. O. Box 1560, Hawassa, Ethiopia
(2)
Hawassa University Comprehensive Specialized Hospital, Hawassa University, Hawassa, Ethiopia

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Copyright

© The Author(s) 2018

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