Critical to screen for depression in people with HIV in SSA

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Since depression can have deleterious consequences on the lives of people liviing with HIV/AIDS, it is critical to encourage its screening and management, integrating these dimensions in HIV care throughout sub-Saharan Africa, a systematic review found.

Depression is very common among people living with HIV in sub-Saharan Africa, according to the results of a systematic review and meta-analysis. Prevalence ranged between 9 and 32%, but differed between screening tools and also according to antiretroviral therapy (ART) status. Risk factors for depression included economic hardship, female sex and immuno-suppression, but there was little consistency between studies.

“This analysis of the available most recent literature confirmed that depression in PLHIV (people living with HIV) represents an increasing concern in sub-Saharan Africa (SSA),” write the authors. “The prevalence of depression is high even if the variability of the data does not allow to describe the phenomenon and to identify strong predictors.”

HIV is now a chronic manageable condition in most settings, including sub-Saharan Africa. Globally, the mental health of HIV-positive individuals is an increasing concern. World Health Organisation ART guidelines recommend that people with HIV should be screened for depression, the presence of which has been associated with poorer health outcomes, low quality of life and suboptimal adherence to ART.

Research in western countries has shown that HIV-positive people are up to three times more likely to have depression compared to individuals in the general population. Little, however, is known about the prevalence and risk factors for depression among people with HIV in sub-Saharan Africa.

A team of investigators therefore undertook a systematic review and meta-analysis of studies published before April 2016 reporting on the prevalence of major depressive disorder (MDD) and depressive symptoms.

A total of 66 studies were included in the review. Some 55 papers reported on the prevalence of major depression and/or depressive symptoms, including ten on MDD only, 40 on depressive symptoms only and five on both. Eleven studies analysed only risk factors associated with depression. The vast majority of studies – 53 (83%) – were published between 2010 and 2016.

“Since 2010, the number of studies on depression in African PLHIV has substantially increased,” comment the investigators, “highlighting the increasing concern on this emerging public health issue.”

The meta-analysis showed a 19% prevalence overall of MDD. MDD prevalence was 12% among people treated with ART and 24% among mixed/untreated individuals. But estimates varied between individual studies, from a low of 3% among ART-treated people to a high of 34% among treatment-naïve individuals.

Prevalence of depressive symptoms was 31% overall. But there was considerable variability between studies, with prevalence varying between 14 and 32% in ART-treated individuals and between 9 and 31% in mixed/untreated individuals.

Factors associated with MDD included low CD4 cell count, disability, younger age, being female, stigma, opportunistic infections, unemployment, negative life experiences, poor quality of life, co-morbidities (including tuberculosis) and a history of mental health problems.

Predictors of depressive symptoms included immune suppression, poorer physical health, being female, lower levels of education, unemployment and stigma.

The researchers at INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, University of Bordeaux School of Public Health (ISPED), Bordeaux, France graded the studies included in their analysis as low, with some of very low quality. They suggest further research is needed to validate the most accurate diagnostic tools; on how to best administer these tests; and evaluation of MDD and/or depressive symptoms in especially at-risk populations, including older people, women and men who have sex with men.

“Depressed PLHIV are at increased risk of developing viral resistance and other poor outcomes because of low level of ART adherence, and more specifically older patients who have even a less efficient immune system,” conclude the researchers. “This may become a significant public health hazard, deserving preventive and corrective measures to assure PLHIV better quality of life and outcomes in SSA.”

Depression, one of the most common psychiatric disorders, is two- to three-times more prevalent in people living with HIV (PLHIV) than in the general population in many settings as shown in western countries but remains neglected in sub-Saharan Africa (SSA). We aimed to summarize the available evidence on the prevalence of depression and associated factors according to the scales used and the treatment status in PLHIV in SSA. The pooled prevalence estimates of depression ranged between 9% and 32% in PLHIV on antiretroviral treatment (ART) and in untreated or mixed (treated/untreated) ones, with a substantial variability according to the measurement scale used and also for a given scale. Low socio-economic conditions in PLHIV on ART, female sex and immunosuppression in mixed/untreated PLHIV were frequently reported as associated factors but with no consensus. As depression could have deleterious consequences on the PLHIV life, it is critical to encourage its screening and management, integrating these dimensions in HIV care throughout SSA.

Charlotte Bernard, François Dabis, Nathalie de Rekeneire

Aidsmap material
PLOS One abstract

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