Depression is highly prevalent among HIV-infected individuals. In a US national study of HIV-infected individuals receiving medical care, the 12-month prevalence of major depressive disorder was 36%,1 much higher than the 5%–7% prevalence reported in the general population.2 Measurement challenges notwithstanding,3 depression is also very common among HIV-infected individuals in resource-limited settings worldwide,4 including HIV-infected persons in Uganda.5,6 The impact of depression on the care and management of HIV infection is also well established: depression is associated with both reduced antiretroviral therapy (ART) adherence,7,8 delayed ART uptake,9 accelerated disease progression,10,11 and reduced survival.12 Thus, understanding the determinants of depression in this population may help identify targets for interventions to improve clinical outcomes.
ART-mediated viral suppression has also been associated with reduced depression symptom severity in HIV-infected individuals.13–16 The improvement of depression on ART is often attributed to psychosocial and lifestyle factors such as improved social support, living situation, and overall health status.15,17,18 Although biological mechanisms may also contribute to improvements in depression on ART,19,20 these mechanisms remain poorly understood.
One key biologic pathway may result from the HIV-associated induction of indoleamine 2,3-dioxygenase-1 (IDO). IDO is induced by microbial products and both types I and II interferons in HIV infection21,22 and results in catabolism of the essential amino acid tryptophan, which is required for serotonin synthesis, into kynurenine and several other downstream immunologically active catabolites.19 IDO induction in the immediate postpartum period has long been implicated as one of the mechanisms in the pathogenesis of postpartum depression in HIV-uninfected women, presumably due to serotonin depletion in the central nervous system.20–23 Increased activity of the kynurenine pathway of tryptophan catabolism (as assessed by the ratio of kynurenine to tryptophan in plasma, KT ratio) has also been associated with progressive AIDS,24,25 and ART-mediated viral suppression decreases the activation of the kynurenine pathway.24 Poor dietary protein intake may also contribute to lower plasma tryptophan levels,25 which may further lower serotonin levels and contribute to the heightened prevalence of depression among HIV-infected individuals in resource-poor settings.26,27
For these reasons, we hypothesized that the kynurenine pathway of tryptophan catabolism contributes to depression in HIV-infected individuals, and that ART-mediated reductions in the kynurenine pathway may explain some of the reductions in depression severity observed among HIV-infected individuals on ART in previous studies. We also hypothesized that the impact of the kynurenine pathway on depression would be greatest among individuals with low dietary protein intake and that increased dietary protein intake would be associated with improved depression severity. To examine these hypotheses, we conducted a longitudinal study of changes in depression symptom severity and tryptophan catabolism among treatment-naive HIV-infected individuals initiating ART in rural Uganda.
Participants were sampled from the Uganda AIDS Rural Treatment Outcomes (UARTO) Study, an ongoing cohort of 504 ART-naive HIV-infected individuals initiating free ART at the Mbarara Immune Suppression Syndrome Clinic in Mbarara, Uganda. Clinic patients were eligible for participation if they were newly initiating ART, were 18 years of age or older, and lived within 20 km of the clinic. Participants undergo structured interviews every 3–4 months, blood draws to determine CD4+ T-cell count and plasma HIV RNA levels, and biologic specimen archiving. All participants with available pre-ART plasma were assessed in the current analysis. This study was approved by the Committee on Human Research, University of California at San Francisco; the Partners Human Research Committee, Massachusetts General Hospital; and the Institutional Ethical Review Committee, Mbarara University of Science and Technology. All participants provided written informed consent.
Cryopreserved plasma was assessed at pre-ART baseline and at months 6 and 12 of ART for tryptophan and kynurenine levels using liquid chromatography–tandem mass spectrometry as previously described.28 Kynurenine pathway activity was assessed as the ratio of plasma kynurenine concentration to plasma tryptophan concentration (KT ratio). All plasma samples were drawn in the morning before 9:30 AM, before receipt of a complimentary snack voucher. However, fasting peripheral blood measures were not planned a priori during cohort enrollment, and participants were not required to have been fasting before their scheduled blood draws. Plasma HIV RNA levels and CD4+ T-cell counts were measured at each visit at a CAP-certified laboratory in Kampala, Uganda.
