Factors associated with depression among people living with HIV in primary health care of Southern Ethiopia

Abstract

Background

Depression is one of the most prevalent mental health disorders among people living with human immunodeficiency virus (PLHIV), with studies estimating depression prevalence in PLHIV remains high (24–42%) in sub-Saharan Africa, nearly twice the rate observed in the general population. Primary health care settings in sub-Saharan Africa often lack standardized mental health screening tools, leading to under diagnosis and untreated depression in PLHIV. This study aims to address this gap by examining the factors associated with depression among PLHIV in n primary health care of Southern Ethiopia.

Methods

A facility-based cross-sectional study was carried out in primary health care setting among adult PLHIV on follow for antiretroviral from January to June of 2023 in Wolaita zone, Southern Ethiopia. A total of 342 sampled adult PLHIV who was registered with an antiretroviral therapy (ART) were included into the study through systematic sampling techniques. Data were collected through face-to-face interviews using structured questionnaires and medical record reviews. Outcome variables (depression symptoms) were assessed using the validated Patient Health Questionnaire-9 (PHQ-9) tool with cutoff score ≥ 10, while exposure variables (clinical/historical factors) were obtained through both self-report and clinical records, with all instruments pretested for local appropriateness. Data were analyzed using STATA version 14, employing bivariate and multivariable logistic regression (p < 0.05 significance) with 95% confidence intervals, preceded by tests for multicollinearity (variance inflation factors < 10) and model fit (Hosmer–Lemeshow p = 0.634).

Results

The study included 334 participants, achieving a 97.6% response rate. The prevalence of depression was 30.2% (95% CI: 25.52–35.40). Significant predictors of depression included: age 30–39 years (AOR = 6.40, 95% CI: 1.71–23.9), history of hospital admission (AOR = 3.37, 95% CI: 1.79–6.33), ART duration < 12 months (AOR = 0.26, 95% CI: 0.12–0.58), presence of opportunistic infections (AOR = 2.63, 95% CI: 1.36–5.08), and CD4-positive T cells count ≥ 350 cells/mm³ (AOR = 0.33, 95% CI: 0.12–0.91).

Conclusions

This study found a high depression prevalence (30.2%, 95% CI: 25.52–35.40) among PLHIV, exceeding general population rates and aligning with WHO reports. Integrating routine mental health screening into ART clinics and providing targeted support for groups with higher odds of depression (younger patients, those hospitalized, or with opportunistic infections) is recommended. Multisectoral collaboration with social services and community organizations may help address stigma (reported by 59.6%) and strengthen social support systems.

Background

People living with human immunodeficiency virus (PLHIV) face a disproportionate burden of depression, with recent meta-analyses reporting pooled prevalence rates of 24–42% in sub-Saharan Africa significantly higher than regional general population estimates [1–4]. The World Health Organization (WHO) estimates that more than 280 million people worldwide suffer from depression, with a disproportionate burden observed in low- and middle-income countries (LMICs) where access to mental health services is often limited [2, 5–10]. Among PLHIV, the prevalence of depression is substantially higher, ranging from 20 to 40%, compared to the general population [5, 9, 11–13]. In sub-Saharan Africa, where over 70% of the global human immunodeficiency virus (HIV) burden exists, the intersection of HIV and depression exacerbates health outcomes, reduces adherence to antiretroviral therapy (ART), and increases mortality risk [14–16].

Ethiopia, with an adult HIV prevalence of 0.9%, faces unique challenges in addressing mental health comorbidities due to fragmented healthcare systems, stigma, and limited integration of mental health services into primary care. Southern Ethiopia, a region with high HIV prevalence and socioeconomic disparities, exemplifies these challenges, yet data on depression and its clinical correlates among PLHIV in this setting remain sparse [16–18].

