Depression Among HIV/AIDS Patients on Highly Active Antiretroviral Therapy in the Southwest Regional Hospitals of Cameroon: A Cross-Sectional Study

HIV/AIDS is a major cause of disability and death, particularly in low- and middle-income nations [1]. The first cases were reported in 1981 and from the beginning of the pandemic more than 3 decades ago to the end of 2015, about 35 million (29.6–40.8 million) people have died of HIV/AIDS-related illnesses [2] with Sub-Saharan Africa being the most affected, accounting for 74% of AIDS-related deaths worldwide in 2013 [3]. Nearly 30 years after its discovery, HIV infection remains the number one cause of disease-related mortality in Sub-Saharan Africa [4]. Globally, 36.7 million (34.0–39.8 million) people were living with HIV(PLWH) at the end of 2015 with approximately 70% residing in Sub-Saharan Africa [5], an area with only approximately 12% of the world’s population. Sub-Saharan Africa also accounted for 410,000 cases of new HIV infection in 2015 [6]. Recent estimates set the prevalence of HIV/AIDS in Cameroon to be 4.46% in adults aged 15–49 years as of 2015 [7].

Mental health and HIV/AIDS are closely interlinked. Mental health problems are associated with an increased risk of HIV/AIDS infection and interfere with the treatment; conversely some mental disorders occur as a direct result of HIV infection [1]. Depression contributes significantly to disease morbidity and affects people in all communities across the globe. Depression nowadays is estimated to affect 350 million people [8]. It is well known that major depressive disorder (MDD) is the most common prevalent neuropsychiatric symptom in HIV-1 patients [9]. Depression and HIV/AIDS are forecasted to be the world’s two leading causes of disability by 2030 [10]. Research has shown those individuals who are infected with HIV are more likely to develop depression than the general population. Depression affects an individual’s ability to comply with HIV/AIDS treatment, as well as quality of life and lifespan [11]. Depression may seem like an inevitable reaction to being diagnosed with HIV/AIDS; however it is a separate illness that can and should be treated, even when a person is on antiretrovirals [12]. Depression is a distressing and impairing condition that has detrimental effects on many of the self-care behaviours necessary for optimal management of HIV [13]. For instance, patients with depression tend to initiate ART at higher HIV-1 RNA levels and at lower CD4 cell counts compared to their non-depressed counterparts [14]. In addition, depression has been closely connected to poor adherence to ART once initiated [15].

Data on the prevalence of depression in HIV-infected patients are conflicting. A study carried out in South Africa gave the prevalence of depression in HIV patients as 42.4% [16]. Similarly a systematic review and meta-analysis carried out in 2014 from studies of low-, middle- and high-income countries on 42,366 HIV patients showed a prevalence of depression ranging from 12.8% to 78% (there was no significant difference in the rate of depressive symptoms in HIV patients across low-, middle- and high-income countries) and found that the likelihood of achieving good adherence was 42% lower in patient with depressive symptoms compared to those who were not [11]. However, a lower prevalence of major depressive disorder (8.1%) was reported in a study carried out in HIV/AIDS patients in a semi-urban district in Uganda [17]. This difference in prevalences can be due to a number of factors such as differences in study methodology (use of patient self-reports versus structured diagnostic instruments or differences in study populations, semi-urban versus urban). A study carried out in Yaoundé, Cameroon, on newly diagnosed HIV-infected patients revealed that 63% of the study population had depressive symptoms [18]. Also, research carried out among HIV-infected patients on ART in a semi-urban centre in Cameroon reported that one in five participants met the lifetime criteria for major depression disorders [19].

Thus, this research aimed at providing data on the prevalence and determinants of depression and its association with adherence to ART among HIV/AIDS patients on HAART in the Southwest Regional Hospitals of Cameroon in view of ameliorating mental health interventions for patients living with HIV/AIDS in the Cameroon, as well as Africa as a whole, by establishing standard guidelines.

We carried out a cross-sectional study on HIV/AIDS patients receiving antiretroviral therapy at the SW Regional Hospitals of an urban area in Cameroon. Our main objective was to determine the prevalence of depressive symptoms amongst HIV/AIDS patients on HAART, its determinants and its influence on adherence amongst patients accessing care in the treatment centres of the BRH and LRH. We recruited 300 participants of whom 73.3% were females. The mean duration on HAART was 47.6 ± 36.8 months with a minimum of 6 months.

The prevalence of depressive symptoms was 26.7% which was in accordance with that observed in the general population (the lower PHQ9 threshold was used, i.e. PHQ 9 score ≥5). Prior studies have shown prevalence of depression among HIV-infected patients of 7% to 63% [18, 19]. Such variations may be explained by the different instruments used to diagnose depression and by other methodological differences, such as the cut-off points used and differences in the study population. This high prevalence of depressive symptoms in our study population could be caused by psychological distress from chronic stress due to unemployment and the burden of care for the disease. Our result is similar to what was reported by a systematic review on depression assessment among persons with HIV in Sub-Saharan Africa by Tsai et al. in 2014, who found a 29.5% prevalence of probable depression [24]. These similarities could exist because both studies had similar study populations.

