Depression and Engagement in Care Among Newly Diagnosed HIV-Infected Adults in Johannesburg, South Africa

Longitudinal Analysis of the Relationship Between Internalized HIV Stigma, Perceived Social Support, Resilience, and Depressive Symptoms Among People Living with HIV in China: A Four-Wave Model

Depression is one of the most common mental health problems among people living with HIV (PLWH). However, the longitudinal psychological mechanism underlying the link of internalized HIV stigma and depressive symptoms remains a research gap. This study attempted to articulate how and to what extent perceived social support and resilience mediate the longitudinal associations between internalized HIV stigma and depressive symptoms. A sample consisting of 1,098 Chinese PLWH (Mage = 38.63, SD = 9.20; 63.9% male) with a six-month interval and four waves of follow-up was used in the current study. Participants were asked to complete self-report questionnaires. The associations among main study variables were examined via a complete longitudinal mediation approach. Results indicated that the linkage between internalized HIV stigma at T1 and depressive symptoms at T4 was serially mediated by perceived social support at T2 and resilience at T3, and perceived social support at T2 and depressive symptoms at T3 serially mediated the relationship between resilience at T1 and internalized HIV stigma at T4. Depressive symptoms at a previous time point consistently predicted the levels of internalized HIV stigma at subsequent time points. The study highlights the complex interplay between internalized HIV stigma, mental health problems, and protective factors in a longitudinal context. The findings suggest the need to incorporate interventions aimed at enhancing social support and resilience in mental health programs for PLWH, as these factors may interrupt the pathway from internalized HIV stigma to depressive symptoms and potentially improve the overall psychological well-being of this population.

Depression and HIV Care-seeking Behaviors in a Population-based Sample in North West Province, South Africa

Depression is associated with key HIV-related prevention and treatment behaviors in sub-Saharan Africa. We aimed to identify the association of depressive symptoms with HIV testing, linkage to care, and ART adherence among a representative sample of 18-49 year-olds in a high prevalence, rural area of South Africa. Utilizing logistic regression models (N = 1044), depressive symptoms were inversely associated with reported ever HIV testing (AOR 0.92, 95% CI 0.85-0.99; p = 0.04) and ART adherence (AOR 0.82, 95% CI: 0.73-0.91; p < 0.01) among women. For men, depressive symptoms were positively associated with linkage to care (AOR: 1.21, 95% CI: 1.09-1.34; p < 0.01). Depression may adversely impact ART adherence for HIV-positive women and reduce the likelihood of HIV testing for women not aware of their HIV status which, in settings with high HIV prevalence, carries severe consequences. For HIV-positive men, findings suggest that depression may encourage help-seeking behavior, thereby impacting their health system interactions. These findings underscore the need for health-care settings to factor mental health, such as depression, into their programs to address health-related outcomes, particularly for women.

Risk of Depression in People With Human Immunodeficiency Virus: A Nationwide Population-based Matched Cohort Study

BACKGROUND

Human immunodeficiency virus (HIV) infection is associated with depression. However, previous studies have not addressed familial factors.

METHODS

Nationwide, population-based, matched cohort study of people with HIV (PWH) in Denmark between 1995 and 2021 who were matched on sex and date of birth with a comparison cohort randomly selected from the Danish population. Family-related factors were examined by inclusion of siblings of those in the cohorts. We calculated hazard ratios (HRs) for depression, receipt of antidepressants, electroconvulsive therapy (ECT), and suicide, as well as the yearly proportions of study cohorts with psychiatric hospital contact due to depression and receipt of antidepressants from 10 years before to 10 years after study inclusion.

RESULTS

We included 5943 PWH and 59 430 comparison cohort members. Median age was 38 years, and 25% were women. We observed an increased risk of depression, receipt of antidepressants, ECT, and suicide among PWH in the 2 first years of observation (HR, 3.3; 95% confidence interval [CI]: 2.5-4.4), HR, 3.0 (95% CI: 2.7-3.4), HR, 2.8 (95% CI: .9-8.6), and HR, 10.7 (95% CI: 5.2-22.2), thereafter the risk subsided but remained increased. The proportions of PWH with psychiatric hospital contact due to depression and receipt of antidepressants were increased prior to and especially after HIV diagnosis. Risk of all outcomes was substantially lower among siblings of PWH than among PWH (HR for receipt of antidepressants, 1.1; 95% CI: 1.0-1.2).

CONCLUSIONS

PWH have an increased risk of depression. Family-related factors are unlikely to explain this risk.

Correlated depressive symptoms within seroconcordant, expectant partners living with HIV in Zambézia Province, Mozambique: a cross-sectional study

Approximately 15% of people with HIV in sub-Saharan Africa have comorbid depression, which impacts treatment outcomes. We describe predictors of baseline depressive symptoms in 1079 female and 1079 male participants in a cluster-randomized trial in Zambézia Province, Mozambique from November 2017 to December 2020. We modeled each partners' depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) using proportional odds models adjusted for enrollment date, age, body mass index [BMI], partner's PHQ-9 score, district, relationship status, education, occupation, WHO HIV clinical stage, and antiretroviral therapy use history. A post hoc analysis assessed covariate-adjusted rank correlation between partner depressive symptoms. Females were younger than males (median 23 vs. 28 years) and more likely to report no education (20.7% vs. 7.9%). Approximately 10% screened positive for depression (PHQ-9 score ≥ 10). Partner depressive symptoms were predictive of higher participant PHQ-9 scores. A male partner PHQ-9 score of 10 (versus 5) increased the odds that the female partner would have a higher PHQ-9 score (adjusted odds ratio: 7.25, 95% Confidence Interval [CI]: 5.43-9.67). Partner PHQ-9 scores were highly correlated after covariate adjustment (Spearman's rho 0.65, 95% CI 0.57-0.72). Interventions aimed to reduce depressive symptoms and improve HIV-related outcomes during pregnancy should address both partners' depressive symptoms.

Mechanisms underlying HIV-associated cognitive impairment and emerging therapies for its management

People living with HIV are affected by the chronic consequences of neurocognitive impairment (NCI) despite antiretroviral therapies that suppress viral replication, improve health and extend life. Furthermore, viral suppression does not eliminate the virus, and remaining infected cells may continue to produce viral proteins that trigger neurodegeneration. Comorbidities such as diabetes mellitus are likely to contribute substantially to CNS injury in people living with HIV, and some components of antiretroviral therapy exert undesirable side effects on the nervous system. No treatment for HIV-associated NCI has been approved by the European Medicines Agency or the US Food and Drug Administration. Historically, roadblocks to developing effective treatments have included a limited understanding of the pathophysiology of HIV-associated NCI and heterogeneity in its clinical manifestations. This heterogeneity might reflect multiple underlying causes that differ among individuals, rather than a single unifying neuropathogenesis. Despite these complexities, accelerating discoveries in HIV neuropathogenesis are yielding potentially druggable targets, including excessive immune activation, metabolic alterations culminating in mitochondrial dysfunction, dysregulation of metal ion homeostasis and lysosomal function, and microbiome alterations. In addition to drug treatments, we also highlight the importance of non-pharmacological interventions. By revisiting mechanisms implicated in NCI and potential interventions addressing these mechanisms, we hope to supply reasons for optimism in people living with HIV affected by NCI and their care providers.