To measure depression symptom severity, we used a modified version of the Hopkins Symptom Checklist for Depression (HSCL-D).29 This version was developed and previously used among HIV-infected individuals in Uganda30,31 and contains an additional item, “Feeling like I don't care about my health” and deletes the item “feeling trapped or caught.” We removed 3 items addressing somatic symptoms of depression based on evidence that the inclusion of these items may inflate depression scores among HIV-infected individuals due to overlap between symptoms of depression and symptoms of HIV.32,33 The total HSCL-D score was calculated by averaging across the remaining 12 cognitive-affective items. The conventional threshold of 1.75 or greater was used to indicate probable depression,34 consistent with the majority of studies conducted in Sub-Saharan Africa that employed the HSCL-D.35,36 The HSCL-D has shown excellent reliability and construct validity among HIV-infected persons in rural Uganda.16,37,38 At baseline, the Cronbach's alpha for the modified HSCL-D was 0.83.
Dietary protein intake was assessed using the Dietary Diversity Scale, which assesses consumption of food in 12 different food groups in a 24-hour reference period.39 Based on the distribution of the data, we constructed a dichotomous variable representing 2 or more (vs. 1 or fewer) sources of dietary protein. Potential sources of dietary protein included beef, eggs, fish, beans, and/or cheese. The nonprotein sources elicited in the Dietary Diversity Scale were bread, Irish potatoes, vegetables, fruits, oil, sugar/honey, and condiments.
Participants were weighed at each study visit. We determined participants' heights at study enrollment. Using these quarterly weight measurements and the participants' height, we calculated body mass index (BMI) as the ratio of weight to height squared.
Baseline sociodemographic variables included age, marital status, educational attainment, household asset wealth, and alcohol use. The wealth index was generated using principal components analysis applied to data from a 25-item questionnaire inquiring about household assets and housing characteristics, with higher values indicating greater household wealth.40 Heavy drinking was defined as a positive screen based on the 3-item consumption subset of the Alcohol Use Disorders Identification Test (AUDIT-C).41,42
Correlations between continuous variables were assessed with Spearman rank order correlation coefficients. Associations between continuous and categorical variables were assessed with the Kolmogorov–Smirnov test. We used random-effects linear regression models to estimate the association between depression symptom severity and duration of ART; these models included both fixed effects and a random effect, where the “fixed effects” are the covariates and the “random effect” is the random intercept. We created a linear spline of duration on ART with a knot at 6 months to account for potentially nonlinear changes. To determine whether ART-associated changes in depression were potentially mediated by tryptophan levels, we added this variable to the regression model and then reassessed the statistical significance of the duration terms. The models were further adjusted for baseline age, gender, marital status, educational attainment, household asset wealth, and AUDIT-C positive screen; and time-varying BMI and CD4+ T-cell count. No variables were removed as part of model selection. Plasma HIV RNA level was not considered as a potential confounder as it is likely to be both a primary cause and a consequence of IDO induction. We fit similar models replacing tryptophan with KT ratio as the explanatory variable.
We also used random-effects linear regression models to assess the relationship between dietary protein intake and plasma tryptophan levels. These regression models were restricted to participants who were recruited after the dietary protein assessment was incorporated into the survey instrument in 2007. Interaction terms were constructed to assess the extent to which dietary protein intake modified the association between KT ratio and depression severity.
Participants were enrolled from July 2005 through September 2010. Most participants were women [318 (63.1%)], median age was 34, and most had AIDS with a median CD4 count of 138 cells per cubic millimeter and high median viral load of 4.97 log10 copies per milliliter at baseline (Table 1). At baseline, the median depression score was 1.42 (interquartile range, 1.17–1.92), and 157 (31.2%) had scores consistent with the screening threshold for probable depression. At pre-ART baseline, the median depression score was greater among women than men (1.71 vs. 1.41, P < 0.001). Greater depression symptom severity was also associated with lower household asset wealth (ρ = −0.11, P = 0.03), lower plasma tryptophan (ρ = −0.16; P < 0.001), and higher plasma KT ratio (ρ = 0.18, P < 0.001).
