ORIGINAL ARTICLE J Nepal Med Assoc 2023;61(261):432-6

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doi: 10.31729/jnma.8157

Depression among People Living With HIV/AIDS Undergoing Antiretroviral

Therapy at a Tertiary Care Centre: A Descriptive Cross-sectional Study
Sunil Kumar Shah,1 Richa Sinha,1 Srijana Bhurtel,1 Gobinda Kandel2
1
Department of Psychiatry, Bharatpur Hospital, Bharatpur, Chitwan, Nepal, 2Department of Internal Medicine,
Bharatpur Hospital, Bharatpur, Chitwan, Nepal.

ABSTRACT

Introduction: HIV affects mental health in multiple ways, including its direct pathophysiological
effects, associated stigma, impacts on social, and economic dimensions, medications used for
long durations and multiple secondary physical health issues that affect the clients and comorbid
substance use. In the post-COVID era, in our socio-cultural and geographical context, depression
among these populations needs assessment to evaluate their mental health care needs. The objective
of this study was to find out the prevalence of depression among people living with HIV/AIDS
undergoing antiretroviral therapy at a tertiary care centre.

Methods: This was a descriptive cross-sectional study conducted at a tertiary care centre from
December 2021 to November 2022 after taking ethical approval from Institutional Review Committee
(Reference number: 078/79-006) from the same institute. Convenience sampling method was used.
Clients 18 years and above under antiretroviral therapy were included and those acutely medically
ill were excluded. The patient health questionnaire (PHQ-9) was used as a self-administered, valid,
screening tool for the assessment of depressive symptoms. Point estimate and 95% Confidence
Interval were calculated.

Results: Among 183 participants, the prevalence of depression was 19 (10.4%) (5.98-14.82, 95%
Confidence Interval).

Conclusions: Depression was found higher among people living with HIV/AIDS as compared to the
other studies done in similar settings. Assessment and timely management of depression could be an
important step in improving lives and the effectiveness of HIV/AIDS intervention efforts, ultimately
improving access to mental health care and universal health coverage.

Keywords: depression; HIV; prevalence.

INTRODUCTION

Depression is a major contributor to the global burden Depression warrants attention due to its high burden
of disease and the treatment gap is huge in low and and significant impact.5
middle-income countries.1 HIV/AIDS being universally
better-taken care of, mental health burden raises The objective of this study was to find out the
concern.2,3 Pathophysiological effects, stigma, socio- prevalence of depression among people living with
economic burden, medicines and secondary medical HIV/AIDS (PLHIV) undergoing antiretroviral therapy at
issues are multiple ways HIV affects mental health. a tertiary care centre.
While mental illnesses and substance use increases
the risk and complication of HIV and puts forward
further challenges.4 Since the pandemic, the need to
______________________________________
address mental health needs has been highlighted for Correspondence: Dr Gobinda Kandel, Department of
Internal Medicine, Bharatpur Hospital, Bharatpur, Chitwan,
wider coverage of the quality treatment of depression.
Nepal. Email: kandelgovinda577@gmail.com, Phone: +977-
9845048388.

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 Shah et al. Depression among People Living With HIV/AIDS Undergoing Antiretroviral Therapy at a Tertiary Care Centre: A Descriptive..

