Background
Currently, global statistics shows that an estimated 35 million people were living with HIV/AIDS in 2013, of which 24.7 million are living in Sub-Saharan Africa and 1.6 million people died related to AIDS [
1]. In 2012 estimation, 9.5 million people in developing countries were receiving HIV treatment [
2]. National prevalence in Ethiopia was 1.3 % and 137 people receive ART in all ages [
1].
There is a significant psychological impact imposed among HIV/AIDS patients. People with HIV often suffer from depression and anxiety as they adjust to the impact of the diagnosis of being infected and face the difficulties like shortened life expectancy, complicated therapeutic regimens, stigmatization, and loss of social and family support. HIV infection can also be associated with high risk of suicide [
3‐
5].
Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration [
6]. Approximately, 350 million people are currently living with depression [
6]. It is the fourth leading cause of disability worldwide and it will become the second leading cause of disability by 2020 [
7]. Its life time prevalence was estimated to be approximately 3 to 17 % [
8].
In Ethiopia the survey done in nine regions reported, the prevalence of depressive episode was 9.1 %, which was associated with age, divorced, widowed, and alcohol drinking status and women are two times affected as compared to men with depression [
9,
10].
Anxiety is a vague, subjective, non-specific feeling of uneasiness, apprehension, tension, (excessive nervousness) fears, and a sense of impending doom, irrational avoidance of objects or situations and anxiety attack [
6]. It was associated with gender, age, and chronic diseases [
11]. Women were affected nearly two times as compared to men by anxiety [
8].
Depression and anxiety disorders are common in HIV infected individuals than general population [
5]. Depression always coming with the symptom of anxiety and they have cause and effect relationship with chronic diseases [
6,
12]. Depressive disorder was three times more common among HIV infected individuals and its lifetime prevalence estimate was 22–45 % [
12,
13]. Depression among HIV patients leads to low adherence to medical treatment, an increase health cost disability and mortality [
14]. HIV/AIDS infected individuals are more prone for depression and anxiety disorders which, in turn, increase stigmatization, decrease quality of life, increase mortality, reduce adherence and impair their immune function [
15].
Risk factors associated with depression and anxiety among HIV infected patients were low income, unemployment, alcohol use, poor medication adherence, HIV/AIDS stage, perceived stigma and social support [
16‐
18]. Even though the co-morbidity of depression and anxiety among HIV/AIDS patients is a major cause of morbidity and mortality in developing countries like Ethiopia, little attention is given for their diagnosis. Therefore, the finding of this study will link the gap in making necessary solution by assessing the prevalence and factors associated with depression and anxiety among people living with HIV/AIDS patients in the study area.
Discussion
This study revealed that the prevalence of co-morbid depression and anxiety was 24.5 %. Specifically, 41.2 % had depression and 32.4 % had anxiety. Perceived HIV stigma, poor social support, HIV stage III and poor medication adherence were significantly associated with depression. Being female, being divorced, having co morbid TB illness and perceived HIV stigma were also significantly associated with anxiety.
The prevalence of depression in the present study was 41.2 %. Regarding to prevalence, the current study result is line with other studies carried out in two areas of Ethiopia, USA and Denmark, in which the prevalence estimates were reported to be 38.94, 43.9, 44, 38 % respectively [
20‐
23].
On the other hand, the present study findings was lower than the studies done in Albanian, China, India and Cameron in which the prevalence's were reported to be 58.75, 73.1, 66.3 and 63 % respectively [
18,
24‐
26]. The variation of the prevalence might be due to different sample size used and different instruments used to assess depression. Only 100 participants were included in Cameron and PHQ-9 with the cutoff point greater than or equal to 9 [
26], 320 participants in china and using CES-D with the cutoff points greater than or equal to16 [
18], in India 160participants and using CES-D [
24] and about 79 participants in Albania [
25].