Our prevalence was higher than what was obtained in other studies: Tung et al. (19%) and Olisah in Nigeria (21.3%) and Joon in Korea (21%) [25‐27]. These differences could be due to the differences in the instruments used to diagnose depression, sample sizes and differences in the study population. The study carried out by Tung et al. had a smaller sample size and the HADS was used to screen for depression [25]. The use of PHQ-9 with a low cut-off (≥5) in terms of severity of depression will discover an extra percentage of individuals with depressive symptoms as opposed to the HADS screening tool with a cut-off of HADS-D ≥8 [23]. Olisah et al. studied adherence to highly active antiretroviral therapy in depressed patients with HIV/AIDS attending a Nigerian university teaching hospital clinic. The Centre for Epidemiological Studies Depression Scale (CES-D) was used to screen for depressive symptoms [26]. Joon et al. used the Beck Depression Inventory and had a smaller sample size [27].

However, the prevalence in our study was lower than what was reported in other studies: L'akoa in Cameroon (63%), Shittu in Nigeria (56.7%), Nakimuli et al. in a systematic review in SSA (31.2%) and Kitshoff in South Africa (62%) [18, 28‐30]. These differences could be due to differences in the tools used, sample size and the study population. The study by L'akoa et al. was on newly diagnosed HIV patients [18]. Shittu et al. in their study included both HIV patients on HAART and HAART-naïve patients [28]. Nakimuli et al. had a larger sample size from a group of studies over a 5-year period as well as differences in study design (systematic review vs. cross-sectional study) [31]. Kitshoff et al. also used the CES-D to screen for depressive symptoms [30].

This study showed that those who were unmarried had a higher prevalence of depressive symptoms. Unmarried people, especially the divorced and widowed, are much more likely to experience negative social determinants than those who are married because they carry the double stress of raising their children by themselves and work. This was similar to findings by Bhatia et al. [32]. In the study by Shittu et al., depressive symptoms were similar between married and unmarried patients [28].

In addition, unemployment was associated with depressive symptoms. This may be because economic instability leads to stress, frustration, dysfunctional family life and feelings of worthlessness. Joon in Korea [27] and Kitshoff in South Africa [30] also reported similar findings.

Also, those who did not have a living companion had a higher prevalence of depressive symptoms. This is in conformity with the literature, which says those who live alone are predisposed to developing depression [33]. This might be because loneliness predisposes them to feeling worthless and having poor appetites and concentration problems since they have no one to talk to and confide in. Tung in Malaysia did not find any significant association between having a living companion and depressive symptoms [25].

Our study showed that participants aged ≤40 years had a higher prevalence of depressive symptoms. This is in line with the literature showing that most people experience depression between the ages of 20 and 40 [33]. This is the age at which most people settle down in life. The stigma associated with getting a job or psychological disturbance of not having a lifetime partner due to their HIV status might account for the increased depression rate. Other studies found no significant association between age and depressive symptoms [28].

Having a low CD4 count was associated with depressive symptoms. This might be due to the patients feeling discouraged and having loss of interest despite taking medication and still having a low CD 4 count level. L'akoa et al. reported similar findings from a study in Yaoundé [18].

The prevalence of depressive symptoms was higher in participants with a formal education, indicating that the level of education plays an important role in the prevalence of depression in patients. This might because those with a higher level of education have a better understanding of their illness and its symptoms. This is similar to findings in Canada [34] where respondents whose educational levels were less than secondary education had the lowest rate of depression and the highest prevalence rate of depression was seen among those with tertiary education. Our findings however contrast with findings by Shittu in Nigeria [35] and Kitshoff in South Africa [30].

Our study did not show a significant relationship between most clinical variables (duration from diagnosis of HIV infection, duration on HAART, type of HAART regimen) and depression. This is in line with findings in other studies: Joon et al. [27] and Tung et al. [25]. This indicates that these variables have no effect on the development of depression.

The non-adherence rate of all participants was 47.3%; 75.0% of participants with depression were non-adherent to HAART compared to 37.3% of those without depression. The expression of depressive symptoms such as loss of interest, hopelessness, lack of energy and poor concentration seen in depressive disorders is likely to have contributed to non-adherence to HAART in the participants with depression. This is similar to the study by Olisah et al. on adherence to highly active antiretroviral therapy in depressed patients with HIV/AIDS attending a Nigerian university teaching hospital clinic where 63.6% of participants with depressive disorder had poor adherence to HAART [26]. These similarities could be due to the similarities in the sample sizes used. This prevalence is higher than that reported by Afiong in Nigeria (40.1%) [36] and Samwel in Kenya (18%) [4].

The prevalence of depressive symptoms is high (26.7%) in HIV patients and depressive symptoms are associated with non-adherence to HAART. This implies that depressed HIV/AIDS patients tend not to follow up their treatment thereby increasing the possibility of complications and poor prognosis. Unemployment, being unmarried, age ≤40 years, living alone and CD4 counts ≤200 cells/µl were found to be factors associated with occurrence of depressive symptoms in HIV patients, with unemployment, age ≤40 years and CD4 counts ≤200 cells/µl being independent factors. Many more female than male HIV patients tend to have depressive symptoms.

Thus, guidelines should be established for routine assessment (screening) of mental health, especially depressive symptoms of HIV patients, to improve the compliance with HAART and prognosis of the disease.