METHODS using IBM SPSS version 21.0. Point estimate and 95%
CI were calculated.
This was a descriptive cross-sectional study conducted
at a tertiary hospital antiretroviral therapy (ART) centre. RESULTS
This study was conducted from 1 December 2021 to
30 November 2022 after taking ethical approval from Among 183 participants, the prevalence of depression
Institutional Review Committee (Reference number: was 19 (10.4%) (5.98-14.82, 95% CI). The mean age
078/79-006) from Bharatpur Hospital, Bharatpur, was 41.37±14.54 years. The majority of the clients, 8
Chitwan, Nepal. PLHIV patients of age 18 years and (42.1%) with depression were from the age category
above who are under ART therapy were included in 30-40. More females were found depressed 11 (57.9%)
the study. Patients with acute medical health issues, (Table 1).
bipolar and psychosis were excluded. Informed
Table 1. Demographic characteristics of clients with
consent was taken. Personal interviews were taken
depression (n= 19).
and data was collected using proforma and PHQ-9.
Variables
Convenience sampling method was used. The sample
Age (Years) n (%)
size was calculated by using the following formula:
<30 4 (21.10)
pxq 30-40 8 (42.10)
n= Z2 x
e2 40-50 3 (15.78)
0.146 x 0.854 50-60 2 (10.52)
= 1.962 x
0.062 >60 2 (10.52)
Gender
= 133 Female 11 (57.89)
Where, Male 8 (42.10)
n= minimum required sample size Marital status
Z= 1.96 at 95% Confidence Interval (CI) Married 17 (89.47)
p= prevalence taken as 14.6% from previous study6 Never married 2 (10.52)
q=1-p Religion
e= Margin of error, 6% Hindu 18 (94.73)
Muslim 1 (5.26)
The calculated sample size was 133. Adding 10% non-
Ethnicity
response rate, obtained sample size was 147. However,
Brahmin 3 (15.8)
we took 183 sample.
Chhetri 3 (15.8)
Data collected with a self-structured questionnaire Madhesi 2 (10.52)
and PHQ-09 was checked for completeness and Gurung 1 (5.26)
coded with serial numbers. The PHQ-9 was used Magar 1 (5.26)
as a self-administered, valid, screening tool for the Newar 1 (5.26)
assessment of the severity of depressive symptoms. Others 6 (31.57)
PHQ-9 includes 9 items which focus on the Diagnostic Occupation of the head of the family
and Statistical Manual of Mental Disorders, 4th The clerical, shop owner, farmer 14 (73.68)
edition (DSM-IV) for major depressive disorder. The Semi-skilled worker 2 (10.52)
questionnaire assesses how often the participants had Unemployment 2 (10.52)
been disturbed by any of the 9 items during the last 2 Unskilled worker 1 (5.26)
weeks. Each item of PHQ-9 was scored on a scale of 0–3 Income of the family (NRs)
(0 =not at all; 1 = several days; 2 = more than a week; 3 14,551 to 24,350 4 (21.05)
= nearly every day). The PHQ-9 total score ranges from 24,351 to 36,550 4 (21.05)
0 to 27 (scores of 5–9 are classified as mild depression; 4851 to 14,550 9 (47.36)
10–14 as moderate depression; 15–19 as moderately 97,451 or more 1 (5.26)
severe depression; ≥20 as severe depression. The test Less than 4850 1 (5.26)
discriminates well between people with and without Economic status
Major depressive disorder (MDD).7-9 The PHQ-9 was Lower (V) 1 (5.26)
found to have acceptable diagnostic properties for Upper lower (iv) 12 (63.15)
detecting major depressive disorder for cut-off scores Lower middle (iii) 6 (31.57)
between 8 and 11.10 The PHQ-9 with a cut-off score of Education
10 or above to identify major depression can be used Middle school 4 (21.05)
regardless of age.11 Data were entered and analysed Primary school or literate 5 (26.31)

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 Shah et al. Depression among People Living With HIV/AIDS Undergoing Antiretroviral Therapy at a Tertiary Care Centre: A Descriptive..