HIV viral load suppression among people with mental disorders at two urban HIV clinics in Uganda: a parallel convergent mixed methods study using the social ecological model

BACKGROUND

Uganda adopted and implemented the Universal Test and Treat (UTT) guidelines in 2017, which require HIV-infected persons to be initiated on antiretroviral therapy (ART) at any CD4 + cell count, and to be routinely monitored for viral load to assess response to ART. However, there is paucity of data on viral load suppression (VLS) among people living with HIV (PLHIV) with mental disorders. We conducted a parallel convergent mixed methods study to determine HIV VLS among people with a mental disorder and explored the socio-cultural determinants of VLS at Butabika hospital and Mulago (ISS) HIV Clinics in Uganda.

METHODS

We conducted a retrospective medical records review; seven key informant interviews (KII) among purposively selected healthcare providers and 12 in-depth interviews (IDI) among clinically stable PLHIV with a mental disorder. Data was collected on demographics, mental disorder, ART, viral load status, social support, stigma, and disclosure of HIV status. Quantitative data was analysed using descriptive statistics and modified Poisson regression, while Inductive thematic analysis was used for the qualitative data.

RESULTS

Of the 240 PLHIV with a mental disorder who were enrolled, 161 (67.1%) were female with mean age 38.9 (± 11.2) years. Overall, 88.8% (95% Cl: 84.0 - 92.2%) achieved VLS. Age (aPR = 1.00, 95%Cl = 1.00-1.00), male gender (aPR = 0.90, 95%Cl = 0.82-0.98), divorced (aPR = 0.88, 95%Cl = 0.82-0.94), widowed (aPR = 0.84, 95%Cl = 0.83-0.86), baseline CD4 count < 200 (aPR = 0.89, 95%Cl = 0.85-0.94), psychotic mental disorders (aPR = 1.11; 95%CI = 1.08-1.13) and fair (85-94%) ART adherence level (aPR = 0.69, 95%Cl = 0.55-0.87) and TDF/3TC/DTG (aPR = 0.92; 95%CI = 0.91-0.94) were associated with HIV VLS. Social support from family members, knowledge of impact of negative thoughts on VLS, fear of breaking up with partners and compassionate healthcare providers positively influenced VLS. Stigma and discrimination from the community, self-perceived stigma hindering social relations, socio-economic challenges and psychiatric drug stock-outs negatively affected VLS.

CONCLUSION AND RECOMMENDATIONS

HIV VLS among PLHIV with mental disorders at institutions that provide integrated HIV and mental health care is still below the UNAIDS 95% target. Health promotion messaging focusing on benefits of VLS and countering stigma to create a safe environment; and active involvement of family members in care could improve HIV treatment outcomes for PLHIV with mental disorders.

Prevalence and trends of advanced HIV disease among antiretroviral therapy-naïve and antiretroviral therapy-experienced patients in South Africa between 2010-2021: a systematic review and meta-analysis

BACKGROUND

Despite the significant progress made in South Africa in getting millions of individuals living with HIV into care, many patients still present or re-enter care with Advanced HIV Disease (AHD). We aimed to estimate the prevalence of AHD among ART-naive and ART-experienced patients in South Africa using studies published between January 2010 and May 2022.

METHODS

We searched for relevant data on PubMed, CINAHL, Scopus and other sources, with a geographical filters limited to South Africa, up to May 31, 2022. Two reviewers conducted all screening, eligibility assessment, data extraction, and critical appraisal. We synthesized the data using the inverse-variance heterogeneity model and Freeman-Tukey transformation. We assessed heterogeneity using the I2 statistic and publication bias using the Egger and Begg's test.

RESULTS

We identified 2,496 records, of which 53 met the eligibility criteria, involving 11,545,460 individuals. The pooled prevalence of AHD among ART-naive and ART-experienced patients was 43.45% (95% CI 40.1-46.8%, n = 53 studies) and 58.6% (95% CI 55.7 to 61.5%, n = 2) respectively. The time trend analysis showed a decline of 2% in the prevalence of AHD among ART-naive patients per year. However, given the high heterogeneity between studies, the pooled prevalence should be interpreted with caution.

CONCLUSION

Despite HIV's evolution to a chronic disease, our findings show that the burden of AHD remains high among both ART-naive and ART-experienced patients in South Africa. This emphasizes the importance of regular measurement of CD4 cell count as an essential component of HIV care. In addition, providing innovative adherence support and interventions to retain ART patients in effective care is a crucial priority for those on ART.

Increased prevalence of depression and anxiety among adults initiating antiretroviral therapy during the COVID-19 pandemic in Shinyanga region, Tanzania

BACKGROUND

Concerns about the interconnected relationship between HIV and mental health were heightened during the COVID-19 pandemic. This study assessed whether there were temporal changes in the mental health status of people living with HIV presenting for care in Shinyanga region, Tanzania. Specifically, we compared the prevalence of depression and anxiety before and during COVID-19, with the goal of describing the changing needs, if any, to person-centered HIV services.

METHODS

We analyzed baseline data from two randomized controlled trials of adults initiating ART in Shinyanga region, Tanzania between April-December 2018 (pre-COVID-19 period, n = 530) and May 2021-March 2022 (COVID-19 period, n = 542), respectively. We compared three mental health indicators that were similarly measured in both surveys: loss of interest in things, hopelessness about the future, and uncontrolled worrying. We also examined depression and anxiety which were measured using the Hopkins Symptom Checklist-25 in the pre-COVID-19 period and the Patient Health Questionnaire-4 in the COVID-19 period, respectively, and classified as binary indicators per each scale's threshold. We estimated prevalence differences (PD) in adverse mental health status before and during the COVID-19 pandemic, using stabilized inverse probability of treatment weighting to adjust for underlying differences in the two study populations.

RESULTS

We found significant temporal increases in the prevalence of feeling 'a lot' and 'extreme' loss of interest in things ['a lot' PD: 38, CI 34,41; 'extreme' PD: 9, CI 8,12)], hopelessness about the future [' a lot' PD: 46, CI 43,49; 'extreme' PD: 4, CI 3,6], and uncontrolled worrying [' a lot' PD: 34, CI 31,37; 'extreme' PD: 2, CI 0,4] during the COVID-19 pandemic. We also found substantially higher prevalence of depression [PD: 38, CI 34,42] and anxiety [PD: 41, CI 37,45].

CONCLUSIONS

After applying a quasi-experimental weighting approach, the prevalence of depression and anxiety symptoms among those starting ART during COVID-19 was much higher than before the pandemic. Although depression and anxiety were measured using different, validated scales, the concurrent increases in similarly measured mental health indicators lends confidence to these findings and warrants further research to assess the possible influence of COVID-19 on mental health among adults living with HIV. Trial Registration NCT03351556, registered November 24, 2017; NCT04201353, registered December 17, 2019.

