Depression has become one of the most common psychiatric disorders and negatively affects adherence to and outcomes of antiretroviral treatment (ART) [1
]. Throughout the course of HIV infection, patients may experience depressive symptoms due to deteriorated health status, difficulty functioning, ART side effects, apathy, stigma, and discrimination [2
]. Conversely, people who suffer from depression may have increased risk of substance abuse, unsafe injection [5
], and engagement in high-risk sexual behaviors [6
] that fuel the spread of HIV epidemics.
The proportion of depression among HIV/AIDS patients receiving ART in resource-constrained settings has been high. For example, it was 45.8% in Ethiopia in 2013 [7
], 47% in Uganda in 2006 [8
], and 25.4% in South Africa in 2012 [2
]. Several positive drivers related to depression were identified, such as poorer socioeconomic background, gender inequalities [7
], and self-isolation as a result of the community’s stigma and discrimination [9
]. In addition to psychotherapy and pharmacotherapy, previous studies have also highlighted social factors that reduce depression among HIV/AIDS patients, for instance, greater support from family members and peer educators as well as socioeconomic empowerment, especially for women [7
Although depression has been well-known as a predictor of poor ART adherence and outcomes, the extent to which this health issue has been prioritized and how interventions incorporated into care and treatment services are very limited in developing countries. Over the course of ART, a large proportion of depressed patients have reported suboptimal adherence, including missing doses and appointments with doctors [12
]. Some studies have found an association between depression and increased risks of HIV transmission [14
] and disease progression [15
], as well as suicidal ideation [16
]. In HIV epidemics largely driven by drug injection, depression was not only affecting the outcomes of care and treatment services but also was a major reinforcing factor contributing to engagement in many risk behaviors and to multiple health and social issues among drug users [17
The HIV epidemic in Vietnam is still in a concentrated stage in which most-at-risk populations include commercial sex workers, drug users, and men who have sex with men (MSM). In 2016, the estimated coverage of ART services was 48% [19
] and the country adapted the WHO Guideline on Universal Treatment Access for patients with HIV/AIDS, which showed that all HIV-infected patients can start having ART as soon as possible with any CD4 cell count and at any clinical stage [20
]. This policy has the potential to improve physical health outcomes and bring hope to such patients as well as reduce the risk of HIV transmission at the population level given the suppressed viral load [20
]. Although ART coverage has been rapidly expanded, psychological and social disorders have continued to affect the lives of patients, and effective interventions are still very limited. It has been documented that early ART initiation may also lead newly diagnosed HIV patient to a fear of HIV disclosure, a higher probability of stigma and discrimination, and a higher risk of suffering from potential side effects of the ART [21
]. Several assessments of depression among patients with HIV/AIDS showed heterogeneity in results. A study conducted in Ho Chi Minh City using the Center for Epidemiologic Studies—Depression scale showed that 36.5% of participants had clinical depression [22
]. The result of another study examining the prevalence of depression among men having HIV infection depicted that the depression rate was 18.7% over a 1-month period, measured by The Phan Vietnamese Psychiatric Scale [23
]. A study of HIV patients receiving ART and attending two HIV outpatient clinics in Hanoi estimated that 26.2% of respondents experienced depression, based on the Center for Epidemiologic Studies—Depression scale [24
]. Consequently, how early initiation of ART influences psychological well-being, such as HRQOL, which is defined as the status of general well-being, be it physical, emotional, or psychological [25
], is still not well-established, especially in the resource-limited settings as Vietnam. The purpose of our study was to examine the prevalence of depression and its relation to the HRQOL of HIV/AIDS patients in various clinics in different geographical locations of Vietnam.
A total of 482 patients enrolled in the study. Table 1
shows that most of the participants were male (61.3%) and living with a spouse/partner (66.6%). The majority of respondents had not completed high school (66.5%). The percentage of patients who were unemployed in the depression group was higher than that of the non-depression group (17.7% and 7.1% respectively). Among the study sites, the proportion of depressive participants was higher than the counterpart at the Thanh Hoa HIV/AIDS Control Center, Quang Xuong District General Hospital, and Ba Vi District General Hospital, and the differences were statistically significant. The mean age of participants was 38.4 (SD = 8.3).
