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

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.


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].

Annals of General Psychiatry
Depressive symptom among HIV-positive clients is associated with low income, widowed, being female, nonadherence 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 highrisk 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.

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.

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).

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).

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 [14][15][16]. 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 [14][15][16]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.