HIV viral load suppression among people with mental disorders at two urban HIV Clinics in Uganda: a parallel convergent mixed methods study using the Social Ecological Model

Background Uganda adopted and implemented the Universal Test and Treat (UTT) guidelines in 2017, which require HIV-infected persons to be initiated on antiretroviral therapy (ART) at any CD4 + cell count, and to be routinely monitored for viral load to assess response to ART. However, there is paucity of data on viral load suppression (VLS) among people living with HIV (PLHIV) with mental disorders. We conducted a parallel convergent mixed methods study to determine HIV VLS among people with a mental disorder and explored the socio-cultural determinants of VLS at Butabika hospital and Mulago (ISS) HIV Clinics in Uganda. Methods We conducted a retrospective medical records review; seven key informant interviews (KII) among purposively selected healthcare providers and 12 in-depth interviews (IDI) among clinically stable PLHIV with a mental disorder. Data was collected on demographics, mental disorder, ART, viral load status, social support, stigma, and disclosure of HIV status. Quantitative data was analysed using descriptive statistics and modified Poisson regression, while Inductive thematic analysis was used for the qualitative data. Results Of the 240 PLHIV with a mental disorder who were enrolled, 161 (67.1%) were female with mean age 38.9 (± 11.2) years. Overall, 88.8% (95% Cl: 84.0% - 92.2%) achieved VLS. Age (aPR = 1.01, 95%Cl = 1.00-1.01), male gender (aPR = 0.95, 95%Cl = 0.95-0.95), divorced (aPR = 0.89, 95%Cl = 0.87-0.91), widowed (aPR = 0.84, 95%Cl = 0.79-0.90), baseline CD4 count < 200 (aPR = 0.89, 95%Cl = 0.82-0.95), and fair (85-94%) ART adherence level (aPR = 0.68, (95%Cl = 0.54-0.87) were associated with HIV VLS. Social support from family members, knowledge of impact of negative thoughts on VLS, fear of breaking up with partners and compassionate healthcare providers positively influenced VLS. Stigma and discrimination from the community, self-perceived stigma hindering social relations, socio-economic challenges and psychiatric drug stock-outs negatively affected VLS. Conclusion and recommendations HIV VLS among PLHIV with mental disorders at institutions that provide integrated HIV and mental health care is still below the UNAIDS 95% target. Health promotion messaging focusing on benefits of VLS and countering stigma to create a safe environment; and active involvement of family members in care could improve HIV treatment outcomes for PLHIV with mental disorders.

Prevalence, severity, and associated factors of depression in newly diagnosed people living with HIV in Kilimanjaro, Tanzania: a cross-sectional study

BACKGROUND

Depression is particularly common among people living with Human Immunodeficiency Virus (HIV), with some studies showing a prevalence of depression three times higher among people living with HIV as compared to the general public. The stress associated with being diagnosed with HIV can be quite impactful, including concerns about one's long-term health, stigma, and the burden of long-term treatment. Therefore, it is common for a new HIV diagnosis to contribute to the onset of depressive symptoms. The objective of this study was to determine the prevalence and severity of depression, and its associated factors in people diagnosed with HIV within the past 12 months.

METHODS

We conducted a cross-sectional survey with patients newly diagnosed with HIV at three hospitals in the Kilimanjaro region of Tanzania utilizing a locally validated version of the Patient Health Questionnaire-9 (PHQ-9) as a screener for depression, the Demographic Health Survey (SES-DHS8) for socio-demographic characteristics, and the Duke-UNC Functional Social Support Questionnaire (FSSQ) to assess perceived social support. We enrolled 272 participants between September and December 2020, diagnosed with HIV within the past 12 months. Analysis of Co-variance (ANCOVA) and Bonferroni post-hoc analysis were used to determine associations of sociodemographic variables with the dependent variable of depression.

RESULTS

Overall prevalence of depression in our sample was 41%, including 54 participants (20%) with moderate symptoms, 42 (15%) with moderately severe symptoms, and 16 (6%) with severe symptoms. Severity was highest in participants diagnosed with HIV less than 1 month ago. An ANCOVA model (overall F = 4.72, p < 0.001) assessing factors associated with greater depression severity revealed significant effects of study site (F = 7.6, p < 0.001), female gender (F = 5.11, p = 0.02), and less time since HIV diagnosis (F = 12.3, p < 0.001).

CONCLUSION

The study demonstrates very high prevalence of depression among people living with HIV in this setting, particularly among those newly diagnosed, female participants, and those seen at the larger regional referral hospital. Integration of mental health screening and interventions into CTC care is vital in the first visits following a positive test result and may be tailored to meet the needs of patients at highest risk for developing symptoms of depression.

Perinatal Depressive Symptoms and Viral Non-suppression Among a Prospective Cohort of Pregnant Women Living with HIV in Nigeria, Kenya, Uganda, and Tanzania

Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013-February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2-4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers.

Functioning Problems Associated with Health Conditions with Greatest Disease Burden in South Africa: A Scoping Review

A notable rise in health-related disability for which evidence-based rehabilitation is beneficial is evident in low-to-middle income countries. This scoping review aimed to systematically identify and map the most common functioning problems associated with health conditions that contribute most to disability in South Africa using the International Classification of Functioning, Disability and Health (ICF) framework. Peer-reviewed evidence published from January 2006 to December 2021 was systematically searched from five databases. Some 268 studies reporting on functioning problems (impairments, activity limitations, and participation restrictions) in South African adults (>18 years) related to 10 health conditions were included. A total of 130 different functioning problems were mapped to the ICF. The most prevalent problems (top 20) were related to mobility, pain, and mental health but spanned across several ICF domains and were mostly in patients at primary care. The high prevalence and wide range of functioning problems may be particularly burdensome on an already strained primary health care (PHC) system. This points towards targeted planning of innovative strategies towards strengthening rehabilitation service delivery at primary care to address these complexities where there is an inadequate rehabilitation workforce.

Possible Association of Nucleobindin-1 Protein with Depressive Disorder in Patients with HIV Infection

Background: Mental disorders linked with dysfunction in the temporal cortex, such as anxiety and depression, can increase the morbidity and mortality of people living with HIV (PLWHA). Expressions of both nucleobindin 1 (NUCB1) and cannabinoid receptor 1 (CNR1) in the neurons have been found to alter in patients with depressive disorder, but whether it is involved in the development of depression in the context of HIV infection is unknown. Objectives To investigate the effects of NUCB1 on depressive disorder among PLWHA and preliminarily explore the underlying molecular mechanisms. Methods: Individuals who were newly HIV diagnosed were assessed on the Hospital Anxiety and Depression scale (HADS). Then SHIV-infected rhesus monkeys were used to investigate the possible involvement of the NUCB1 and the CNR1 protein in depression-like behavior. Results: The prevalence rate of depression among PLWHA was 27.33% (41/150). The mechanism results showing elevated NUCB1 levels in cerebrospinal fluid from HIV-infected patients suffering from depression were confirmed compared to those of HIV-infected patients. Moreover, the immunohistochemical analysis indicated the expression of NUCB1 in the temporal cortex neurons of SHIV-infected monkeys was higher than that of the healthy control. Conversely, CNR1 expression was down-regulated at protein levels. Conclusions: Depression symptoms are common among PLWHA and associate with NUCB1 expression increases, and NUCB1 may be a potential target for depression.