The result of the study was higher than the studies conducted in south Africa, Ghana, Nigeria, USA, Brazil, India, in which the prevalence were reported to be 25.4, 5.4, 23.1, 32, 14.15 and 35.5 % respectively [
16‐
22,
24,
26‐
42]. The use different measurement tools used to assess depression and sample size difference that were in Ghana using DASS greater than or equal to 10 and 107 participants [
37], in Nigeria 130 participants and using clinical interview DSM-IV [
19] and in India using BDI-II and 152 participants [
27].
Regarding to associated factors, having HIV stage III was associated with depression, which was 2.8 times more likely to develop depression as compared to that of HIV stage one patients. This was supported with the study done at Debirebirhan hospital in Ethiopia [
21].
Perceived HIV stigma was strongly associated with depression in this study, which was 3.6 times having depression as compared with non-stigmatized HIV patients, which was supported with the studies done in Ethiopia at Debirbirahan hospital and USA [
21,
35]. Stigma increase levels of fatigue and decrease attention or felling of worthlessness [
35].
Having poor social support was 2 times more likely to develop depression as compared with those who had good social support that was comparable with the studies done in Ghana, India and two areas in china [
17,
18,
43,
19]. HIV/AIDS patients preferred to avoid seeking help from others and avoid opening up about their health due to social stigma towards themselves, which increases their isolation and loneness [
18,
19].
Having poor medication adherence was 1.6 times more likely to develop depression compared with those who had good medication adherence. This was supported by the study done in USA that was perceived HIV stigma and depression were the two interconnected factors that were aggravated poor medication adherence [
35].
The prevalence of anxiety in this study was 32.4 %, which was similar to the studies done in USA, South Africa, Canada and western Europe together, in which the prevalence were reported to be 33, 30.6, 33.4, 33.3 % respectively [
16,
27,
37,
44].
On the other hand, the current study findings was lower than the studies done in Albanian and two areas of china, in which the prevalence were reported to be 82.3, 45.6, 49 % respectively [
18,
25,
43]. The possible reason might be the difference of tools used to assess anxiety and different sample size used. Which was 320 and 800 participants in two areas of China respectively and the same measurement tool used to assess anxiety, which was Zung self-rating anxiety scale with the cut of points greater than or equal to 50 and greater than or equal to 40 respectively.
Additionally, our findings was higher than the studies done in Ethiopia at Debrebirhan hospital, Ghana, Thailand, Brazil and Asia, in which the prevalence were reported to be 22.2, 7.2, 16.3, 12.6, 20.3 % respectively [
30,
37,
45,
46,
19]. The above prevalence variations might be due to the difference in sample size used and different measurement tools used to assess anxiety. In Ethiopia and Brazil studies done to assessed the prevalence of anxiety by using BAI greater than or equal to 22 and 436 and 346 of their study participants respectively. In Thailand to assessed anxiety symptoms by using HADS with the cut of points greater than or equal to 11 and 251 participants and in Ghana used to assess anxiety by using DASS with the cut of points greater than or equal to 8 and 107 participants.
Being female had 3 times to develop anxiety as compared to male that was similar to the studies done in Ethiopia and Ghana [
30,
35]. Being female is the exposure of acute life experience, low social interaction and had less social support from friends and families might be increased risk of anxiety [
30,
35].
The present study revealed that being divorced was significantly associated with anxiety. In this study, being divorce was 2.5 times risk of developing anxiety as compared to married. This study was supported study done at Debretabor hospital in Ethiopia that was one of the outcome of divorce was affects the whole family structure and which leads to low self-confidence and financial problem [
30].
Having TB/HIV co-infection had 2.7 times risk of developing anxiety as compared with those who had no co morbid illness. The possible reason might be drug-drug interaction, increase adverse effects and co-infection leads to high level of stigma and discrimination by verbal, gossip and name calling may lead to high rate of anxiety.
HIV perceived stigma had 4 times risk of developing anxiety as compared with those who had non-stigmatized HIV patients. This outcome was consistent by the studies done in Ethiopia and South Africa that were stigma was associated with anxiety [
27,
30].
Acknowledgements
The authors acknowledge Amanuel Mental Specialized Hospital, Ethiopia for funding the study. The authors appreciate the respective study institutions and the study participants for their cooperation in providing the necessary information.