Symptoms of depression, anxiety, and thoughts of suicide/self-injury in adolescents and young adults living with HIV in Botswana

Prevalence of common mental disorders and sleep disorder among adolescents and young adults with HIV: a systematic review and meta-analysis

OBJECTIVE

Adolescents and young adults (AYA) with HIV are a population at high risk of experiencing mental issues and sleep disorder. We aim to summarise the global prevalence and risks of depression, anxiety, post-traumatic stress disorder (PTSD) and sleep disorder among AYA with HIV.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Web of Science, Embase and PsycINFO were searched from inception to 3 August 2024.

ELIGIBILITY CRITERIA

Observational studies reporting the prevalence of depression, anxiety, PTSD or sleep disorder among AYA with HIV and published in English were included. Reviews, case reports, conference papers, notes, editorials and non-observational research were excluded.

DATA EXTRACTION AND SYNTHESIS

Titles, abstracts and full texts were reviewed and screened, and data were independently extracted. A modified Newcastle-Ottawa Quality Assessment Scale (NOS) was used to evaluate study quality. Heterogeneity was assessed by I2 statistics, and subgroup analysis was performed to identify the source of heterogeneity. The pooled prevalence and the risks of depression, anxiety, PTSD and sleep disorder by comparison with HIV-uninfected peers were measured with random-effects and fixed-effects models. Publication bias was examined using Egger's correlation tests and funnel plot. The Grading of Recommendations Assessment, Development and Evaluation was used to assess the certainty of evidence.

RESULTS

56 articles were included in the final analysis. According to the modified NOS, 13 (23.2%) studies were considered good, 38 (67.9%) were satisfactory and 5 (8.9%) were unsatisfactory. 51 studies including 21 735 AYA with HIV contributed data for the pooled prevalence of depression (28%, 95% CI 24% to 32%, I2=98.68%; low certainty evidence); 21 studies including 8021 cases contributed data for the pooled prevalence of anxiety (22%, 95% CI 17% to 27%, I2=98.35%; low certainty evidence); 9 studies including 3691 cases contributed data for the pooled prevalence of PTSD (12%, 95% CI 8% to 17%, I2=95.60%; low certainty evidence); and 4 studies including 1909 cases contributed data for the pooled prevalence of sleep disorder (51%, 95% CI 31% to 70%, I2=98.37%; low certainty evidence). Compared with AYA without HIV, those with HIV had a higher risk of depression (OR=2.67, 95% CI 1.63 to 5.90, I2=84.0%), anxiety (OR=1.89, 95% CI 1.32 to 2.69, I2=50.3%), PTSD (OR=1.58, 95% CI 1.23 to 2.04, I2=40.1%) and sleep disorder (OR=2.11, 95% CI 1.51 to 2.95, I2=0.0%). A subgroup analysis found that studies conducted in Asia had a lower prevalence of depression (21.7% vs 29.6%, p<0.001) and anxiety (14.7% vs 21.9%, p<0.001) than studies conducted in Africa. Egger's test indicated that there was significant publication bias in the estimates of the prevalence of depression (p<0.001), anxiety (p<0.001) and PTSD (p=0.049), but not in the estimates of the prevalence of sleep disorder (p=0.861).

CONCLUSIONS

AYA with HIV are a population at high risk of experiencing depression, anxiety, PTSD and sleep disorder. More sensitive screening strategies and more comprehensive intervention methods are needed. However, in view of the high heterogeneity, the differences between studies need to be considered and the pooled estimates interpreted with caution.