Clinical factors such as advanced HIV disease stage (e.g., low CD4 count), opportunistic infections (e.g., tuberculosis), ART side effects, and comorbidities (e.g., chronic pain) are strongly implicated in depression pathogenesis. For instance, immunosuppression (CD4 count < 200 cells/mm³) has been linked to neuroinflammation and depressive symptoms, while ART regimens like efavirenz are associated with neuropsychiatric adverse effects [19–21]. However, most evidence derives from high-income settings, limiting generalizability to resource-limited contexts like Ethiopia, where late HIV diagnosis, malnutrition, and high rates of opportunistic infections may amplify depression risk. Furthermore, primary health care (PHC) settings in sub-Saharan Africa often lack standardized mental health screening tools, leading to under diagnosis and untreated depression in PLHIV [22].

Existing studies in Ethiopia have primarily concentrated on urban settings or health care facility with higher tier rank, leaving a critical gap in understanding clinical factors associated with depression primary health care setting. This study addresses critical gaps by investigating factors associated with depression among adult PLHIV in PHC settings in Southern Ethiopia.

Methods and materials

Study context, period and approach

A facility-based cross-sectional study was carried out in primary health care settings among adult patients living with HIV attending ART follow-up from January to June 2023 in the Wolaita Zone, Southern Regional State, Ethiopia. The Wolaita Zone is located in the Southern Regional State, approximately 380 km from Ethiopia’s capital, Addis Ababa. The zone has a total of 80 public PHC facilities (8 primary hospitals and 72 health centers) that provide comprehensive general health care services across various outpatient and inpatient departments, serving populations from nearby districts and regions. However, during the study period, only 19 public PHC facilities (8 primary hospitals and 11 health centers) in the Wolaita Zone provided ART services. These facilities had a total of 2444 patients currently on ART follow-up, including 975 in primary hospitals and 1499 in health centers.

Source and study population

Source population

All adult PLHIV and receiving ART follow-up services at public primary health care (PHC) facilities in the Wolaita Zone, Southern Regional State, Ethiopia.

Study population

Adult PLHIV who were on ART follow-up at selected public PHC facilities in the Wolaita Zone during the study period (January to June 2023) and who fulfilled the inclusion criteria.

Inclusion and exclusion criteria

All selected HIV-positive adults receiving ART follow-up at primary health care facilities in Wolaita zone, Southern Ethiopia, who met the study population criteria were included. Participants who were severely ill during the study period or had incomplete baseline medical information were excluded from the study.

Sample size and sampling procedures

Sample size for studying was determined by using single population proportion formula by considering prevalence of depression 33.5% from study done previously [23], a 95% of confidence interval (CI), and 5% of marginal = = n = 342, final sample was n = 342.

The study was conducted at randomly selected three primary hospitals (Tebela, Bele Awassa, and Gesuba Hospital) and three health center (Areka, Bodit and Bedessa health center) across the study setting. A systematic random sampling technique was used to identify the study subjects and 162 adult PLHIV on ART at Tebela primary Hospital, 138 at Bele Awassa primary Hospital, 168 at Gesuba primary Hospital, 221 at Areka health center, 932 at Sodo health center, and 91 at Bedesa health center. The patient's medical registration number from each primary health care settings registration book was first used to establish a sampling frame. Following that, each PHC setting received a proportionate share of the computed sample size. Next, a computer-generated specialized random sampling procedure was used to choose research participants from each of the chosen PHC settings. Participants were systematically recruited during their routine ART clinic visits at the six selected health facilities. Trained research assistants approached eligible patients in designated consultation areas after their clinical appointments, using ART appointment registers to verify eligibility and prevent duplicate enrollment. No home visits or community-based recruitment were conducted to maintain standardization across sites.

Data collection tools, technique and quality control

Data was gathered using a structured interview administered questionnaire that was adapted from different literatures reviews [3, 21, 22, 24–26]. Data collection tools include socio-demographic characteristics, clinical related characteristics and psychosocial related characteristics. In which collection of data, study was aided by three supervisors and ten research assistants. They were experienced psychiatric professionals fluent in the local language. Data collectors and supervisor received two days of training at their respective zonal centers regarding the study’s objective, the tools contents, and data collection procedures. The pretest was performed with 17 participants (5% of sample) at Gununo Health Center, with results validating our instruments. Duplicate entries were prevented by tracking unique ART numbers throughout the study period.