We next evaluated the impact of ART-mediated viral suppression on both depression severity and tryptophan levels. Among those contributing data at months 6 and 12 of ART, 402 of 430 (93.5%) and 330 of 360 (91.7%) participants, respectively, had a plasma HIV RNA level of ≤400 copies per milliliter. Over the 12-month study period, depression scores declined to a median of 1.08 (P < 0.001), and 28 of 353 (7.9%) participants met screening criteria for probable depression (P < 0.001). The change in depressive symptoms was nonlinear over the 12-month period, with the greatest rate of improvement in HSCL-D score observed in the first 6 months (−0.05 points per month, P < 0.001) and a somewhat slower rate of improvement observed between months 6 and 12 (−0.02 points per month, P < 0.001) (Fig. 1A).
The median plasma KT ratio decreased from 122 nM/μM to 60 nM/μM over the 12-month study period (P < 0.001). This decrease was also nonlinear, paralleling the decline in depression severity (Fig. 1B). KT ratio was associated with the level of depression symptom severity (+0.02 for each 10 nM/μM increase in KT ratio, P < 0.001). The median plasma tryptophan level increased from 3710 ng/mL to 5280 ng/mL during the 12-month study period (P < 0.001). This increase was also nonlinear, mirroring the changes observed in depression severity (Fig. 1C). Plasma tryptophan level was associated with the level of depressive symptom severity (−0.07 for each 1000 ng/mL increase in tryptophan level, P < 0.001) (Table 2).
After adjustment for age, gender, marital status, educational attainment, BMI, household asset wealth, AUDIT positive screen, and CD4+ T-cell count, the association between tryptophan level and depression symptom severity remained statistically significant [b = −0.05; 95% confidence interval (CI): −0.07 to −0.03; P < 0.001] as did the association between KT ratio and depression (b = 0.01; 95% CI: 0.004 to 0.02; P = 0.004). Because IDO induction may partially mediate the associations between gender and depression and between CD4 count and depression (ie, these factors might not appropriately be considered confounders), we conducted sensitivity analyses excluding these variables from the regression model. We also refit the regression models while limiting the sample to the 305 participants who had achieved viral suppression at months 6 and 12. The estimates from these sensitivity models were qualitatively similar to our main adjusted findings (Table 2).
We next assessed the degree to which ART-mediated changes in tryptophan levels and KT ratio may have explained the observed declines in depression symptom severity. Inclusion of tryptophan in the regression model attenuated the association between duration of ART and depression symptom severity (Table 3): the z-score corresponding to the level difference in depression symptom severity during the first 6 months on ART was reduced by 17.7%. Similarly, on the addition of KT ratio to the regression model, the z-score for the first 6 months on ART was reduced by 28.1%. In both models, the duration of ART variable remained statistically significant.
At the time of the first dietary diversity assessment, the median number of self-reported dietary protein sources was 2 (range, 0–5), with 99 participants (37.5%) reporting very few (0–1) protein sources. The median number of nonprotein sources was 4 (range, 0–7). In the multivariable regression models, each additional dietary protein source was associated with a mean of 188 ng/mL greater tryptophan level (P = 0.01), whereas the number of non-protein sources was not (36 ng/mL of tryptophan per nonprotein source, P = 0.44). A lower number of dietary protein sources were also associated with depression symptom severity after adjustment for covariates (b = −0.05; 95% CI: −0.08 to −0.01; P = 0.01).