Mental Health Interventions for Young People Living With HIV/AIDS in Sub-Saharan Africa: A Systematic Review

Introduction: Young people (aged 15-24) living with HIV/AIDS (YPLHIV) in sub-Saharan Africa (SSA) experience higher rates of mental health conditions compared to their uninfected peers. Research and practitioners have expressed interest in designing and implementing mental health interventions to improve the mental health and well-being of this vulnerable population. However, there is limited effort to systematically synthesize existing evidence on mental health interventions for YPLHIV to address salient questions relating to effectiveness, characteristics, practice issues among others to inform practice, and future research endeavors. This systematic review was conducted to take stock and synthesize existing data to address the above issues. Methods: This review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy was implemented, utilizing five electronic databases and gray literature repositories. Studies (1) from SSA that focused on young adults with HIV/AIDS and (2) examined the effectiveness of interventions designed to enhance mental health outcomes and treatment adherence were included. Two independent reviewers were involved in the study selection, data extraction, and quality assessment, resolving discrepancies by consensus or consultation. Data were presented using narrative syntheses. Results: Eight studies met the inclusion criteria, with a total sample size of 1510 participants, reporting on interventions from six African countries. The interventions were categorized as follows: cognitive behavioral therapy-based, family-based, peer support, and community-based. The interventions showed mixed effectiveness for depression, with three studies demonstrating significant improvements while four showed no substantial change. The only study on improving anxiety reported promising results. Four interventions positively influenced ART adherence, although with varying magnitudes. Peer support, family-based approach, and digital (mobile phone) approaches were identified as effective strategies. Conclusions: The review showed promising approaches to improve mental health in YPLHIV, namely, through peer support, family-based, and digital (i.e., mobile phone) approaches. Although the results were mixed for depression and limited but positive for anxiety, several interventions improved ART adherence. However, the modest evidence base and varied measurement approaches necessitate more research across SSA.

A Booklet Self-Help Intervention for People Living with HIV and Depressive Symptoms in Botswana: A Randomized Controlled Trial

In low- and middle-income countries (LMICs), there is a scarcity of psychological treatment options for people living with HIV (PLWH) with depressive symptoms. Self-help programs for depressive symptoms, in particular, are cost-effective and scalable, and therefore a promising tool in the treatment of depressive symptoms for people in low-resourced countries. This paper presents the results of a study that examined the effectiveness of a guided self-help program in reducing depressive symptoms in PLWH in Botswana. A Randomized Controlled Trial (RCT) was conducted on a sample of PLWH who were screened at HIV treatment centers in Botswana. The RCT had two conditions: an intervention group that received the self-help program with coaching and an attention-only control group. In both groups, a pre-test, post-test, and 3-month follow-up measurement were administered. Patients in the intervention group followed a booklet Cognitive Behavioral Therapy (CBT)-based self-help program. Seventy-two participants were included in the study. The results indicated significantly larger decreases in depressive symptoms in the intervention group than in the attention-only control group, both in the short and longer term, with large effect sizes. In addition, there were significant reductions in anxiety symptoms in the intervention group compared to the control group. The user satisfaction was high. Implementing this low-cost and scalable self-help program in a LMIC such as Botswana is critical in bridging the existing mental health treatment gap. This clinical Trial was registered with the Netherlands Trial registry, number NTR5407on August 23, 2018.

Suicidal Ideation and Attempts Among Youth Living With HIV/AIDS Attending Botswana-Baylor Children's Clinical Centre of Excellence: A Comparison Between Substance Users and Non-Substance Users

Introduction

Young people with HIV/AIDS (YLWHIV) who use substances early in life are at higher risk of suicidal thoughts and attempts. In Botswana, there is a lack of data needed to provide comprehensive care for this group. This study aimed to compare rates and predictors of suicidal ideation (SI) and attempts (SA) between substance users and non-users among YLWHIV at Botswana-Baylor Children's Clinical Centre of Excellence (BBCCCE).

Methods

This cross-sectional study, conducted from August 2022 to January 2023, involved 255 participants aged 15 to 24 and used the Youth Risk Behavior Surveillance System, the Oslo Social Support Scale, and the Patient Health Questionnaire-9. Chi-square tests were used to compare the prevalence of suicidal ideation and attempts among substance users and non-users, while logistic regression was used to identify factors associated with SI and SA.