The majority of respondents were asymptomatic (82.7%) (Table 2
). The proportion of respondents satisfied with treatment results in the depression group was significantly lower than that in the non-depression group (85.1% vs. 94.8%). Approximately half of the patients were smokers (53.6%) and drug users (44%), and the percentage of participants who were drug users in the depression group was statistically higher than that in the non-depression group (55.2% and 41.2%, respectively). About 60% of the participants received ART in the clinic integrating HCT services (58.5%). Approximately 30% of participants received early ART initiation with a CD4 cell count ≥500. The average duration of ART was 3.8 years (SD = 2.5). The mean number of CD4 cell measurements at the start of ART and the last test of treatment duration was 389 (SD = 252) and 455 (SD = 244).
illustrates that half of the respondents were not depressed (49.1%) and approximately one-third of patients had mild depressive symptoms (30.8%). Among respondents suffering from major depressive syndrome (20.2%), 12.8% had moderate depressive symptoms, 4.6% had moderate severe depressive symptoms, and 2.7% had severe depressive symptoms.
Health-related quality of life among respondents is depicted in Table 4
. The percentage of patients reporting any problems in mobility, self-care, usual activities, pain/discomfort, and anxiety/depression in the depression group was statistically significantly higher than those who had health problems in the non-depression group. The mean of total EQ-5D utility scores was 0.8 (SD = 0.2), and the EQ-5D index in the depression group was less statistically significantly than that in the non-depression group (0.6 and 0.8, respectively). In addition, the mean EQ-VAS score was 73.6 (SD = 15.3) with a statistically higher score in the non-depression group compared to the depression group (76.4 and 62.1 respectively).
The prevalence of stigma and discrimination among ART patients is shown in Table 5
. The study reveals that the proportions of patients who felt shame about their health status were higher in the depression group compared to the non-depression group. Most of the respondents also experienced discrimination in the community (69.8%), and nearly fifty percent of patients were under the fear of HIV transmission to others (46.1%). Two-thirds of participants received support from peers and shared their health information with them.
In Table 6
, regarding clinical characteristics, participants who had a CD4 cell count from 350 to 500 were more likely to have depression compared to those who had a CD4 cell count ≥500. In addition, a higher likelihood of depression was associated with participants having ART in a clinic that did not provide HCT services. Being in a symptomatic stage and having a higher AUDIT score were positively associated with depression, while participants who were satisfied with treatment results were less likely to suffer from depression. In terms of health status, having problems with mobility and performing daily activities and suffering from pain and discomfort were related to a higher risk of depression among ART patients. Furthermore, regarding stigma and discrimination, depression was also positively associated with those who experienced discrimination in the workplace and in the community and negatively associated with disclosed health status with family.
indicates the various factors associated with HRQOL among participants. Those having depression were more likely to have a lower quality of life according to both the EQ-5D-5L index and EQ-VAS. Moreover, being unemployed, experiencing discrimination, and having complications and concurrent disease increased the likelihood of having a lower quality of life.
Findings of the study provide valuable information about depression among HIV/AIDS patients in the era of early universal ART access in Vietnam. We found that about one-fifth of participants had depression. Participants who had a lower CD4 cell count at the start of ART or who received ART at the clinic without HCT services were more likely to suffer from depression. In addition, having a physical health problem and suffering from discrimination in the workplace and community were also positively associated with depression. By contrast, satisfaction with treatment results and disclosing health status with family were factors that decreased the depression score. Depression was also associated with a higher risk of a low quality of life.
The percentage of participants having depression in our study was lower than that of other studies in Vietnam [22
] and China [30
]. The difference can be explained by the fact that our study was conducted among facilities from different levels of health systems in urban, rural, and mountainous areas, while other studies were carried out in urban areas only. In addition, in order to assess depression among participants, we used the PHQ-9 questionnaire, while other studies used different instruments such as Center for Epidemiologic Studies—Depression scale and The Phan Vietnamese Psychiatric Scale.