Since poor dietary protein intake could plausibly exacerbate the effect of the kynurenine pathway of tryptophan catabolism on depression, we next assessed whether the relationship between KT ratio and depression was modified by self-reported dietary protein intake. As hypothesized, KT ratio tended to be more strongly associated with depression symptom severity among participants reporting 0–1 dietary protein sources (b = 0.02 for each 10 nM/μM increase in KT ratio; 95% CI: 0.01 to 0.03; P < 0.001) than among those reporting 2 or more dietary protein sources (b = 0.01; 95% CI: −0.004 to −0.017; P = 0.27), but the formal test for interaction was not statistically significant (P = 0.08).
It has long been recognized that depression is more common among HIV-infected individuals than in the general population and that ART leads to improved depression symptom severity.13–16 Although these observations have often been attributed to changes in psychosocial and general improvements in health,18 our study has identified a potential biologic mechanism that may at least partially explain these observed findings. In this longitudinal study of HIV-infected individuals initiating ART in rural Uganda, we found baseline levels of tryptophan catabolism (through the kynurenine pathway) approximately 2-fold higher compared to HIV negative control populations,29,30 and higher tryptophan catabolism and lower plasma tryptophan level were associated with greater depression symptom severity both before and during ART. We confirmed earlier reports finding that depressive symptoms are common among HIV-infected persons in Uganda,5,6 and that symptoms improve during early ART,15,17,18 and demonstrated that at least part of the ART-associated improvements in depression symptom severity may be mediated by increased plasma tryptophan levels. In ancillary analyses, we found that having few dietary protein sources was associated with low tryptophan level and increased depression symptom severity. Furthermore, the association between kynurenine pathway activity and depression symptom severity tended to be stronger among those with protein-deficient diets.
Our findings suggest that the immunologic changes associated with HIV infection and its treatment may at least partly explain the greater prevalence of depression observed among HIV-infected persons, as well as improvements in depressed mood observed during ART. IDO has long been recognized as an important immunoregulatory enzyme induced in activated dendritic cells and monocytes in response to several inflammatory diseases, cancers, and infections including HIV.24,43–46 IDO induces the catabolism of tryptophan into several downstream immunologically active catabolites that decrease T-cell proliferation and suppress Th17 cells, effects that appear to be important in the prevention of fetal allograft rejection during pregnancy, the evasion of many cancers from the host immune response, and in HIV pathogenesis.47–50 However, the kynurenine pathway of tryptophan catabolism can also have important psychological effects.19 Tryptophan is required for serotonin synthesis, and the relative depletion of serotonin in the central nervous system has been implicated in the pathogenesis of depression.51 Furthermore, some downstream tryptophan catabolites, including quinolinic acid, can be neurotoxic and could contribute to cognitive impairment or mood disorders in this setting.52 Indeed, the increase in IDO activity observed among women after giving birth is thought to be one potential biologic mechanism explaining postpartum depression among HIV-uninfected women.20–23 Our finding that HIV-associated IDO induction of tryptophan depletion is associated with increased depression symptom severity both before and during ART is consistent with this earlier body of work and may provide unique insights into the biologic basis for depression in HIV infection.
This hypothesis is further supported through several of our ancillary analyses. Having few dietary protein sources was associated with low levels of tryptophan and greater depression symptom severity. Also, while the formal test for statistical interaction was not statistically significant, the association between kynurenine pathway activity and depression symptom severity was stronger among those with a protein-deficient diet. This suggests, but is not proven in our study, that the kynurenine pathway is causally related to depressive symptoms in this setting and not simply a marker for an alternative immunologic mechanism. Moreover, the observations may also partially explain the high prevalence of depression among HIV-infected individuals in resource-limited settings where food insecurity is common53 and may suggest a greater likelihood of observing an “antidepressant” effect of ART in these settings compared to the resource-rich settings where these findings were first noted.13,18 If true, then dietary protein supplementation would be expected to have beneficial effects on depression among HIV-infected individuals with protein-limited diets, a hypothesis that is potentially testable in randomized controlled trials.