Risk factors for late linkage to care and delayed antiretroviral therapy initiation amongst HIV infected adults in sub-Saharan Africa: a systematic review and meta-analyses

BACKGROUND

Late treatment initiation threatens the clinical and public health benefits of antiretroviral therapy (ART). Quantitative synthesises of the existing evidence related to this is lacking in sub-Saharan Africa (SSA), which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesise the available literature on factors affecting linkage to care and ART initiation amongst HIV-infected adults in SSA.

METHODS

Systematic searches were undertaken on four databases to identify observational studies investigating factors affecting both HIV care outcomes amongst adults (age ≥19 years) in SSA, and were published between January 1, 2015 and June 1, 2021. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with 95% confidence interval and <0.05 level of significance.

RESULTS

Forty-six studies were included in the systematic review, of which 18 fulfilled requirements for meta-analysis. In both narrative review and meta-analyses, factors related to health care delivery, individual perception and sociodemographic circumstances were associated with late linkage to care and delays in ART initiation.

CONCLUSION

This review identified a range of risk factors for late linkage to care and delayed ART initiation amongst HIV-infected adults in SSA. We recommend implementation of patient-centred intervention approaches to alleviate these barriers.

Depressive Symptoms, Gender, Disclosure, and HIV Care Stage Among People Living with HIV in Cameroon

Depression is associated with suboptimal HIV care outcomes. Little is known about the extent to which the prevalence of depressive symptoms varies across the HIV care continuum. Also, the relationship among gender, HIV disclosure, HIV care stage, and depressive symptoms in PLWH remains poorly understood. We analyzed cross-sectional data from 12,507 PLWH at enrollment in International epidemiology Databases to Evaluate AIDS (IeDEA) Cameroon between 2016 and 2020. Recent depressive symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2). A score of three or greater on the PHQ-2 was considered indicative of likely major depressive disorder. We estimated the prevalence of depressive symptoms across three stages of HIV care: those not yet on antiretroviral therapy (ART), recent ART initiators (ART initiation ≤ 30 days prior), and ART users (ART initiation > 30 days prior). Adjusted prevalence differences (aPD) of depressive symptoms were estimated comparing recent ART initiators and ART users. Disclosure and gender were examined as effect measure modifiers of the relationship between HIV care stage and depressive symptoms. The prevalence of depressive symptoms was 11.9%, 22.0%, and 8.7% among PLWH not yet on ART, recent ART initiators, and ART users, respectively. ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD - 0.09 [95% CI - 0.11, - 0.08]). Neither gender nor HIV disclosure modified the effect measure of the relationship between HIV care stage and depressive symptoms. Depressive symptoms were commonly reported among this group of PLWH and were associated with recent ART initiation. Integration of screening and treatment of depression into HIV care should be prioritized and may be particularly relevant for PLWH initiating ART.

HIV-Related Internalized Stigma and Patient Health Engagement Model in an Italian Cohort of People Living With HIV

The care engagement of people living with HIV (PLWH) measured with the patient health engagement (PHE) model and its association with HIV-related internalized stigma are not well established. Indeed, currently there are no data yet about the engagement of PLWH measured with the PHE model. This study aimed to evaluate the effects of HIV-related internalized stigma on care engagement and mental health and to fill the lack of data on PHE model applied to PLWH. We found that the internalized stigma score was significantly higher for PLWH (n=82) in worse care engagement phase and both higher internalized stigma scores and worse engagement were associated to major depression symptoms.In conclusion, our findings describe for the first time the engagement in care of PLWH measured with PHE and highlight the importance of PLWH support to find strategies to cope stigma-related stress and optimize their care engagement.

Improving Detection of Depression in People Living with HIV: Psychometric Properties of the South African Depression Scale (SADS)

Most measures developed in high income countries to screen for major depressive disorder (MDD) among people living with HIV (PWH) demonstrate suboptimal psychometric properties when utilized in non-western, resource limited settings due to their high false positive rates. For standardized MDD screening to be implementable in local settings, a measure is needed that reduces diagnostic burden by being highly sensitive while limiting false positives. This study sought to evaluate the ability of the locally developed South African Depression Scale (SADS) to screen for MDD in PWH in Cape Town. The SADS was administered along with the SCID-5-RV as gold standard to 236 PWH. It demonstrated good discriminating ability in detecting MDD with an area under the curve of 0.85. A cut-off of 27 yielded 78.2% sensitivity and 54.4% PPV. Given its robust psychometric properties, routine use of the SADS in community clinics to screen at-risk PWH, combined with evidence-based depression treatment, could improve the health outcomes and well-being of PWH in South Africa.ResumenLa mayoría de las medidas desarrolladas en países de ingresos altos para detectar el trastorno depresivo mayor (TDM) entre las personas que viven con el VIH (PVV) demuestran propiedades psicométricas subóptimas cuando se utilizan en entornos no occidentales de recursos limitados debido a sus altas tasas de falsos positivos. Para que la detección de TDM estandarizada sea implementable en entornos locales, se necesita una medida que reduzca la carga diagnóstica al ser altamente sensible mientras limita los falsos positivos. Este estudio trató de evaluar la capacidad de la Escala de Depresión Sudafricana (SADS, por sus siglas en inglés) desarrollada localmente para detectar TDM en PVV en Ciudad del Cabo. El SADS se administró junto con el SCID-5-RV como el test de referencia a 236 PWH. Demostró una buena capacidad discriminatoria en la detección de TDM con un área bajo la curva de 0,85. Un corte de 27 produjo un 78,2% de sensibilidad y un 54,4% de VPP. Dadas sus sólidas propiedades psicométricas, el uso rutinario del SADS en clínicas comunitarias para detectar las PVV en riesgo, combinado con un tratamiento de depresión basado en la evidencia, podría mejorar los resultados de salud y el bienestar de las PVV en Sudáfrica.

Mental health and well-being of older adults living with HIV in sub-Saharan Africa: a systematic review

OBJECTIVE

In this systematic review, we aimed to summarise the empirical evidence on common mental disorders (CMDs), cognitive impairment, frailty and health-related quality of life (HRQoL) among people living with HIV aged ≥50 years (PLWH50 +) residing in sub-Saharan Africa (SSA). Specifically, we document the prevalence and correlates of these outcomes.

DESIGN, DATA SOURCES AND ELIGIBILITY CRITERIA

The following online databases were systematically searched: PubMed, CINAHL, PsycINFO, Embase and Scopus up to January 2021. English-language publications on depression, anxiety, cognitive function, frailty and quality of life among PLWH50+ residing in SSA were included.

DATA EXTRACTION AND SYNTHESIS

We extracted information, including study characteristics and main findings. These were tabulated, and a narrative synthesis approach was adopted, given the substantial heterogeneity among included studies.