Of more clients on the TLD regimen, 15 (78.9%) were 9.6 Likewise, in a comparative cross-sectional study
found to have depression. Of those who were identified conducted in Ethiopia in 2018, the prevalence was
with HIV for more than 10 years, 9 (47.4%) were more significantly higher in people with HIV/AIDS compared
among the sufferers. Those with family members also with the community sample (16.6% vs 12.3%).14
having HIV suffered more, 12 (63.2%). Clients reporting
facing discrimination counted more among depressed Some other studies had shown still a higher prevalence
ones, 10 (52.6%) (Table 2). of depression among PLHIV. The prevalence of
depression was 26.7% (20.6–33.7, 95% CI) in a study
Table 2. Clinical and social factors of clients (n= 19). done from 2014 to 2015 in Cameroon.15 In another
Variables n (%) study in Nepal done in 2014, 29.6% of the participants
ART regimen had depressive symptoms (CESD).16 Similarly, in
*TLD 15 (78.94) a hospital-based study in Karnataka in 2018, 108
†TLE 4 (21.05) (33.5%) PLHIV had depression according to PHQ 9
HIV identified years (in years) questionnaire.17
1-5 6 (31.57)
5-10 4 (21.05) While some other studies report a much higher
>10 9 (47.36) prevalence of depression among PLHIV. In a study
Initiation of ART in duration (in years) done in Nepal in 2019, depression was very prominent
1-5 7 (36.84) among HIV-positive patients, 40% of participants were
5 -10 4 (21.05) found to have depression.18 While the report from
>10 8 (42.10) the pilot study of the national mental health survery
Distance to ART centre from home ( in Km) states that, among adults aged 18 years and above,
0-10 1 (5.26) major depressive disorder (current) was found among
10-20 6 (31.57) 3.4%.1 In addition, a study in a medical college in
20-30 4 (21.05) Delhi, published in 2014 found that the prevalence
30-40 3 (15.78) of depression in patients with HIV under ART was
40-50 1 (5.26) 58.75%.19 Likewise in a study done in Indonesia in
>50 4 (21.05) 2018, depressive symptoms were exhibited by 50.9%
of participants.20
HIV-related complications in the last
year
Wide variation in the prevalence of depression among
URTI 2 (10.52)
PLHIV under ART has been observed across studies in
Family history of HIV 12 (63.15)
various parts of the world. A multitude of factors could
Been discriminated against due to
10 (52.63) be contributing to the variations in the prevalence of
your HIV status
depression among participants. Tools cut-off scores
*TLD= Tenofovir disoproxil Lamivudine, Dolutegravir, used for assessment of depression could be one factor
†
TLE= Tenofovir disoproxil, Lamivudine, Efavirenz contributing to the differences in prevalences. The
impact of HIV on multiple dimensions of the affected,
DISCUSSION like social, economic, psychological, physical etc
could be the reason behind this finding. Lately, the
In our study, depression was prevalent among 19 pandemic has affected lives significantly causing a
(10.4%) of 183 (5.97-14.82, 95 % CI) HIV patients rise in various social, economic, physical and mental
under ART. As per the national mental health survey health issues.21,22 Mental health plays a critical role in
of Nepal, lifetime prevalence and current prevalence the acquisition of HIV and PLWH experience higher
of depressive disorders among the adult population rates of mental disorder.23
were found 2.9 (2.3-3.7, 95% CI) and 1.0 (0.8-1.4 at,
95% CI) respectively.12 Prevalence of depression The limitation of the study was that it was conducted at
among the study participants is clearly several folds a hospital. Convenient sampling technique was used.
higher than among the general population of Nepal. In
CONCLUSIONS
2020, communities affected by COVID-19 faced mental
illnesses like major depression and anxiety.13 Similar Depression was found highly prevalent among PLHIV
findings have been reported across several studies. under ART from the clinic as compared to the general
The prevalence of depression among adult HIV/AIDS population as reported by the National Mental health
patients on ART was 14.6% (10.9-18.2, 95% CI) in a study survey. So, regular assessment and strengthening the
of 2015 in Ethiopia. In this study, a positive depression psychological support system might be suggestible.
screen was defined as a PHQ-9 score greater than

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 Shah et al. Depression among People Living With HIV/AIDS Undergoing Antiretroviral Therapy at a Tertiary Care Centre: A Descriptive..

ACKNOWLEDGEMENTS administration for all their cooperation.

The authors would like to acknowledge AHF Conflict of Interest: None.

Nepal Bharatpur unit, PLHIV clients and hospital

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