Our findings that higher tryptophan catabolism through the kynurenine pathway and lower plasma tryptophan levels were significantly associated with greater depression symptom severity during ART may also explain the observation that depression is associated with more rapid disease progression and death in both treated and untreated HIV-infected individuals.10–12 HIV-associated immune activation may cause more rapid disease progression and death, but it may also lead to greater IDO-mediated depletion of tryptophan and, therefore, increased depressive symptom severity.
It is important to highlight that the correlations between KT ratio, tryptophan levels, and depressive symptoms, while statistically significant, were modest in magnitude and that duration of ART retained a statistically significant association with depressive symptoms even after adjustment for tryptophan level and/or KT ratio. This suggests that factors other than tryptophan level and IDO induction are likely contributing to the apparently beneficial effect of ART on depression. Indeed, social integration, food insecurity, and overall health status typically improve during ART,54–58 and each of these factors likely contributed to decreased depressive symptoms as well. It is also relevant to acknowledge the possibility that both depression and kynurenine pathway induction may be less severe in patients starting ART at earlier disease stages. While we did not find evidence of interaction by CD4+ T-cell count (data not shown), we cannot exclude the possibility that the estimated association between KT ratio and depression would be less strong in HIV-infected patients at earlier stages of disease.
There are several limitations to this analysis. First, we did not have access to formal Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition diagnoses of major depressive disorder, so there may have been some misclassification of depression in this study. Second, depression may itself increase the risk of HIV acquisition59 and thereby have independent effects on the immune system. Because our measures of IDO activity were concurrent with the measures of depression, and because we do not have plasma samples and depression measures obtained before the participants' acquisition of HIV infection, we cannot confirm the causal direction of these relationships. Third, IDO induction and poor protein intake may simply be a consequence of poor overall health status that may drive depression through independent mechanisms. Fourth, our measure of dietary diversity is an imperfect measure of dietary protein intake (ie, a person who eats a large amount of a single type of protein may have greater total protein intake than one who eats small amounts of multiple protein sources). Yet, this is likely to have biased the association between tryptophan level and the number of dietary protein sources toward the null. Fifth, the tryptophan and kynurenine determinations were based on plasma specimens that were not confirmed to be fasting, which may have made associations more difficult to detect. Recent protein intake transiently increases both plasma tryptophan level and KT ratio, but this effect is likely modest relative to the wide distribution of levels observed in HIV-infected individuals60 and, if anything, also would have biased the association between these measures and depression toward the null. Sixth, we did not have measurements of peripheral serotonin, which would have allowed us to observe more directly the link between depression and plasma tryptophan. Finally, tryptophan 2,3-dioxygenase (TDO) may also contribute to tryptophan catabolism through the kynurenine pathway. Unlike IDO, TDO is not inducible and mainly expressed in the liver, such that the dramatic changes in kynurenine pathway activity seen in HIV infection and with ART are much more likely to be driven by changes in IDO then TDO expression.61 HIV-mediated changes in the composition of the gut microbiome may also contribute to systemic kynurenine levels, even in the setting of ART-mediated viral suppression.62 Thus, other factors beyond host IDO activity may contribute to kynurenine levels, and their role in the biologic mechanisms underlying depression in HIV should be considered in future studies.
In summary, we identified the kynurenine pathway of tryptophan catabolism as a biologic mechanism that may partially explain why HIV-infected individuals have an increased risk of depression and why ART appears to decrease depression symptom severity. These data suggest that interventions designed to further reduce the inflammatory state and kynurenine pathway activity during ART may also have beneficial effects on depressive symptoms and that protein supplementation may also have beneficial effects on depression in resource-poor settings. Both of these hypotheses are testable in randomized clinical trials.
The authors thank the UARTO participants and staff who made this study possible. The authors also acknowledge the following additional sources of support: The Norwegian Research Council, Drug Research Program; NIH K23MH087228, K23MH096620, K23MH079713, K24MH087227, R56AI100765, T32AA007240, and R21AI078774; and the Doris Duke Charitable Foundation (Clinical Scientist Development Award No. 2008047).