Depression symptoms was assessed by using patient Health Questionnaire-9 (PHQ-9) tool that had 9 items; commonly used to screen for symptoms of depression in primary health care and in outpatients and validated in Ethiopia with sensitivity = 86% and specificity = 67%. The scales use a cutoff score for depression of greater than or equal to 5 [27]. The degree of perceived stigma was measured using an HIV-related stigma scale with 10 items. HIV related stigma: respondents who scored higher than the mean overall were deemed to have experienced stigma, while those who scored lower than the mean were deemed not [28]. Social support was evaluated using the Social Support Questionnaire (SSQ-6), which has a total sum score of six items. Respondents with scores above the mean were deemed to have good social support while those with scores below the mean were deemed to have poor social support [29]. Adverse effects of antiretroviral therapy (ART): in their medical records, respondents disclose side effects such as altered appetite, nausea, vomiting, rash, numbness, and pain in limb, fatigue, change in body shape, hair loss, and changes in vision [3]. Smoking data were collected using WHO STEPS questions (30-day recall), with any tobacco use classified as 'current smoker and ART adherence was categorized via SMAQ: Good (< 2 missed doses/month), Fair (2–5), Poor (> 5), aligning with Ethiopia’s national ART guidelines as both measures were interviewer-administered to minimize misclassification. Monthly income was categorized as < 500 ETB (extreme poverty), 501–1500 ETB (lower-middle income), and ≥ 1501 ETB (above regional average wages), based on World Bank poverty lines and EDHS standards [30, 31]. All data collectors received additional training on recognizing and responding to acute mental health needs. Participants scoring PHQ-9 ≥ 10 were managed according to our stepped-care protocol (see Ethical Considerations), ensuring immediate support while maintaining research integrity.

Data analysis

Data were analyzed using STATA version 14, beginning with descriptive statistics (frequencies, percentages, mean ± SD), followed by bivariable logistic regression (p < 0.25 cutoff for multivariable inclusion), and finalized with multivariable logistic regression (backward stepwise approach), with multicollinearity assessed via variance inflation factors (VIF < 10), normality verified by Q-Q plots, and model fit confirmed using the Hosmer–Lemeshow test (p = 0.634).

Results

Sociodemographic characteristics of participants

The study achieved a 97.6% response rate. Participants had a mean age of 35.0 ± 7.86 years, with predominance of males (61.4%) and married individuals (69.8%). Nearly half (47.0%) had completed primary education, and 77.2% reside in urban areas. Among respondents, 55.7% reported living alone (without family members). Employment distribution indicated 47.0% held government positions, with 38.3% earning monthly incomes below 500 ETB (Table 1).

Table 1.

Socio-demographic characteristics of adult PLHIV in primary health care of Southern Ethiopia 2023

Variables	Category	Frequency	Percent (%)
Age (Years)	18–29	88	26.3
	30–39	203	60.8
	40–49	29	8.7
	50 +	14	3.9
Sex	Male	205	61.4
	Female	129	38.6
Marital status	Married	233	69.8
	Single	57	17.1
	Divorced	28	8.4
	Widowed	16	4.8
Occupation	Merchant	70	21.0
	Daily laborer	33	9.9
	Private	74	22.2
	Government employee	157	47.0
Educational status	No formal education	22	6.6
	Primary	157	47.0
	Secondary	112	33.5
	college and above	43	12.9
Residents	Urban	258	77.2
	Rural	76	22.8
Current living condition	living alone	186	55.7
	with wife	71	21.3
	with family	51	15.3
	Others*	26	7.8
Monthly income (ETB)	< 500	128	38.3
	501–1500	72	21.6
	≥ 1501	134	40.1

Abbreviation: ETB: Ethiopian birr, *other: with friends, in institutional care, homeless

Clinical and psychosocial characteristics of study participants

Among the study participants, 150 (44.9%) were in WHO clinical stage I, 74 (22.2%) in stage II, 70 (21.0%) in stage III, and 40 (12.0%) in stage IV. Opportunistic infections were reported in 118 (35.3%) of participants. The majority, 200 (59.9%), had good ART adherence, while 67 (20.1%) had fair adherence, and 67 (20.1%) had poor adherence.