RESULTS

A total of 50 studies from fifteen SSA countries met the inclusion criteria. About two-thirds of these studies emanated from Ethiopia, Uganda and South Africa. Studies regarding depression predominated (n=26), followed by cognitive impairment (n=13). Overall, PLWH50+ exhibited varying prevalence of depression (6%-59%), cognitive impairments (4%-61%) and frailty (3%-15%). The correlates of CMDs, cognitive impairment, frailty and HRQoL were rarely investigated, but those reported were sociodemographic variables, many of which were inconsistent.

CONCLUSIONS

This review documented an increasing number of published studies on HIV and ageing from SSA. However, the current evidence on the mental and well-being outcomes in PLWH50+ is inadequate to characterise the public health dimension of these impairments in SSA, because of heterogeneous findings, few well-designed studies and substantial methodological limitations in many of the available studies. Future work should have sufficiently large samples of PLWH50+, engage appropriate comparison groups, harmonise the measurement of these outcomes using a standardised methodology to generate more robust prevalence estimates and confirm predictors.

PROSPERO REGISTRATION NUMBER

CRD42020145791.

Improvement in depressive symptoms after antiretroviral therapy initiation in people with HIV in Rakai, Uganda

Depression is common following HIV infection and often improves after ART initiation. We aimed to identify distinct dimensions of depression that change following ART initiation in persons with HIV (PWH) with minimal comorbidities (e.g., illicit substance use) and no psychiatric medication use. We expected that dimensional changes in improvements in depression would differ across PWH. In an observational cohort in Rakai, Uganda, 312 PWH (51% male; mean age = 35.6 years) completed the Center for Epidemiologic Studies-Depression (CES-D) scale before and up to 2 years after ART initiation. Twenty-two percent were depressed (CES-D scores ≥ 16) pre-ART that decreased to 8% after ART. All CES-D items were used in a latent class analysis to identify subgroups with similar change phenotypes. Two improvement phenotypes were identified: affective-symptom improvement (n = 58, 19%) and mixed-symptom improvement (effort, appetite, irritability; n = 41, 13%). The affect-improvement subgroup improved on the greatest proportion of symptoms (76%). A third subgroup was classified as no-symptom changes (n = 213, 68%) as they showed no difference is symptom manifestation from baseline (93% did not meet depression criteria) to post-ART. Factors associated with subgroup membership in the adjusted regression analysis included pre-ART self-reported functional capacity, CD4 count, underweight BMI, hypertension, female sex(P's < 0.05). In a subset of PWH with CSF, subgroup differences were seen on Aβ-42, IL-13, and IL-12. Findings support that depression generally improves following ART initiation; however, when improvement is seen the patterns of symptom improvement differ across PWH. Further exploration of this heterogeneity and its biological underpinning is needed to evaluate potential therapeutic implications of these differences.

Association Between Depression and HIV Care Engagement Outcomes Among Patients Newly Initiating ART in Lilongwe, Malawi

As in other sub-Saharan countries, the burden of depression is high among people living with HIV in Malawi. However, the association between depression at ART initiation and two critical outcomes-retention in HIV care and viral suppression-is not well understood. Prior to the launch of an integrated depression treatment program, adult patients were screened for depression at ART initiation at two clinics in Lilongwe, Malawi. We compared retention in HIV care and viral suppression at 6 months between patients with and without depression at ART initiation using tabular comparison and regression models. The prevalence of depression among this population of adults newly initiating ART was 27%. Those with depression had similar HIV care outcomes at 6 months to those without depression. Retention metrics were generally poor for those with and without depression. However, among those completing viral load testing, nearly all achieved viral suppression. Depression at ART initiation was not associated with either retention or viral suppression. Further investigation of the relationship between depression and HIV is needed to understand the ways depression impacts the different aspects of HIV care engagement.

The potential impact of urine-LAM diagnostics on tuberculosis incidence and mortality: A modelling analysis

BACKGROUND

Lateral flow urine lipoarabinomannan (LAM) tests could offer important new opportunities for the early detection of tuberculosis (TB). The currently licensed LAM test, Alere Determine TB LAM Ag ('LF-LAM'), performs best in the sickest people living with HIV (PLHIV). However, the technology continues to improve, with newer LAM tests, such as Fujifilm SILVAMP TB LAM ('SILVAMP-LAM') showing improved sensitivity, including amongst HIV-negative patients. It is important to anticipate the epidemiological impact that current and future LAM tests may have on TB incidence and mortality.

METHODS AND FINDINGS

Concentrating on South Africa, we examined the impact that widening LAM test eligibility would have on TB incidence and mortality. We developed a mathematical model of TB transmission to project the impact of LAM tests, distinguishing 'current' tests (with sensitivity consistent with LF-LAM), from hypothetical 'future' tests (having sensitivity consistent with SILVAMP-LAM). We modelled the impact of both tests, assuming full adoption of the 2019 WHO guidelines for the use of these tests amongst those receiving HIV care. We also simulated the hypothetical deployment of future LAM tests for all people presenting to care with TB symptoms, not restricted to PLHIV. Our model projects that 2,700,000 (95% credible interval [CrI] 2,000,000-3,600,000) and 420,000 (95% CrI 350,000-520,000) cumulative TB incident cases and deaths, respectively, would occur between 2020 and 2035 if the status quo is maintained. Relative to this comparator, current and future LAM tests would respectively avert 54 (95% CrI 33-86) and 90 (95% CrI 55-145) TB deaths amongst inpatients between 2020 and 2035, i.e., reductions of 5% (95% CrI 4%-6%) and 9% (95% CrI 7%-11%) in inpatient TB mortality. This impact in absolute deaths averted doubles if testing is expanded to include outpatients, yet remains <1% of country-level TB deaths. Similar patterns apply to incidence results. However, deploying a future LAM test for all people presenting to care with TB symptoms would avert 470,000 (95% CrI 220,000-870,000) incident TB cases (18% reduction, 95% CrI 9%-29%) and 120,000 (95% CrI 69,000-210,000) deaths (30% reduction, 95% CrI 18%-44%) between 2020 and 2035. Notably, this increase in impact arises largely from diagnosis of TB amongst those with HIV who are not yet in HIV care, and who would thus be ineligible for a LAM test under current guidelines. Qualitatively similar results apply under an alternative comparator assuming expanded use of GeneXpert MTB/RIF ('Xpert') for TB diagnosis. Sensitivity analysis demonstrates qualitatively similar results in a setting like Kenya, which also has a generalised HIV epidemic, but a lower burden of HIV/TB coinfection. Amongst limitations of this analysis, we do not address the cost or cost-effectiveness of future tests. Our model neglects drug resistance and focuses on the country-level epidemic, thus ignoring subnational variations in HIV and TB burden.

CONCLUSIONS

These results suggest that LAM tests could have an important effect in averting TB deaths amongst PLHIV with advanced disease. However, achieving population-level impact on the TB epidemic, even in high-HIV-burden settings, will require future LAM tests to have sufficient performance to be deployed more broadly than in HIV care.

