Background: Depression is significant disease burden and associated with poor health outcomes among people living with HIV (PLHIVs) globally. Majority of them are under diagnosed and untreated. Depression is also linked with poor antiretroviral therapy (ART) adherence causing ART inefficient and has a negative impact on the quality of life among PLHIVs. Objectives: This study aims to explore the prevalence of depression and potential associated factors among PLHIVs attending ART centers in Yangon region, Myanmar. Methods: This cross-sectional analytic study was conducted at public ART centers of Yangon region, Myanmar. A total of 425 PLHIVs were interviewed with pretested structured questionnaires. Center for Epidemiology Studies Depression Scale (CES-D) was used to assess the depression symptoms. Multiple logistic regression analysis was administered to determine the potential associated factors for depression. Results: The prevalence of depression among PLHIVs was 30.12% (95% CI = 25.74-34.49). The older age (Adjusted Odds Ratio (AOR) = 5.74; 95% Confidence Interval (CI) = 1.01-32.50), low education level (Adjusted Odds Ratio (AOR) = 0.11; 95% Confidence Interval (CI) = 0.01-0.85), unemployment (Adjusted Odds Ratio (AOR) = 2.81; 95% CI = 1.39–5.67), poor patient–provider relationship Adjusted Odds Ratio (AOR) = 1.82; 95% Confidence Interval (CI) = 1.01-3.30), lack of satisfaction (Adjusted Odds Ratio (AOR) = 4.61; 95% Confidence Interval (CI) = 2.03-10.46), and lack of exercise (Adjusted Odds Ratio (AOR) = 3.51; 95% Confidence Interval (CI) = 1.93-6.38) were found to be associated with depression. Conclusion: A considerable proportion of the clinic attendees at the public ART centers were found to have depression. It should be noted by the policy makers and program managers to establish early diagnosis and prompt treatment to achieve the better quality of life among PLHIVs.
Keywords: Depression, Myanmar, PLHIVs, public ART centers
HIV/AIDS is one of the global burden diseases, recognized as a serious public health problem and can spread throughout the world affecting all population. In Myanmar, about 75,000 people living with HIV (PLHIVs) have been receiving antiretroviral therapy (ART) from both public and private ART centers in 2014. Psychiatric disorders are significant disease burden among PLHIVs globally and have a negative impact on the ART adherence obviously with major depressive disorder., Although the prevalence of mental health disorders is high among PLHIVs, the mental health conditions are underdiagnosed and undertreated. Mental disorders may attribute to acquiring HIV infection due to high-risk behaviors and inability to judge., HIV-positive individuals have nearly twice the risk of developing depressive disorder compared with those without HIV. One out of three PLHIVs may suffer depression. Depression is not only an underdiagnosed but also a commonly untreated disease even among the general population. In high-income countries, the prevalence of depression among PLHIVs widely ranged from 20 to 48% and from 9 to 72% in resource-limited countries.,
Depression is related to medication nonadherence in chronic medical diseases, and patients with depression were three times less likely to adhere to the treatment compared with patients without depression., Many studies have documented the association of depression with poor ART adherence among PLHIVs, leading to an increased risk of viral mutations, rendering ART inefficient and causing disease progression, developing resistance to other antiretroviral drugs, or increasing the spread of multiresistant strains of HIV., One meta-analysis reported that ART adherence improved with antidepressant treatment among PLHIVs with depression.
A number of studies have considered the factors associated with depression among PLHIVs receiving ART, while some have focused on sociodemographic characteristics like age, gender, education, unemployment, and income and ethnicity, others have emphasized on health behavior like drug and alcohol use and domestic violence; some concentrated on the HIV-related symptoms.,, Although a few studies have been conducted on depression among the general population, little is known about the prevalence of depression and its determinants among PLHIVs in Myanmar. This study aims to explore the prevalence of depression and possible associated factors among PLHIVs in Myanmar to provide the observatory evidence for the policy makers and healthcare providers to develop an appropriate intervention program for early diagnosis and prompt treatment of depression among PLHIVs to attain a better quality of life.
This cross-sectional analytic study was undertaken at all public ART centers of Yangon region between June and August 2015. The required sample size of 425 participants was calculated by PASS software version 13 based on the multiple logistic regressions formula. The patients taking ART for 3 months duration and at least 18 years of age were eligible for this study. The eligible samples were recruited from eight public ART centers with proportional to size of the clinic attendees at each ART center.