Most patients had CD4 counts > 350 cells/mm3 and had received Art for than 12 months was 84.7%. first-line ART regimens were used by 79.9%, and opportunistic infections were reported by 35.3% of participants.

Regarding psychosocial characteristics, 44.6% reported having a regular treatment support, while 55.4% did not. Stigma related to HIV was reported by 59.6% of the participants. Substance use in the past month was reported by 10.8% of respondents. Opportunistic infections were present in 35.3%, while 79.9% used first-line ART regimens and 59.0% reported no ART side effects (Table 2).

Table 2.

Clinical and psychosocial characteristics among adult PLHIV on ART in primary health care facilities of Southern Ethiopia, 2023

Variables	Category	Frequency	Percent (%)
WHO clinical stage	I	150	44.9
	II	74	22.2
	III	70	21.0
	IV	40	12.0
CD4 count	< 350	26	7.8
	≥ 350	308	92.2
INH prophylaxis	Yes	250	74.9
	No	84	25.1
Presence of OI	Yes	118	35.3
	No	216	64.7
Current ART drug line	1st line	267	79.9
	2nd line	52	15.6
	3rd line	15	4.5
Duration of ART	< 12month	51	15.3
	≥ 12month	283	84.7
History of ART drug side effects	Yes	197	59.0
	No	137	41.0
History of hospital admission	Yes	107	32.0
	No	227	68.0
CPT prophylaxis	Yes	293	87.7
	No	41	12.6
Adherence to ART drug	Good	200	59.9
	Fair	67	20.1
	Poor	67	20.1
Social support	Poor	185	55.4
	Good	149	44.6
Perceived HIV related social stigma	Yes	199	59.6
	No	135	40.4
Current Smoking cigarettes	Yes	36	10.8
	No	298	89.2

Abbreviation: ART: Antiretroviral therapy, CPT: had cotrimoxazole prophylaxis, OI: Opportunistic Infection, INH: isoniazid prophylaxis, WHO: World Health Organization

Prevalence of depression symptoms among study participants

Depression affected 30.2% of study participants (95% CI: 25.52–35.40). Among those affected, 62.4% were female adult patients and 71.3% were from urban settings.

Factors associated with depression

Variables independently associated with depression in bivariate analysis at p-value < 0.25, were sex, residence, history of hospital admission, duration on ART treatment, WHO stage, presence of opportunistic infection, CD4 + T lymphocyte count, adherence to ART treatment and CPT prophylaxis. History of hospital admission, age category, patients’ duration on ART treatment, having opportunistic infection, and CD4 cell count ≥ 350 were significantly associated with depression of adult PLHIV.

In multivariate analysis, a history of hospital admission was strongly associated with depression, with 3.4 times higher odds of depression compared to those with no history of hospital admission (AOR = 3.37; 95% CI: 1.79–6.33; p < 0.001). Age groups 18–29 and 30–39 years had significantly higher odds of depression compared to those 50 years and above, with adjusted odds ratios of 6.4 (95% CI: 1.71–23.90; p < 0.05) and 6.4 (95% CI: 2.08–6.90; p < 0.01), respectively. Duration on ART treatment less than 12 months was associated with a 74% reduction in odds of depression compared to ≥ 12 month on ART (AOR = 0.26; 95% CI: 0.12–0.58; p = 0.001). Presence of opportunistic infection was associated with increased odds of depression (AOR = 2.63; 95% CI: 1.36–5.08; p < 0.01). Participants with CD4 + T lymphocyte count < 350 cells/mm³ were had lower odds of depression compared to those with counts ≥ 350 cells/mm³ (AOR = 0.33; 95% CI: 0.12–0.91; p = 0.033; p < 0.05) (Table 3).

Table 3.