Screening for Traumatic Experiences and Mental Health Distress Among Women in HIV Care in Cape Town, South Africa

Traumatic events can negatively affect clinical outcomes among HIV positive women, particularly when those events result in ongoing psychological distress. Consequently, there have been calls to integrate screening and treatment of traumatic experiences and associated mental health disorders into HIV care. In South Africa, screening for traumatic experiences and mental health is not a routine part of HIV care. The goal of this study was to examine the prevalence of traumatic experiences and mental health distress among women in an HIV clinic in Cape Town, South Africa, and to explore the acceptability of routine screening in this setting. Seventy HIV positive women were screened following referral from health care workers in the clinic. Among the participants, 51% reported a history of sexual abuse and 75% reported physical intimate partner violence (physical IPV). Among all participants, 36% met screening criteria for depression; among those with traumatic experiences (n = 57), 70% met screening criteria for posttraumatic stress disorder (PTSD). Compared with reporting no sexual abuse or physical IPV, having experienced both sexual abuse and physical IPV was significantly associated with higher odds of depression, while reporting either sexual abuse or physical IPV individually was not significantly associated with increased odds of depression. Among women reporting sexual abuse, 61% were disclosing their experience for the first time during the screening; 31% of women with physical IPV experience were disclosing for the first time. Overall, 98% of participants thought screening should be routine and extended to all women as part of clinic care. Screening women for sexual abuse and physical IPV may be an important component of ensuring HIV care engagement.

Prevalence and correlates of depressive symptoms among people living with HIV attending tertiary care hospitals in Oman

INTRODUCTION

depressive symptoms have been widely reported among people living with HIV (PLHIV) around the world. The extent of this on PLHIV in the Arabian Peninsula is unclear. This study aims to examine the prevalence of depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9) in adult Omani patients with HIV attending a tertiary care hospital. It also aims to investigate the relationship between clinical and socio-demographic variables and depressive symptoms.

METHODS

LHIV, age >18 (n=101), participated in the study who were followed up at a teaching hospital in Muscat, Oman. Participants were identified by a convenient and consecutive sampling of eligible patients who came for consultation on the days that the investigator conducted recruitment. The presence of depressive symptoms was quantified by the Patient Healthcare Questionnaire-9 (PHQ-9). Various socio-demographic backgrounds and risk factors will be also sought as well as activities of daily living (ADL). Chi-square test, Fisher´s exact test, t-test and logistic regression were used to explore which variables were associated with patients having depressive symptoms.

RESULTS

the prevalence rate of depressive symptoms in this cohort was 41.6%. Depression among PLHIV was found to be significantly associated with age (p <0.001), HIV disease duration (p <0.001), total dependency for ADL (p <0.001) and comorbid hypertension (p <0.001).

CONCLUSION

depressive symptoms are common in Omani patients living with HIV. HIV care providers are urged to be vigilant to recognize depressive symptoms in these mood-vulnerable populations and to call for a multidisciplinary team with mental health professionals, for the prevention and treatment of depressive symptoms among PLHIV in Oman.

Burden of Depression in Outpatient HIV-Infected adults in Sub-Saharan Africa; Systematic Review and Meta-analysis

Despite the substantial burden of HIV in Africa, and the knowledge that depression causes worse HIV outcomes, the burden of depression in people living with HIV in Africa is unknown. We searched Pubmed and four other databases using key terms: depression, Africa, HIV, and prevalence from 2008 to 2018. We summarized depression prevalence by country. We estimated the burden of depression using our prevalence data and 2018 UNAIDS HIV estimates. Our search yielded 70 articles across 16 African countries. The overall prevalence of major depression in those HIV-infected using a diagnostic interview was 15.3% (95% CI 12.5-17.1%). We estimate that 3.63 million (99.7% CI 3.15-4.19 million) individuals with HIV in Sub-Saharan Africa have major depression and provide country-level estimates. We estimate that 1.57 million (99.7% CI 1.37-1.82 million) DALYs are lost among people with depression and HIV in Sub-Saharan Africa. There is a significant burden of depression in Africans with HIV. Further work to screen for and treat depression in Sub-Saharan Africa is needed to improve HIV outcomes and achieve the 90-90-90 UNAIDS goals.

HIV care continuum characteristics among people with opioid use disorder and HIV in Vietnam: baseline results from the BRAVO study

BACKGROUND

Little is known about patient characteristics that contribute to initiating antiretroviral therapy (ART) and achieving viral suppression among HIV people with opioid use disorder in Vietnam. The primary objective of this analysis was to evaluate associations between participant characteristics and the critical steps in the HIV care continuum of ART initiation and HIV viral suppression among people with opioid use disorder and HIV in Vietnam.

METHODS

We assessed baseline participant characteristics, ART status, and HIV viral suppression (HIV RNA PCR < 200 copies/mL) enrolled in a clinical trial of HIV clinic-based buprenorphine versus referral for methadone among people with opioid use disorder in Vietnam. We developed logistic regression models to identify characteristics associated with ART status and HIV viral suppression.

RESULTS

Among 283 study participants, 191 (67.5%) were prescribed ART at baseline, and 168 of those on ART (90%) were virally suppressed. Years since HIV diagnosis (aOR = 1.12, 95% CI 1.06, 1.19) and being married (aOR = 2.83, 95% CI 1.51, 5.34) were associated with an increased likelihood of current prescription for ART at baseline. Greater depression symptoms were negatively associated with receipt of ART (aOR = 0.97, 95% CI = (0.94, 0.9963)). In the HIV suppression model, once adjusting for all included covariates, only receipt of ART was associated with viral suppression (aOR = 25.9, 95% CI = (12.5, 53.8). In bivariate analyses, methamphetamine was negatively correlated with ART prescription (p = 0.07) and viral suppression (p = 0.08).

CONCLUSION

While fewer than 90% of participants had received ART, 90% of those on ART had achieved HIV viral suppression at baseline, suggesting that interventions to improve uptake of ART in Vietnam are essential for achieving UNAIDS 90-90-90 goals in people who use heroin in Vietnam. Social determinants of health associated with ART and HIV viral suppression suggest that social support may be a key to facilitating both of these steps in the HIV care continuum.

Health outcomes and cost-effectiveness of treating depression in people with HIV in Sub-Saharan Africa: a model-based analysis

High prevalence of depression among people living with HIV (PLHIV) impedes antiretroviral therapy (ART) adherence and viral suppression. We estimate the effectiveness and cost-effectiveness of strategies to treat depression among PLHIV in Sub-Saharan Africa (SSA). We developed a microsimulation model of HIV disease and care in Uganda which captured individuals' depression status and the relationship between depression and HIV behaviors. We consider a strategy of screening for depression and providing antidepressant therapy with fluoxetine at ART initiation or re-initiation (if a patient has dropped out). We estimate that over 10 years this strategy would reduce prevalence of depression among PLHIV by 16.0% [95% uncertainty bounds 15.8%, 16.1%] from a baseline prevalence of 28%, increase adherence to ART by 1.0% [1.0%, 1.0%], and decrease rates of loss to followup by 3.7% [3.4%, 4.1%]. This would decrease first-line ART failure rates by 2.5% [2.3%, 2.8%] and increase viral suppression rates by 1.0% [1.0%, 1.0%]. This strategy costs $15/QALY compared to the status quo, and was highly cost-effective over a broad range of sensitivity analyses. We conclude that screening for and treating depression among PLHIV in SSA with fluoxetine would be effective in improving HIV treatment outcomes and would be highly cost-effective.