1. Bing EG, Burnam MA, Longshore D, et al.. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58:721–728.
2. Kessler RC, Berglund P, Demler O, et al.. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095–3105.
3. Summerfield D. Afterword: against “global mental health”. Transcult Psychiatry. 2012;49:519–530.
4. Collins PY. Challenges to HIV prevention in psychiatric settings: perceptions of South African mental health care providers. Soc Sci Med. 2006;63:979–990.
5. Nakimuli-Mpungu E, Musisi S, Katabira E, et al.. Prevalence and factors associated with depressive disorders in an HIV+ rural patient population in southern Uganda. J Affect Disord. 2011;135:160–167.
6. Kaharuza FM, Bunnell R, Moss S, et al.. Depression and CD4 cell count among persons with HIV infection in Uganda. AIDS Behav. 2006;10:S105–111.
7. Gonzalez JS, Batchelder AW, Psaros C, et al.. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr. 2011;58:181–187.
8. Tsai AC, Weiser SD, Petersen ML, et al.. A marginal structural model to estimate the causal effect of antidepressant medication treatment on viral suppression among homeless and marginally housed persons with HIV. Arch Gen Psychiatry. 2010;67:1282–1290.
9. Fairfield KM, Libman H, Davis RB, et al.. Delays in protease inhibitor use in clinical practice. J Gen Intern Med. 1999;14:395–401.
10. Burack JH, Barrett DC, Stall RD, et al.. Depressive symptoms and CD4 lymphocyte decline among HIV-infected men. JAMA. 1993;270:2568–2573.
11. Ickovics JR, Hamburger ME, Vlahov D, et al.. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study. JAMA. 2001;285:1466–1474.
12. Page-Shafer K, Delorenze GN, Satariano WA, et al.. Comorbidity and survival in HIV-infected men in the San Francisco Men's Health Survey. Ann Epidemiol. 1996;6:420–430.
13. Low-Beer S, Chan K, Yip B, et al.. Depressive symptoms decline among persons on HIV protease inhibitors. J Acquir Immune Defic Syndr. 2000;23:295–301.
14. Judd FK, Cockram AM, Komiti A, et al.. Depressive symptoms reduced in individuals with HIV/AIDS treated with highly active antiretroviral therapy: a longitudinal study. Aust N Z J Psychiatry. 2000;34:1015–1021.
15. Nakasujja N, Skolasky RL, Musisi S, et al.. Depression symptoms and cognitive function among individuals with advanced HIV infection initiating HAART in Uganda. BMC Psychiatry. 2010;10:44.
16. Tsai AC, Bangsberg DR, Frongillo EA, et al.. Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Soc Sci Med. 2012;74:2012–2019.
17. Brechtl JR, Breitbart W, Galietta M, et al.. The use of highly active antiretroviral therapy (HAART) in patients with advanced HIV infection: impact on medical, palliative care, and quality of life outcomes. J Pain Symptom Manage. 2001;21:41–51.
18. Rabkin JG, Ferrando SJ, Lin SH, et al.. Psychological effects of HAART: a 2-year study. Psychosom Med. 2000;62:413–422.
19. Maes M, Leonard BE, Myint AM, et al.. The new “5-HT” hypothesis of depression: cell-mediated immune activation induces indoleamine 2,3-dioxygenase, which leads to lower plasma tryptophan and an increased synthesis of detrimental tryptophan catabolites (TRYCATs), both of which contribute to the onset of depression. Prog Neuropsychopharmacol Biol Psychiatry. 2011;35:702–721.
20. Kohl C, Walch T, Huber R, et al.. Measurement of tryptophan, kynurenine and neopterin in women with and without postpartum blues. J Affect Disord. 2005;86:135–142.
21. Schrocksnadel H, Baier-Bitterlich G, Dapunt O, et al.. Decreased plasma tryptophan in pregnancy. Obstet Gynecol. 1996;88:47–50.
