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Reliability and Validity of Depression Assessment Among Persons With HIV in Sub-Saharan Africa: Systematic Review and Meta-analysis

Tsai, Alexander C. MD*,†,‡,§

JAIDS Journal of Acquired Immune Deficiency Syndromes: August 15th, 2014 - Volume 66 - Issue 5 - p 503–511
doi: 10.1097/QAI.0000000000000210
Clinical Science

Objective: The aim of this study was to systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa.

Design: Systematic review and meta-analysis.

Methods: A systematic evidence search protocol was applied to 7 bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on the data collected from HIV-positive adults in any African member state of the United Nations. A random-effects meta-analysis was used to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.

Results: Of 1117 records initially identified, I included 13 studies of 5373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach alpha ranged from 0.63 to 0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% [95% confidence interval (CI): 20.5 to 39.4], whereas the pooled prevalence of major depressive disorder was 13.9% (95% CI: 9.7 to 18.6). The Center for Epidemiologic Studies Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI: 0.73 to 0.87) for detecting major depressive disorder.

Conclusions: Depression-screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.

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*Chester M. Pierce, MD Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA;

Massachusetts General Hospital Center for Global Health, Boston, MA;

Harvard Medical School, Boston, MA;

§Mbarara University of Science and Technology, Mbarara, Uganda.

Correspondence to: Alexander C. Tsai, MD, Massachusetts General Hospital Center for Global Health, Room 1529-E3, Massachusetts General Hospital, 100 Cambridge Street, 15th Floor, Boston, MA 02114 (e-mail:

No specific funding was awarded for the conduct of this study. The author receives salary support from US National Institutes of Health K23MH096620 and the Robert Wood Johnson Health and Society Scholars Program.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received January 08, 2014

Accepted April 25, 2014

© 2014 by Lippincott Williams & Wilkins