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Erschienen in: Annals of General Psychiatry 1/2018

Open Access 01.12.2018 | Primary research

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

verfasst von: Bereket Duko, Epherem Geja, Mahlet Zewude, Semere Mekonen

Erschienen in: Annals of General Psychiatry | Ausgabe 1/2018

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.

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.

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.
Not applicable.
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.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.
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Metadaten
Titel
Prevalence and associated factors of depression among patients with HIV/AIDS in Hawassa, Ethiopia, cross-sectional study
verfasst von
Bereket Duko
Epherem Geja
Mahlet Zewude
Semere Mekonen
Publikationsdatum
01.12.2018
Verlag
BioMed Central
Erschienen in
Annals of General Psychiatry / Ausgabe 1/2018
Elektronische ISSN: 1744-859X
DOI
https://doi.org/10.1186/s12991-018-0215-1

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