22. Schrocksnadel K, Widner B, Bergant A, et al.. Longitudinal study of tryptophan degradation during and after pregnancy. Life Sci. 2003;72:785–793.
23. Maes M, Lin AH, Ombelet W, et al.. Immune activation in the early puerperium is related to postpartum anxiety and depressive symptoms. Psychoneuroendocrinology. 2000;25:121–137.
24. Zangerle R, Widner B, Quirchmair G, et al.. Effective antiretroviral therapy reduces degradation of tryptophan in patients with HIV-1 infection. Clin Immunol. 2002;104:242–247.
25. Markus CR. Dietary amino acids and brain serotonin function; implications for stress-related affective changes. Neuromolecular Med. 2008;10:247–258.
26. Weiser SD, Young SL, Cohen CR, et al.. Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. Am J Clin Nutr. 2011;94:1729S–1739S.
27. Kinyanda E, Hoskins S, Nakku J, et al.. Prevalence and risk factors of major depressive disorder in HIV/AIDS as seen in semi-urban Entebbe district, Uganda. BMC Psychiatry. 2011;11:205.
28. Favre D, Mold J, Hunt PW, et al.. Tryptophan catabolism by indoleamine 2,3-dioxygenase 1 alters the balance of TH17 to regulatory T cells in HIV disease. Sci Transl Med. 2010;2:32ra36.
29. Derogatis LR, Lipman RS, Rickels K, et al.. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci. 1974;19:1–15.
30. Bolton P. Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. J Nerv Ment Dis. 2001;189:238–242.
31. Bolton P, Wilk CM, Ndogoni L. Assessment of depression prevalence in rural Uganda using symptom and function criteria. Soc Psychiatry Psychiatr Epidemiol. 2004;39:442–447.
32. Kalichman SC, Rompa D, Cage M. Distinguishing between overlapping somatic symptoms of depression and HIV disease in people living with HIV-AIDS. J Nerv Ment Dis. 2000;188:662–670.
33. Kalichman SC, Sikkema KJ, Somlai A. Assessing persons with human immunodeficiency virus (HIV) infection using the Beck Depression Inventory: disease processes and other potential confounds. J Pers Assess. 1995;64:86–100.
34. Derogatis LR, Lipman RS, Rickels K, et al.. The Hopkins Symptom Checklist (HSCL). A measure of primary symptom dimensions. Mod Probl Pharmacopsychiatry. 1974;7:79–110.
35. Bass JK, Annan J, McIvor Murray S, et al.. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med. 2013;368:2182–2191.
36. Hatcher AM, Tsai AC, Kumbakumba E, et al.. Sexual relationship power and depression among HIV-infected women in Rural Uganda. PLoS One. 2012;7:e49821.
37. Martinez P, Andia I, Emenyonu N, et al.. Alcohol use, depressive symptoms and the receipt of antiretroviral therapy in southwest Uganda. Alcohol Clin Exp Res. 2006;30:605–612.
38. Tsai AC, Weiser SD, Steward WT, et al.. Evidence for the reliability and validity of the internalized AIDS-related stigma scale in rural Uganda. AIDS Behav. 2013;17:427–433.
39. Swindale A, Bilinsky P. Household Dietary Diversity Score (HDDS) for Measurement of Household Food Access: Indicator Guide, Version 2. Washington DC, WA: Academy for Educational Development; 2006.
40. Filmer D, Pritchett LH. Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India. Demography. 2001;38:115–132.
41. Bush K, Kivlahan DR, McDonell MB, et al.. The AUDIT alcohol consumption questions (AUDIT-C)—an effective brief screening test for problem drinking. Arch Intern Med. 1998;158:1789–1795.
42. Bradley KA, Bush KR, Epler AJ, et al.. Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med. 2003;163:821–829.
43. Mellor AL, Munn DH. IDO expression by dendritic cells: tolerance and tryptophan catabolism. Nat Rev Immunol. 2004;4:762–774.
44. Taylor MW, Feng GS. Relationship between interferon-gamma, indoleamine 2,3-dioxygenase, and tryptophan catabolism. FASEB J. 1991;5:2516–2522.