Psychiatric Comorbidity of Unipolar Mood, Anxiety, and Trauma Disorders Prior to HIV Testing and the Effect on Linkage to Care Among HIV-Infected Adults in South Africa

Psychiatric comorbidity, the presence of two or more psychiatric disorders, leads to worse HIV outcomes in the United States; this relationship has not been studied in sub-Saharan Africa. We conducted a preliminary study to describe the prevalence of psychiatric comorbidity (unipolar mood, anxiety, and trauma disorders) among 363 adults prior to HIV testing at Witkoppen Health and Welfare Centre, a primary care clinic in Johannesburg, South Africa. We also examined whether psychiatric comorbidity predicted subsequent linkage to HIV care 3 months later. Prevalence of psychiatric comorbidity prior to HIV testing was approximately 5.5%. In the final HIV-positive subsample (n = 76), psychiatric comorbidity of unipolar mood, anxiety, and trauma disorders did not predict linkage to care [adjusted relative risk = 1.01 (0.59, 1.71)] or number of follow-up appointments (adjusted relative risk = 0.86 (0.40, 1.82)]. A similar psychiatric profile emerged for HIV-positive and HIV-negative individuals before becoming aware of their HIV status. The psychiatric burden typically seen in HIV-positive individuals may manifest over time.

Differential Item Functioning by HIV Status and Sexual Orientation of the Center for Epidemiological Studies-Depression Scale: An Item Response Theory Analysis

The Center for Epidemiological Studies-Depression Scale (CES-D) is the most widely used instrument to assess depressive symptoms in people living with HIV. However, its differential item functioning (DIF) by HIV status and sexual orientation has yet to be explored. This study examined DIF and measurement invariance of the CES-D using an item response theory (IRT) framework, and a more traditional factor analytic approach. Data from 841 HIV-infected and HIV-uninfected individuals, from Miami, Florida, were analyzed. Uniform DIF by HIV status was detected in Items 4, 12, and 16 from the Positive Affect factor. Nonuniform DIF was detected in Items 13 and 17. Uniform DIF by sexual orientation was detected in Items 2, 15, and 19, two of them from the Interpersonal factor. Nonuniform DIF was detected in Item 2. Using a factor analytic approach, the CES-D was invariant at the configural and metric levels by HIV and sexual orientation. These findings indicate that overall, however, using IRT, the magnitudes of DIF were negligible, the CED-D was somewhat invariant using factor analytic methods; the CES-D may be reliably used to compare by HIV status or sexual orientation.

Epidemiology of depressive disorders in people living with HIV in Africa: a systematic review and meta-analysis: Burden of depression in HIV in Africa

OBJECTIVE

The burden of HIV infection is higher in Africa where 70% of people living with HIV (PLHIV) resides. Since depression can negatively impact the course of HIV infection, it is therefore important to accurately estimate its burden among PLHIV in the continent.

METHODS

We searched multiple databases to identify articles published between January 2000 and February 2018, reporting the prevalence of (major) depressive disorders in PLHIV residing in Africa. We used a random-effects meta-analysis model to pool studies.

RESULTS

Overall, 118 studies (60,476 participants, 19 countries) were included. There was no publication bias. The overall prevalence estimates of depressive disorders and probable major depressive disorders were 36.5% (95% CI 32.3-41.0; 101 studies) and 14.9% (12.1-17.9; 55 studies) respectively. The heterogeneity of the overall prevalence of depressive disorders was significantly explained by screening tool used, period (higher prevalence in recent studies) and distribution in sub-regions. The study setting, site, CD4 cell counts, age, sex, proportion of people with undetectable viral load were not sources of heterogeneity.

CONCLUSIONS

This study shows that more than one third of PLHIV face depressive disorders and half of them having major form, with heterogeneous distribution in the continent. As such, depressive disorders deserve more attention from HIV healthcare providers for improved detection and overall proper management.

Probable antenatal depression at antiretroviral initiation and postpartum viral suppression and engagement in care

OBJECTIVE

To estimate the association of probable antenatal depression with postpartum HIV care engagement among pregnant women in Malawi.

DESIGN

We conducted a prospective cohort study of 299 women who were initiating antiretroviral therapy (ART) through Option B+ at a government antenatal clinic in Malawi.

METHODS

Probable antenatal depression was assessed on the day of ART initiation with the validated Chichewa version of the Edinburgh Postnatal Depression Scale (EPDS). We estimated crude and adjusted risk differences (RD, aRD) of visit attendance and prevalence differences (PD, aPD) of viral suppression through 12 months post-ART initiation comparing women with versus without probable antenatal depression.

RESULTS

One in 10 women had probable antenatal depression. Most women were engaged in care through 12 months post-ART initiation: 85% attended all scheduled ART visits, and 81% were in care and virally suppressed. Women with and without probable antenatal depression had a comparable probability of attending all scheduled visits (RD: -0.02; 95% CI -0.16 to 0.12; aRD: -0.04; 95% CI -0.18 to 0.10), and of viral suppression (PD: -0.02; 95% CI -0.17 to 0.13; aPD: -0.01; 95% CI -0.17 to 0.15) in crude and adjusted analyses.

CONCLUSION

Probable antenatal depression was not associated with engagement in HIV care through 12 months post-ART initiation. In a population with high HIV care engagement, antenatal depression may not impair HIV-related outcomes.

Prevalence and incidence of probable perinatal depression among women enrolled in Option B+ antenatal HIV care in Malawi

BACKGROUND

Perinatal depression is a common condition of pregnancy and the postpartum period. Depression negatively affects engagement in HIV care, but systematic screening for perinatal depression is not done in most sub-Saharan African countries. Estimating the burden and timing of perinatal depression can help inform medical programs with the current scale-up of HIV care for pregnant women.

METHODS

Women (n = 299) initiating antiretroviral therapy for HIV were recruited from a government antenatal clinic in Malawi in 2015-2016 into a cohort study. Probable perinatal depression was assessed at enrollment and at 6 weeks and 3, 6, and 12 months postpartum with the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-9 (PHQ-9). We estimated point prevalence and incidence of depression as well as concordance between EPDS and PHQ-9 scores.

RESULTS

One in ten women screened positive for probable antenatal depression, whereas 1-6% screened positive postpartum. Sensitivity analyses to account for loss to follow-up suggested that postpartum depression prevalence could have ranged from 1-11%. At postpartum time points, 0-3% of participants screened positive for incident probable depression. EPDS and PHQ-9 scores were concordant for 96% of assessments during antenatal and postpartum visits.

LIMITATIONS

Lack of diagnostic psychiatric evaluation precludes actual diagnosis of major depression, and social desirability bias may have contributed to low postpartum scores.

CONCLUSIONS

Probable depression was more common during the antenatal period than postpartum among our participants. Given the association between depression and negative HIV outcomes, screening for depression during pregnancy should be integrated into antenatal HIV care.

