Wu, Diana Ying MD, MSc*; Munoz, Maribel RN†; Espiritu, Betty RN†; Zeladita, Jhon RN†; Sanchez, Eduardo MD†; Callacna, Miriam RN†; Rojas, Christian MD†; Arevalo, Jorge MD†; Caldas, Adolfo MSW‡; Shin, Sonya MD, MPH‡
Depression impacts HIV outcomes both through nonadherence to antiretroviral therapy1-6 and direct physiological effects on the immune system.7-10 The end result is the association of depression with increased HIV progression and a 2-fold mortality risk among persons living with HIV/AIDS (PLHA).8,11-13 In resource-poor settings, the burden of depression among PLHA is indisputable.14 Although reports vary due to sociocultural and sampling/measurement differences, the prevalence of depression among PLHA living in resource-poor settings ranges from 21% to 57%.2,15-22 The vicious cycle of depression and HIV is worsened by poverty-related factors, such as social isolation, lack of material resources, and gender inequality.2,21,23,24 In many settings, women living in poverty disproportionately bear the burden of these 2 diseases.25-28 Yet, few have described the frequency and characteristics of depression specifically among women living with HIV/AIDS (WLHA) in such settings.28 To contribute to our limited knowledge of depression among women in resource-limited settings, we describe the prevalence of and factors associated with depression among Peruvian WLHA.
STUDY SETTING AND METHODS
In Peru, an estimated 93,000 individuals (0.6%) live with HIV.29 Published reports on HIV transmission in Peru cite primary risk factors for HIV of early sexual activity and number of past partners among women.30 Among the most impoverished strata of patients in Lima, heterosexual sex is an increasingly prevalent mode of transmission. Supported by the Global Fund, the Peruvian National HIV Program began to offer free highly active antiretroviral therapy (HAART) in 2004. Since 2005, the Peruvian National HIV Program has collaborated with a nongovernmental organization, Socios En Salud, to implement a community-based accompaniment program, consisting of home-based directly observed HAART, psychosocial support, and socioeconomic assistance with the goal of improving adherence among Peruvian patients initiating HAART for the first time. Although all impoverished patients starting HAART were eligible, referring physicians gave priority to women and tuberculosis coinfected patients.31 Between November 2005 and August 2007, we enrolled 159 adults-of these 78 women-recently starting or about to start HAART based on World Health Organization guidelines.32 Our study took place in 2 hospitals (Hospital Hipolito Unanue and Hospital Dos de Mayo). Patients provided informed consent, which was verbally read to all patients.
Data Collection and Analysis
Baseline socioeconomic and clinical data were collected using standardized forms, based on patient interview and chart review. Psychosocial data were obtained in a series of one-on-one verbal interviews, conducted privately in a site specified by the patient. To assess depression, we used the Hopkins Symptom Checklist-15.33,34 This 15-item questionnaire has demonstrated adequate performance in assessing depression in HIV-positive individuals and in multicultural populations,18,35-37 including Latino college students in the United States,38 and Spanish-speaking populations in El Salvador and Guatemala.39-41 Questions are scored on a severity scale from 1 (para nada) to 4 (mucho), with a higher score indicating more depressive symptoms. Although not calibrated in our cohort, we used the conventional cutoff score of 1.75.42-44 We assessed stigma and social support using the Berger Stigma Instrument45 and Duke University of North Carolina Social Support Scale.46 A review of these instruments and our validation procedures is described elsewhere.47 For all instruments, the Cronbach's alpha was >0.80 in this cohort. Data were entered into an ACCESS database (Microsoft, Seattle, WA). We summarized demographic, clinical, and psychosocial characteristics of patients and performed a univariate analysis to assess for characteristics associated with depression, using χ2 test or Fisher exact test for categorical variables and the t test or Wilcoxon test for continuous variables. All variables with a level of significance of <0.05 were included in a multivariable analysis using a stepwise logistic regression model to retain only those variables with a P value of <0.05. For this model, we created binary psychosocial variables assigning a poor status for those scoring worse than the cohort median. We did not include colinear variables (defined as a Pearson correlation coefficient >0.6) in the model. Analyses were conducted using SAS Version 9.1 (SAS Institute, Inc, Cary, NC).
The study was approved by the Partners Human Subjects Committee at the Brigham and Women's Hospital, the Institutional Review Board of the Peruvian National Institute of Health, and the ethics committees of both participating hospitals. Given the high rates of depression and other psychosocial stressors in our cohort, we developed a brief checklist of psychiatric symptoms. Health promoters administer this interview monthly to identify and refer cases with severe psychiatric and psychosocial problems.