45. Grant RS, Naif H, Thuruthyil SJ, et al.. Induction of indoleamine 2,3-dioxygenase in primary human macrophages by HIV-1. Redox Rep. 2000;5:105–107.
46. Huengsberg M, Winer JB, Gompels M, et al.. Serum kynurenine-to-tryptophan ratio increases with progressive disease in HIV-infected patients. Clin Chem. 1998;44:858–862.
47. Munn DH, Zhou M, Attwood JT, et al.. Prevention of allogeneic fetal rejection by tryptophan catabolism. Science. 1998;281:1191–1193.
48. Frumento G, Rotondo R, Tonetti M, et al.. Tryptophan-derived catabolites are responsible for inhibition of T and natural killer cell proliferation induced by indoleamine 2,3-dioxygenase. J Exp Med. 2002;196:459–468.
49. Boasso A, Herbeuval JP, Hardy AW, et al.. HIV inhibits CD4+ T-cell proliferation by inducing indoleamine 2,3-dioxygenase in plasmacytoid dendritic cells. Blood. 2007;109:3351–3359.
50. Muller AJ, DuHadaway JB, Donover PS, et al.. Inhibition of indoleamine 2,3-dioxygenase, an immunoregulatory target of the cancer suppression gene Bin1, potentiates cancer chemotherapy. Nat Med. 2005;11:312–319.
51. Delgado PL, Price LH, Miller HL, et al.. Serotonin and the neurobiology of depression. Effects of tryptophan depletion in drug-free depressed patients. Arch Gen Psychiatry. 1994;51:865–874.
52. Maes M, Kubera M, Obuchowiczwa E, et al.. Depression's multiple comorbidities explained by (neuro)inflammatory and oxidative & nitrosative stress pathways. Neuro Endocrinol Lett. 2011;32:7–24.
53. Tsai AC, Bangsberg DR, Emenyonu N, et al.. The social context of food insecurity among persons living with HIV/AIDS in rural Uganda. Soc Sci Med. 2011;73:1717–1724.
54. Zuch M, Lurie M. “A virus and nothing else”: the effect of ART on HIV-related stigma in rural South Africa. AIDS Behav. 2012;16:564–570.
55. Castro A, Farmer P. Understanding and addressing AIDS-related stigma: from anthropological theory to clinical practice in Haiti. Am J Public Health. 2005;95:53–59.
56. Campbell C, Skovdal M, Madanhire C, et al.. “We, the AIDS people...”: how antiretroviral therapy enables Zimbabweans living with HIV/AIDS to cope with stigma. Am J Public Health. 2011;101:1004–1010.
57. Weiser SD, Gupta R, Tsai AC, et al.. Changes in food insecurity, nutritional status, and physical health status after antiretroviral therapy initiation in rural Uganda. J Acquir Immune Defic Syndr. 2012;61:179–186.
58. Tsai AC, Bangsberg DR, Bwana M, et al.. How does antiretroviral treatment attenuate the stigma of HIV? Evidence from a Cohort Study in Rural Uganda. AIDS Behav. 2013;17:2725–2731.
59. Miller AH, Maletic V, Raison CL. Inflammation and its discontents: the role of cytokines in the pathophysiology of major depression. Biol Psychiatry. 2009;65:732–741.
60. de Jong WH, Smit R, Bakker SJ, et al.. Plasma tryptophan, kynurenine and 3-hydroxykynurenine measurement using automated on-line solid-phase extraction HPLC-tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci. 2009;877:603–609.
61. Badawy AAB. Tryptophan: the key to boosting brain serotonin synthesis in depressive illness. J Psychopharmacol. 2013;10:878–893.
62. Vujkovic-Cvijin I, Dunham RM, Iwai S, et al.. Dysbiosis of the gut microbiota is associated with HIV disease progression and tryptophan catabolism. Sci Transl Med. 2013;5:193ra191.