Depression symptoms were measured by using Center for Epidemiology Studies Depression Scale (CES-D). The CES-D instrument consists of 20 items and rated from 0 (never or rarely) to 3 (mostly or all of the time). The participant had to recall the frequency of the occurrence of each item for the past 7 days. The CES-D is widely used to measure depressive symptoms in epidemiological studies and has been validated in different study population., The scores varied from 0 to 60, and the total scores of 16 or higher indicated depression.
The primary outcome of this study was depression, which was categorized into depressed and nondepressed. The independent variables were age, sex, education, occupation, income, marital status, disclosure status, duration of ART, CD4 count, comorbidities, patient–provider relationship, patients’ satisfaction, and health-related behaviors.
The data were collected by face-to-face interview with pretested structured questionnaires except the self-report form for assessment of depression. The questionnaires were translated into Myanmar and back translated into English by an independent translator. Prior to the interview, the researcher trained five research assistants for data collection on sampling procedure and data collection tool. To ensure privacy and confidentiality, separate rooms for data collection were also prepared. The data were collected on the OPD days of each ART center by applying systematic random sampling from the OPD register book on the day of data collection. The latest CD4 counts and associated comorbidities were recorded by reviewing of medical records of the respondents. The collected data were checked immediately after interview for consistency and completeness to assure the quality of the data.
The data were analyzed by using the Stata program version 13.0 (Stata Corp., College Station, Texas). The data were checked for validation before analysis. The sociodemographic and baseline characteristics of the participants were described with frequency and percentage for categorical data and mean and standard deviation for continuous data. The prevalence of depression with 95% CI was calculated. To determine the factors associated with depression, odds ratios (ORs) and 95% CI were estimated using multiple logistic regression model. Significant factors in a bivariate analysis with P less than 0.25 were included in a multiple logistic regression analysis. All test statistics were two-sided and P value less than 0.05 was considered as statistically significant. The Cronbach’s alpha coefficient was calculated for depression scale (0.78) to assess internal consistency.
Ethical clearance was approved by the Khon Kaen University Ethics Committee for human research with the reference number HE 582057. Permission to undertake this study was obtained from the responsible persons of the public ART centers. Verbal consent was taken from all participants after explaining the purpose of the study. The participation in this study was totally voluntary and the participants could withdraw any time during the data collection. All information provided by the participants was kept confidential.
Depression was assessed by the 20-item CES-D. The mean depression score for the respondents was 13.31, with SD of 7.59. The minimum and maximum depression scores were 0 and 49, respectively. CES-D score of 16 and above was considered to be depressed. The prevalence of depression among PLHIVs was 30.12% (95% CI = 25.74-34.49).
More than half of 425 respondents were male (55.53%), and majority of the respondents (49.41%) were in the productive age group of 30-44 years. The prevalence of depression was highest among the age group of 45-59 years (59.35%). Most of the participants (55.06%) were married, followed by divorce and widow group (25.88%) and single (19.6%). Regarding educational attainment, only 1.88% of the PLHIVs were illiterate or can read and write, the prevalence of depression was the highest in this group (75%) with compared to other educational levels. About 20% of the respondents were unemployed. The prevalence of depression was higher in unemployed than in employed group. The average per capita income per month was 72,891.26 Myanmar Kyats (SD: 58,141.07). Majority of them had low income (84.24%) of less than 100,000 Myanmar Kyats. The prevalence of depression was found to be higher in the low-income group (84.24%) [Table 1].
The prevalence of depression was higher in those PLHAs who have been taking ART for more than 6 months duration (33.80%), experiencing side effect of ART (36.21%), and had comorbidities (38.67%). About two third of the participants (68.71%) were found to have CD4 count of more than 500 mm3. Only 26 respondents reported that they missed ART doses in the last month [Table 2]. Very few participants (3.29%) mentioned that they did not disclose their HIV status. The prevalence of depression was higher among smokers (49.38%) and alcoholics (37.50%). Of those patients who were satisfied with the ART providing services, 84.24 and 60.94% reported having good relationship with the healthcare providers [Table 3].