Logistic regression analysis of factors associated with depression among adult PLHIV on ART in primary health care facilities, Southern Ethiopia, 2023

Variables	Category	Depression		COR (95% CI)	AOR (95% CI)	p-value
		No	Yes
Age (years)	18–29	62	26	2.78 (0.85–9.07)	6.40 (1.71–23.90)	0.016**
	30–39	149	54	3.21 (1.03–4.50)	6.40 (2.08–6.90)	0.006**
	40–49	15	14	1.25 (0.33–4.63)	1.42 (0.31–6.52)	0.651
	50 +	7	7	1 (reference)	1 (reference)
Sex	Male	167	38	1 (reference)	1 (reference)	0.133
	Female	66	63	4.19 (2.56–6.87)	1.44 (0.82–2.53)
WHO stage	I	100	50	1 (reference)	1(reference)
	II	58	16	0.33 (1.42–7.53)	1.12 (0.38–3.32)	0.827
	III	54	16	3.05 (1.32–7.03)	1.61 (0.56–4.62)	0.373
	IV	21	19	3.05 (1.32–7.03)	1.61 (0.56–4.62)	0.203
History of hospital admission	Yes	174	53	2.67 (1.67–4.35)	3.37 (1.79–6.33)	< 0.001**
	No	59	48	1.00 (reference)	1.00 (reference)
Presence of opportunistic infection	Yes	168	48	2.85 (1.75–4.63)	2.63(1.36–5.08)	0.004**
	No	65	53	1.00 (reference)	1.00 (reference)
Duration of ART treatment	< 12month	26	25	0.38 (0.21–0.70)	0.26 (0.12–0.58)	0.001**
	≥ 12month	207	76	1 (reference)	1 (reference)
Adherence to ART treatment	Good	151	49	1 (reference)	1 (reference)
	Fair	36	31	0.53 (0.26–1.07)	0.45 (0.18–1.08)	0.076
	Poor	46	21	1.40 (0.76–2.58)	1.31 (0.61–2.78)	0.482
CD4 + T lymphocyte count (cells/mm3)	≥ 350	13	13	1 (reference)	1 (reference)
	< 350	220	88	2.50 (1.15–5.43)	0.33 (0.12–0.91)	0.033**
CPT prophylaxis	Yes	36	5	3.50 (1.33–9.22)	2.3 (0.76–6.97)	0.138
	No	197	96	1 (reference)	1 (reference)
Residents	Urban	186	72	1.59 (0.93–2.72)	1.52 (0.72–3.18)	0.267
	Rural	47	29	1.00 (reference)	1.00 (reference)

^*Abbreviation: ART: Antiretroviral therapy, CPT: cotrimoxazole prophylaxis, WHO: World Health Organization, **significance level at p<0.05

Discussion

In this study, the prevalence of depression among individual having with HIV was 30.2% with (95% confidence interval, 25.52–35.40). This is consistent with findings from South Africa [32] and Hawassa, Ethiopia (33.5%) [23]. However, it is higher than prevalence estimates from similar studies conducted in Guinea (Conakry) at 8.1% [33], in Nigeria (South western) at 21.9% [34], and in Ethiopia (Addis Ababa) at 24.5% [26]. The high depression prevalence (30.2%) reflects intersecting vulnerabilities: HIV-related stigma (59.6%), poor social support (55.4%), and conflict-driven healthcare gaps (32% hospitalization rates), as observed in similar marginalized Ethiopian cohorts [23]. However, this prevalence finding was lower than in a previous similar study conducted in Bahir Dar, Ethiopia (39.8%) [24]. These discrepancies may be attributed in part to the predominance of urban residents (77.2%) in the current study compared to more rural cohorts in other studies.

PLHIV with CD4 + T lymphocyte count < 350 were 67% times less probability be depressed compared to Patient living with HIV with CD4 + T lymphocyte count ≥ 350. This inline a study conducted in Uganda [27], in Malawi [35], in Addis Ababa, Ethiopia [36] and in Hawassa Ethiopia [37] showed that high CD4 + T lymphocyte count were associated with lower phenomenon of depression (protective). This could be because of a low CD4 + T lymphocyte count, which can lead to unstable clinical condition, weaken the bond between the patients and doctors, and eventually impair concentration, cause feelings of worthlessness, and interfere with self-management activities.

