Depression increases the risk of disease progression and death in HIV-positive Tanzanian women

Depression plays an important role in clinical disease progression and death in HIV-1-infected women in Sub-Saharan Africa, according to the findings of a retrospective study published in the April edition of the Journal of Acquired Immune Deficiency Syndromes. The study found that depression is common among HIV-infected Tanzanian women and recommends screening for depression and providing psychosocial interventions as part of a comprehensive HIV care.

There is increasing evidence that depression or stress may accelerate HIV disease progression. Depression might directly alter immune functions or might cause behavioural changes resulting in non-adherence to treatment regimes and a reduced food uptake.

The prevalence of psychiatric disorders among HIV-infected African women is not known. Although depression has been reported in 47% of Ugandan HIV-infected men and women and in about 30% of HIV-infected Rwandese women, there is a paucity of studies which link depression and HIV clinical disease progression in developing countries. A team of Tanzanian and US investigators have addressed this issue.

The study was nested within a randomised controlled trial of vitamin supplementation in pregnant women. The women were offered HIV testing and recruited into the trial from April 1995 to July 1997 at selected antenatal clinics in Dar es Salaam. The HIV-positive rate was 13% (1,819/14,000) and 1,078 HIV-1-infected women were followed up until June 2003.

The primary end-points of the parent study included vertical transmission rates, pregnancy outcomes, HIV disease progression, and mortality among the women and their children born into the study. Nine hundred and ninety-six women with at least one depression measure taken during pregnancy or more than twelve months postpartum were eligible for the depression study. Post-partum depression was eliminated by excluding the depression data collected between delivery and twelve months postpartum.

The women were followed up monthly and later quarterly for approximately six to eight years after HIV diagnosis. Survival and mortality data were collected through tracing participants if a clinic visit was missed. A woman was classified as alive on the day of contact if a home visitor reported talking to or seeing her.

About two months after enrolment, every six months until 2001, and every twelve months thereafter, a psychosocial questionnaire was administered to assess depression /anxiety symptoms based on eight out of the 25-item scale of the Hopkins Symptoms Checklist (HSCL-25). A previous study in this population validated the usefulness of the eight point sub-scale for assessing depression. A social support scale, based on a ten-item questionnaire on emotional or affective (six) and material or instrumental (four) support, was used to assess social support among the patients.

A psychiatric nurse provided individual counselling in the clinic and facilitated a weekly peer support group for women who needed or required counseling for depressive or anxiety symptoms. Women were encouraged to visit the study clinic if they were ill or required counselling.

The mean age of the women was 25 years; about 37% of the women were poor; 76% had completed five to eight years of formal education, 73% were unemployed, and about 90% were married or cohabited. At enrolment, 82, 17, and 1% of the women had WHO clinical stage I, II, and III disease, respectively. About 31, 57, and 12% had CD4 cell counts of 500 cells/mm³ or greater, between 200 and 499 cells/mm³, and 3.

Women (N = 996) with at least one eligible measure of depression were followed for about six years and completed a median of five depression assessments. More than one-half of the women (566) scored above the threshold for depression at least once during the follow up. About 20% of the women attended one group session (median = six sessions, range 1-68 sessions) and 29% received individual counselling (median = five sessions, range 1-45 sessions).

It was of interest to assess depression in HIV-infected women who had just received the results of HIV testing. About 43% (380/891) of the women with antenatal assessments were depressed at baseline while about 45% were depressed during follow-up twelve months after delivery. Among those who were depressed at all, about 37% were depressed in the antepartum period and > twelve months after delivery.

Immunologic status at baseline was independently associated with clinical progression and mortality during follow up as expected. Women who at baseline had a CD4 count less than 200 or 200-500 cells/mm³ were more likely to progress clinically or to die than those with CD4 counts higher than 500 cells/mm³.

Depression was significantly associated with an increased risk of being diagnosed with WHO clinical stage III/IV disease (hazard ratio [HR] = 1.61, 95% confidence interval (CI) 1.28-2.03). Counselling or group attendance and low social support at baseline were not significantly associated with disease progression. However, low education was significantly associated with disease progression (less than five years: HR =1.68, 95% CI 1.10-2.58; 5-8 years: HR = 1.43, 95% CI 1.02-2.01). Women working in offices were at an increased risk (HR = 1.63, 95% CI 1.02-2.58) while women working as professionals were at a significantly lower risk of clinical progression (HR = 0.45, 95% CI 0.22-0.92).

Depression was significantly associated with an increased risk of death (HR = 2.65, 95% CI 1.89-3.71). This relationship was independent of baseline stage of disease and CD4 cell count. As for clinical progression, there was no association between death and counselling or support group attendance and low social support. The same relationship with occupation was observed but the statistical significance was only marginal.

Depression is not only common but is an independent predictor of disease progression and death among HIV-infected African women, the authors conclude. This brings into sharp relief the urgent need for additional studies to assess the effectiveness of psychosocial interventions in preventing or delaying disease progression.

The policy implication is that, alongside antiretroviral drug treatment, management of depression and psychiatric disorders must be an integral part of the health care package provided to all HIV-infected patients.