Low prevalence of depressive symptoms among stable patients on antiretroviral therapy in Johannesburg, South Africa

Background

Depression is a leading cause of disability and may be associated with decreased adherence to ART. We sought to describe the prevalence of depressive symptoms and outcomes one year after screening among patients receiving ART at a large HIV Clinic in Johannesburg, South Africa.

Methods

Adult (≥18) patients who had been on first-line ART between 6–18 months who could communicate in English were eligible. Depressive symptoms were evaluated using the Patient Health Questionnaire (PHQ)-9 and a score ≥10 indicated depression.

Results

97 patients enrolled. Patients had been on ART for a median (IQR) of 8 (7–10) months, 61% were female, the median (IQR) age at enrollment was 38 (33–42) years, and the median (IQR) CD4 count at ART initiation was 154.5 (65–263) cells/mm³. 7 (7%) patients were found to have symptoms of depression; 4 (4%) had symptoms of moderate depression (PHQ score of 10–14) and 3 (3%) had symptoms of moderate/severe depression (PHQ score of 15–19). Women (10%) were more likely to have symptoms of depression than men (3%; prevalence difference [PD]: 7.5%; 95% confidence interval [CI]:-1.7%-16.8%); as were patients under the age of 30 (14%) compared to those 30–39 (4%; PD: -10.2; 95% CI: -29.4–9.0%) or ≥40 (9%; PD: -5.5%; -26.1%-15.2%), those with lower CD4 counts at ART initiation (<200 cells/mm³ vs ≥200 cells/mm³: 8% vs 3%; PD: 4.8%; 95% CI: -4.5%-14.0%), and those with high viral loads (>1000 copies/mL vs. <400 copies/mL: 40% vs. 5%; PD: 34.6%; 95% CI: -8.6%-77.6%). No relationship between depressive symptoms and retention in HIV care one year after screening was observed.

Conclusions

We found a lower prevalence of depressive symptoms compared to findings from other HIV-positive populations in South Africa but more than one-third of patients with an elevated viral load had evidence of depression. Further research on the relationship between depression, adherence, and viral failure is warranted as this may present an opportunity for early interventions to improve treatment outcomes and reduce the need for second-line treatment.

Depressive Symptoms, Disclosure, HIV-Related Stigma, and Coping Following HIV Testing Among Outpatients in Uganda: A Daily Process Analysis

As efforts to end the HIV epidemic accelerate there is emphasis on reaching those living with undiagnosed HIV infection. Newly diagnosed individuals face a number of psychosocial challenges, yet we know little about depressive symptoms in the weeks immediately following diagnosis and how disclosure, coping, and other factors may affect short and longer-term depressive symptoms. Purposively sampled Ugandan outpatients completed structured interviews immediately prior to testing for HIV, daily for 28 days after receiving their test results, and at 3 and 6 months post-test. The sample included a total of 244 participants: 20 who tested HIV positive at baseline and who provided 342 daily data points, and 224 who tested HIV negative at baseline and who provided 4388 daily data points. We used linear mixed effects modeling to examine changes in depressive symptom scores over the 28 day daily interview period and predictors of depressive symptom scores and changes over time. Results from the mixed modeling revealed that while those diagnosed with HIV showed initially high depressive symptoms following diagnosis, their symptoms decreased significantly and on average fell below the cutoff for possible depression approximately 15 days after diagnosis. Among those who tested HIV-negative, on average their depressive symptoms were below the cutoff for possible depression and did not change over time. Among those diagnosed with HIV, disclosure, especially to a partner, on a particular day was associated with higher depressive symptoms that day. However, those who disclosed to their partner during the 28 days after diagnosis had significantly lower depression scores by the end of the 28 days as well as lower depression scores 3 and 6 months after diagnosis than did those who did not disclose to their partner during the 28 days after diagnosis. Scoring higher on HIV-related stigma on a particular day was associated with higher depressive symptoms that day and engaging in positive coping on a particular day was associated with lower depressive symptoms that day. Positive coping also accelerated the decrease in depressive symptoms over time. These data underscore the importance of timely disclosure to partners and suggest that regular depression screening after diagnosis and provision of mental health services could improve HIV care engagement and treatment outcomes.

Depression and ART Initiation Among HIV Serodiscordant Couples in Kenya and Uganda

Depression is a known barrier for antiretroviral therapy (ART) adherence, but less is understood about its effects on ART initiation. We followed 1013 HIV-infected individuals participating in the Partners Demonstration Project, an open-label study of integrated pre-exposure prophylaxis (PrEP) and ART delivery for HIV serodiscordant couples in Kenya and Uganda. Associations between depression, measured annually with the Hopkins Symptoms Checklist-Depression (HSCL-D), and ART initiation were assessed with Cox proportional hazards regression. At enrollment, 162 participants (16.0%) reported symptoms consistent with probable depression, defined by a HSCL-D mean score >1.75, and this proportion decreased during study follow-up (6.7 and 3.6% at 12- and 24-months, respectively; p value < 0.001). Greater depressive symptom severity was associated with a greater likelihood of ART initiation overall (adjusted hazard ratio [aHR] 1.32, 95% CI 1.01-1.73) and among participants with CD4 count ≤ 350 cells/µl (aHR 1.30, 95% CI 1.01-1.67). Depression decreased 6 months after ART initiation (adjusted odds ratio [aOR] 0.34, 95% CI 0.23-0.51). Among East African HIV-infected persons in HIV serodiscordant couples, depression was not a barrier to ART initiation. ART initiation was associated with improved depressive symptoms in this setting.

Predicting Factors of Depression, Antidepressant Use and Positive Response to Antidepressants in Perinatal and Postpartum Women

Background:

In the United States, there is a disparity in knowledge of nationwide depression prevalence, the antidepressant use and the antidepressant responses during perinatal/postpartum periods.

Objective:

This study investigated the predicting factors of depression, antidepressant use and positive antidepressant response during the perinatal/postpartum periods.

Method:

The 2007-2012 National Health and Nutrition Examination Surveys (NHANES) were combined to identify adult pregnant women, those within the 18-month postpartum period (n=492) and their depression statuses via demographics, health care accessibility, antidepressant use and illicit drug use information. The characteristics of different study groups were compared (depression versus no-depression groups, antidepressant users versus non-antidepressant users, and antidepressant responders versus antidepressant non-responders). Multivariable logistic regression analysis was used to predict factors of perinatal depression (PND)/ postpartum depression (PPD), antidepressant use and antidepressant positive response in PND/PPD.

Results:

PND/PPD individuals had higher rates of mental health visits. No predicting factor for developing PND/PPD was shown. Antidepressant users were significantly older with insurance and recent health checkups/ mental visits. Being below the poverty level and having some health care accessibility are predictors for being on antidepressants. Recent non-illicit drug use is a predictor for PND/PPD symptom improvement while on antidepressants.

Conclusion:

The group of those with social-economic disadvantages was more likely to be on antidepressants for PND/PPD. Illicit drug users were less likely to show improvement with antidepressants. The safety and efficacy of antidepressant use during this period is controversial. More studies need to focus on the barriers involving antidepressant treatments, the safety and outcomes of antidepressants for PND/PPD management.