Bivariate analysis revealed that the sociodemographic factors such as older age, low education attainment, unemployment, and low income were associated with depression [Table 1]. Taking ART for more than 6 months duration and missing ART doses in the last month were linked with depression. Depression was found to be prevalent respondents who were smokers, alcoholics, unsatisfied with ART provider services, and had poor patient-provider relationship in the bivariate analysis [Table 3]. In a multivariate analysis after adjusting the confounders, depression was associated with 45-59-year-age group (AOR = 8.53; 95% CI = 2.29-32.11) and those respondents who were 60 years and above (AOR = 5.74; 95% CI = 1.01-32.50). The higher the education level was, the lesser the likelihood of developing depression (AOR = 0.11; 95% CI = 0.01-0.85). Unemployment was significantly related with depression (AOR = 2.81; 95% CI = 1.39-5.67). Those participants who had missed the ART doses in the last month were found to have 4.5 times odds of developing depression (AOR = 4.50; 95% CI = 1.04-19.42). The lack of patient’s satisfaction (AOR = 4.61; 95% CI = 2.03-10.46) and poor patient-provider relationship were significantly associated with depression (AOR = 1.82; 95% CI = 1.01-3.30). Those who were not doing regular exercises were significantly more likely to develop depression (AOR = 3.51; 95% CI = 1.93-6.38) [Figure 1].
The prevalence of depression in this study population was 30.12%. Previous literature documented that the prevalence of depression varied widely among PLHIVs ranging from 22 to 62%.,, This might be due to different study design, different measuring tools to assess the depression, and different settings. Although the prevalence of depression was not very high in this study, it should be noted to explore the depression cases among PLHIVs attending the public ART centers in order to give the treatment as early as possible. Age was associated with depression in the current study, which was consistent with findings of other studies conducted in Ethiopia and Uganda., The older age group was more likely to have depression normally and the impact of HIV infection and social factors may potentiate the development of depression in patients with HIV.
The research conducted among PLHIVs in Africa found that women were more likely to become depressed compared with men., These findings were contrary to the results of the current study, where gender was not associated with the development of depression among the participants. Depression was significantly related with unemployment in this study. That might be due to financial hardship leading to psychological distress and frustration. Low level of education was one of the significant risk factors for developing depression. This finding supported the other studies undertaken in low- and middle-income countries.,, Those who reported missing ART doses in the last month were more likely to develop depression. However, many studies revealed that PLHIVs with depression were less likely to adhere ART. Therefore, the association between missed doses of ART and depression could not be concluded the cause and effect relationship because of the cross-sectional study.
Previous literature mentioned that there was significant association between HIV disease progression and depression. However, one meta-analysis documented that depression was not related to the disease stage in PLHIVs. This study showed no association between disease severity measured by the CD4 count and depression. Depression was found to be significantly associated with the lack of satisfaction and poor patient–provider relationship. Good patient–provider relationship was vital for HIV care services and also essential to accomplish the patients’ satisfaction. Patient-provider relationship and patients’ satisfaction were significantly influenced the mental health status of the respondents. In fact, good patient-provider relationship should be created at the ART clinic and the ART provision centers to ensure more confidence in providers, resulting in a better quality of life. HIV infection profoundly influenced not only the quality of life but also the psychosocial status of the patients. So, it should be noted that the psychosocial support should be provided at the time of counseling.
This current study had some limitations. Because of the subjective nature of the questions for assessing depression score, the result could be either under- or overestimated. Because of the cross-sectional nature of the study, it could not allow to conclude the temporal relationship between potential risk factors and depression. Since the current study was cross-sectional, further study with longitudinal research design with appropriate intervention should be recommended at both public and private ART centers in order to assess and compare the prevalence of depression and its associated factors. Despite having a number of limitations, our findings could be useful for the policy maker to develop an integrated mental health care in National AIDS program for early diagnosis and prompt treatment of depression to attain a better quality of life for those with HIV infection in Myanmar.
In conclusion, a considerable proportion of the clinic attendees at the public ART centers of Yangon region were found to have depression. The older age, low level of education, unemployment, poor patient–provider relationship, lack of satisfaction, and lack of physical exercise were associated with depression.
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[Table 1], [Table 2], [Table 3]