Results

SI was found in 29.4%, SA in 6%, and depression in 39.6% of the participants, while tobacco, alcohol, and illicit drug use were 20.4%, 45.9%, and 11.8%. Depression (adjusted odds ratios [AOR] 9.71, 95% CI: 4.23-22.33), being bullied (AOR = 5.42, 95% CI: 1.97-14.91), and family history of completed suicide (AOR = 6.56, 95% CI: 1.16-37.12) were associated with the outcome, SI. Self-reported good health status (AOR = 0.23, 95% CI: 0.05-0.98), lack of family support (AOR = 5.92, 95% CI: 1.45-24.10), and past-year tobacco use (AOR = 7.37, 95% CI: 1.18-46.10) were associated with SA.

Conclusion

Due to the high rates of suicidal behavior among YLWHIV in BBCCCE, health facilities should scale up mental health services for this vulnerable group. This includes suicide risk assessments, bullying prevention, depression screenings, and counseling by trained lay health workers to promote their mental well-being.

Mental health interventions for adolescents living with HIV/AIDS in sub-Saharan Africa: protocol for a systematic review

INTRODUCTION

Adolescents living with HIV/AIDS in sub-Saharan Africa have heightened risk for mental health and psychosocial burden owing to their exposure to a multiplicity of adverse conditions such as stigma and discrimination. However, there is no comprehensive evidence synthesis and evaluation of the effectiveness of mental health interventions for adolescents living with HIV/AIDS in this region. We aim to conduct a systematic review to synthesise the literature on existing mental health interventions for adolescents living with HIV/AIDS in sub-Saharan Africa.

METHODS AND ANALYSIS

This review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses reporting guidelines. Eligible studies will include those investigating the effectiveness of psychosocial, psychological or other forms of interventions on mental health outcomes, conducted in sub-Saharan African countries and involving adolescents (aged 10-19 years) living with HIV/AIDS. Comprehensive searches will be conducted in electronic databases (PubMed, MEDLINE, CINAHL, Scopus and PsycINFO) and grey literature sources. The search will be restricted to studies published from 2004 onwards and in the English language. Study authors will be contacted, and reference lists of retrieved articles will be reviewed for additional papers. Study selection and data extraction will be performed by two independent reviewers, with any disagreements resolved by consensus or involving a third party. A narrative synthesis will be conducted, and if possible, meta-analyses will be performed to estimate the overall effect sizes of interventions on mental health outcomes. Eligible studies will undergo quality assessment using standardised criteria appropriate for each respective study design.

ETHICS AND DISSEMINATION

No primary data collection will be undertaken; therefore, no ethical approval is required. The findings of this review will be disseminated through publication in a peer-reviewed journal and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42024538975.

Prevalence of mental disorders among young people living with HIV: a systematic review and meta-analysis

Objective

This meta-analysis aims to evaluate the global prevalence of mental disorders among young people living with HIV.

Methods

A comprehensive search was conducted of the PubMed, Embase, and Cochrane Library databases for articles relevant to the study, published between January 2013 and June 2023. To identify sources of heterogeneity and compare prevalence estimates among various groups, subgroup analyses were conducted. Study heterogeneity was assessed using Cochran's Q and the I 2 tests. The robustness of the findings was ascertained through sensitivity analyses, while publication bias was evaluated with funnel plots and Egger's test.

Results

Sixty studies were included in this meta-analysis. It revealed that approximately one-quarter of YLWH experience depression, with a prevalence of 24.6% (95% CI: 21.1-28.2%). The prevalence of anxiety was found to be 17.0% (95% CI: 11.4-22.6%). Regarding suicidality, the prevalence of suicidal ideation and lifetime suicidal ideation in YLWH was 16.8% (95% CI: 11.3-22.4%) and 29.7% (95% CI: 23.7-35.7%), respectively. Additionally, the prevalence rates for suicidal attempts and lifetime suicidal attempts were 9.7% (95% CI: 4.0-15.4%) and 12.9% (95% CI: 2.8-23.1%), respectively. The prevalence of Post-Traumatic Stress Disorder and Attention Deficit Hyperactivity Disorder was identified as 10.5% (95% CI: 5.8-15.2%) and 5.0% (95% CI: 3.1-7.0%), respectively.