Of 275 women identified to start HAART in the study hospitals during the study period, 91 women were referred to and enrolled into our study. We excluded 13 from analysis who died before completing baseline interviews. Of the remaining 78 women, 53 (68.0%) met criteria for depression. Of these, providers identified depression in only 11 (24.5%). Fourteen women had contemplated suicide in the past 30 days, but only 2 had communicated this to their provider. As shown in Table 1, the majority of women were unemployed and had difficulty accessing health services. Almost half reported food scarcity, defined as having gone at least a day in the past 3 months without eating, due to economic hardship.
On univariate analysis, food scarcity, having missed an appointment in the past 30 days, high stigma, and low emotional social support were associated with depression. None of these variables were colinear. Stepwise regression retained food scarcity and stigma greater than cohort mean, with adjusted odds ratios (95% confidence interval) of 3.95 (1.23, 12.69) and 4.81 (1.34, 17.30), respectively.
Based on Hopkins Symptom Checklist criteria, we encountered a high prevalence of depression (68%). This rate is much higher than the prevalence of depression among women in Lima, Peru (13.5% lifetime).48 This high burden of depression may be partially attributable to the nature of our cohort, WLHA who were specifically targeted for psychosocial support due to their impoverished and marginalized status. The rate of suicidal ideation among these women (18.0%) was lower than that found in a US study of HIV-positive men and women (26%)49 but higher than that found in a Brazilian study of depression in women with HIV (15.8%).22 Both depression and suicidal ideation were underdiagnosed by providers. These findings highlight the need to train HIV providers to diagnose and manage depression and suicidal ideation in their patients.
Stigma was significantly associated with depression in our cohort, consistent with other reports.17,50-52 Stigma and disclosure concerns stress women's relationships with partners and extended family, limiting their ability to tap into social supports and fulfill their roles as caregivers.53-55 Women also worry that their diagnosis may stigmatize their children.53
Lower socioeconomic status-reflected in missed appointments in the past 3 months due to economic hardship and low educational level-was associated with depression. Among socioeconomic indicators, food scarcity was most strongly associated with depression. This association has been described among other vulnerable women, although not among WLHA.56-59 This relationship reflects the pervasive stress associated with obtaining food day after day for oneself and one's family.60 This struggle for sheer survival characterizes the lives of many impoverished WLHA and limits their ability to adopt healthy behaviors, such as HAART adherence, avoiding breast-feeding, and practicing safe sex.61 The implications of food scarcity on health outcomes go beyond its impact on depression because malnutrition and micronutrient deficiencies accelerate HIV progression and increase mortality among HIV-positive individuals.62-67
Although not significant on multivariable analysis, we found a trend of association between lack of emotional social support and depression in our cohort. This finding corroborates other reports.68-71 The intense synergy between depression, low social support, poverty, and stigma among PLHA is remarkably consistent across cultures.17,50,54,72,73
Our findings did not support the association between depression and time since HIV diagnosis16 or substance use,17,74,75 nor did we find a significant association between depression and CD4 cell count, similar to some studies76-78 and contrary to others.21 The small cohort size limits the null findings of our study. Further, our cohort comprises women who were specifically referred for psychosocial support and may reflect referral bias of the most vulnerable women. Therefore, our findings may not be generalizable to the overall female HIV population in this region or elsewhere but at least highlight the formidable barriers faced by the most vulnerable WLHA. Another limitation is the lack of validation of the Hopkins Symptom Checklist cutoff score in our population. If this score overestimates the rate of depression, then the high rate of depression and the discordance between Hopkins Symptom Checklist defined and physician-documented depression could reflect poor calibration. However, our preliminary data demonstrate a decrease in depression based on this cutoff from 57% at baseline to 4% at 12 months,31 suggesting that this cutoff score may be appropriate in this population. Finally, we could not quantify or rule out the contribution of other factors (eg, cognitive disorders, central nervous system pathology, substance use, and medication toxicity) and modifying factors (eg, use of antidepressant therapy) on depressive symptoms.
Our findings provide insight into the complex interplay of poverty, stigma, and depression among HIV-positive women. Depression and suicidal ideation were largely not communicated to providers and went unaddressed, highlighting the need to integrate the wide array of evidence-based treatment of depression into HIV care.79-85 Although funding for global health has increased, there remains insufficient allocation for mental health services, which are crucial components of effective health interventions for all types of diseases.86 Community-based services could be one cost-effective approach to expand availability of mental health interventions.87
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