Participants who had a lower CD4 cell count at the first time of receiving ART were more likely to have depression compared to those with a CD4 cell count ≥500. This can be explained by the fact that early initiate ART can improve health status, delay the early onset of co-morbidity, decrease the adjusted mortality rates compared to those who defer ART until reaching CD4 <500 cells/μL [31
], and therefore improve mental health and quality of life of HIV/AIDS patients [32
]. On the other hand, individuals with depressive symptoms may diminish the effort to receive HIV care and initiate ART [33
] due to cognitive impairment and self-isolation [35
]. In addition, receiving ART in the clinic without HCT services also increases the risk of suffering from depression. Typically, HCT consists of pretest and posttest counseling sessions that help individuals to understand their personal health status and make informed choices based on their knowledge [36
]. Furthermore, users are also offered information related to psychosocial support [37
], and adequate ongoing counseling can prevent serious or prolonged psychological problems as well as avoid stigma and discrimination [38
Compared to previous studies, we found similar results that indicate that the depression scores were higher among participants who were in the symptomatic stage compared to those who were in the asymptomatic stage [39
]. This can be explained by the fact that patients with a more severe and progressive illness would be more likely to be depressed. During the symptomatic stage, patients have to cope with residual opportunistic infections, the deterioration of the immune system, and the side effects of ART medication [27
Most depressed participants in the study had physical health problems. In particular, those suffering from pain and discomfort had a significantly higher risk of depression compared to who did not, and this finding is consistent with a previous study [41
]. Patients who undergo pain may have depression for a longer period and with greater severity compared to those who do not [42
]. HIV patients, especially those who are in a symptomatic or AIDS stage, may consider pain as a symptom of depression or as an aversion that triggers an extremely negative reaction such as depression [41
]. Conversely, the depressive disorder can forecast the development of pain due to the somatization of emotional problems [44
]. In addition, the results of multivariate regression analysis also indicate that patients who have a higher AUDIT-score have a greater likelihood of depression. The relationship between alcohol and depression is bi-directional, meaning that people who are depressed may abuse substances to lift their mood and escape feelings of despair [45
]. Conversely, those who abuse substances are also more likely to suffer from depression due to the withdrawal process or the consequence of repeated use [46
In Vietnamese settings, discrimination and stigma are considered as significant barriers that affect ART outcomes [11
]. In our study, participants who suffered from discrimination in the workplace were more likely to be depressed compared to those who did not. This finding is consistent with previous studies, which indicate that self-stigma and discrimination may contribute to the development of depressive symptoms [47
]. The majority of participants were self-employed and blue-collar-workers who were more likely to perceive a discriminatory environment compared to white-collar workers [49
]. According to the “People Living with HIV Stigma Index” report in 2012, HIV patients lost their job or source of income, were refused opportunities to work, and experienced discriminatory attitudes from their colleagues who became aware of their HIV status as a result of HIV infection [50
]. Therefore, being blocked access to daily activities and undergoing prejudice may trigger negative attitudes as well as depression among people living with HIV/AIDS. Furthermore, disclosing one’s health status to family members was negatively associated with depression. This finding is consistent with previous studies that showed that the majority of participants reported disclosure as a positive event for both them and family [51
]. Several psychological disorders and behavioral issues may be increased by the lack of health status disclosure [52
Our study results also suggest a negative association between depression and quality of life. This finding is similar to previous studies in which it was observed that the more severe the depressive symptoms, the poorer the quality of life scores were [54
] and that symptoms of depression may negatively impact quality of life in various evaluated dimensions [55
]. A study of Multicenter AIDS Cohort Studies in 2006 also revealed that lower mental health measured by the SF-36 questionnaire was significantly related to an increased depression score [56
]. Moreover, results of a six-month follow-up study illustrate that hopelessness, which is considered a major symptom of depression, predicted a poor quality of life [57
Several implications can be drawn from this study. Since depression was less prevalent among those initiating ART early, depression screenings and interventions should be targeted at participants who started ART late. A comprehensive health care program that integrates HCT delivery models with ART should be developed, and information regarding psychological support during treatment procession for HIV/AIDS patients should be provided. ART patients should be encouraged to share their health status and derive support from family members, reducing the risk of depression. From a community perspective, as a high level of discrimination was positively associated with depression, community-based legal support services and educational campaigns based on behavioral changes should be prioritized to address the myths and beliefs regarding stigma and discrimination among HIV/AIDS patients.
The strengths of this study include the recruitment of patients from many levels of health systems in rural, urban, and mountainous areas. Several international instruments were also employed, such as PHQ-9 and EQ-5D-5L, in order to help to increase the comparability between these study findings and worldwide studies. However, we should acknowledge some limitations in this study. Firstly, the convenience sampling technique was conducted to recruit participants, which may limit the generalizability of our results to other study populations. Secondly, because of the self-reported information, the data is susceptible to the recall bias of interviewers and to social desirability. In order to minimize biases, we removed the interviewers who were affiliated with selected health centers, and we also explained the instructions as well as the benefits and drawbacks to participants once they became involved in the study. Finally, because our study design was cross-sectional, causal inferences could not be made.