Conclusion

The findings indicate a heightened risk of mental disorders among YLWH, underscoring the necessity for targeted intervention strategies to mitigate their suffering and potentially diminish the adverse impacts.

Systematic Review Registration

PROSPERO, identifier CRD42023470050, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023470050.

Stigma and discrimination faced by adolescents living with HIV and experiencing depression in Malawi

BACKGROUND

In Malawi, approximately 25% of adolescents living with HIV (ALWH) also suffer from depression. Not only is HIV stigma a major contributor to depression but it also adversely impacts HIV care engagement. ALWH can experience HIV stigma as stereotyping, social exclusion, low social support, and abuse, and these experiences are associated with poor mental health. Despite recognition of the deleterious effects of HIV stigma, we have limited knowledge of how stigma is experienced by ALWH with comorbid depression. Guided by the Health Stigma and Discrimination Framework, we describe stigma faced by ALWH and comorbid depression in Malawi and its implications for future interventions.

METHODS

As part of a larger formative study to adapt a mental health counseling intervention, we conducted in-depth interviews, social support mapping sessions, and focus-group discussions with 25 ALWH, 4 caregivers of ALWH, 3 HIV providers, and 5 participants and 5 staff of a prior mental health counseling intervention. After analyzing the stigma codes, we used the Health Stigma and Discrimination Framework to organize the data into four key domains: drivers, manifestations, outcomes, and health and social impacts.

RESULTS

Major drivers of HIV stigma included fear of HIV transmission, negative effects of antiretroviral therapy (ART), association with death, inaccurate knowledge, and negative attitudes towards ALWH. The most common manifestations of HIV stigma were gossip, insults and mocking, and physical and social distancing. Decreased ART adherence and missed HIV appointments were commonly cited outcomes of HIV stigma. Broader health impacts of HIV stigma were notable for mental health comorbidities including depression, anxiety, substance use, and suicidality. Identified resilience strategies included support for HIV care engagement and psychosocial support from family and friends.

CONCLUSIONS

This study systematically describes the stigmatization process faced by ALWH and experiencing depressive symptoms in Malawi. Notably, HIV stigma continues to disrupt HIV care and detrimentally impacts mental health during adolescent development. Further studies focused specifically on stigma are needed to better characterize this process and identify additional resilience factors. Investment in stigma-reduction interventions for ALWH is needed to avert poor mental health and HIV outcomes.

"We did more than survive": lessons learned from studies of risk and resilience of young people growing up with HIV and mental health needs

Despite advances in HIV-treatment, adolescents and young adults (AYA) with HIV (AYAHIV) face myriad challenges. They are less likely than children and older adults to be virally suppressed and are at higher risk for mental health conditions compared to their peers who do not have HIV. AYA are also developing in the context of numerous biomedical, neurocognitive, and psychosocial developmental changes. Normative challenges during this time can be exacerbated by HIV and can result in significant physical and mental health problems. Yet, many AYAHIV have shown resilience with positive assets and resources and few health or mental health problems. Historically research has had a risk-focused approach to understanding AYAHIV needs. This paper discusses the rationale for a shift from a risk-focused only approach to one that examines AYAHIV needs from both a risk and resilience perspective. This paper presents: (1) epidemiological data on AYAHIV; (2) conceptual models for understanding both risk (e.g., poverty, stress, trauma, limited resources) and resilience/protective factors (e.g., family and peer support, future orientation, problem-solving skills); (3) global data examining risk and protective factors for physical and mental health challenges; and (4) promising interventions that incorporate elements of resilience to improve overall outcomes among AYAHIV.