Age category below 39 years PLHIV who were 6.40 times more likely to be depression compared to age category 50 + years PLHIV. This is in line with Harar Town, Eastern Ethiopia [19] and in Southern Ethiopia [21] that showed the probability of depression were higher among younger age group of patients compared to aged [1, 25]. This may be because of stigmas around HIV that is connected to self-isolation, which can exacerbate depressive symptoms and make it more difficult to maintain relationships with friends, family, and others, community members. It can also cause patients to worry and feels stressed out trying to get through daily tasks, which can further exacerbate depressive symptoms.

History of hospital admission of PLHIV was 3.37 times more probability be depression compared to no history of hospital admission PLHIV. Due to their HIV status-one of the chronic, lifelong disease that is highly stigmatized-they can feel it not difficult spaciousness in order keep away from prejudice or humiliation, or they might fatigue to participate in party. For example, depression alone may results after hospitalization for treatment [38]. It should be mentioned that HIV is a chronic illness that is likely to cause stigma, shame, and discrimination in society. As results, people living with HIV may choose spouseless in order keep away from the humiliation particular exacerbate their depressed symptoms [3].

Duration on ART treatment patient living less than 12 month with HIV was 74% less probability to be depressed (adjusted odd ratio of 0.26 with 95% confidence interval: (0.12–0.58) compared to duration of ART treatment patient living with HIV. One explanation for this cloud is that the lack of opportunistic infection did not increase the negative feelings associated with ART, which consequently reduced depression. Early ART medication initiation is linked to reduction in viral load, which does not result in immunological suppression or poor health outcomes. Furthermore, this make sense since patients would be more likely to experience depression if their illness were more severe and progressed [39–41].

Having opportunistic infection of patient living with HIV was 2.63 times probability to be depression compared to no opportunistic infection patient living with HIV. This finding agree with the finding in Africa (East) [23, 42]. This could be because of opportunistic infection that makes a person’s unhappy with the way look, which could be the cause of depression. Over all this could as result of to have weakened immune depression and HIV illness is one of root cause of depression and anxiety [12].

Limitations

The cross-sectional design limits the ability to establish causality between HIV-related clinical factors and depression symptoms. Although significant associations were observed, the temporal direction of these relationships cannot be determined. Additionally, unmeasured factors such as childhood trauma may persist despite statistical adjustments. The use of self-reported measures could also introduce recall and social desirability biases.

Conclusion

The prevalence of depression (30.2%) was notably higher than rates in the general population and consistent with WHO benchmarks for PLHIV. Age, duration of ART treatment, having opportunistic infections, history of hospital admission, and higher CD4 + T lymphocyte count were significantly associated with depression symptoms. Health care facilities should consider depression screening and management as part of routine HIV care, especially for patients with these characteristics. Further longitudinal research is needed to explore causal relationships.

Abbreviations

BMI

Body mass index

CI

Confidence interval

CPT

Cotrimoxazole prophylaxis

ETB

Ethiopian birr

INH

Isoniazid prophylaxis

OI

Opportunistic infection

PHC

Primary health care

PHQ-9

Patient health questionnaire-9

PLHIV

People living with HIV

SPSS

Statistical package for the social sciences

WHO

World health organization

Author contributions

TY, AA, BY and EI conceived and designed the study. TY, AA, BY, and EI implemented the study. TY and BY analyzed the data. TY and EI had primary responsibility for final content. All authors participated in writing, read and approved the final manuscript.

Funding

The authors declare(s) that no financial or any commercial support was received for the study, authorship, and/or publication of this article.

Data availability

Data that supporting the finding of this study will be made available upon request from the corresponding author, without undue reservation.

Declarations

Ethics approval and consent to participate

The Ethical Review Committee (ERC) of college of health science, school of public health, Jinka University was approved with reference number of jcu/1149/14. Also, formal letters of permission were obtained from Sodo town health office, Tebela town administrative health office, Bele awassa town administrative health office, Bodit town administrative health office, Gesuba town administrative health office, Bitana district health office and Bomb district health office. The formal letter of permission was written to the respective hospitals. The study's objectives and methods were explained to each participant. Additionally, prior to participation, all study participants provided written informed permission. The study's goal, the thorough review of their medical records, and the potential benefits of the research were also explained to the participants. The data gathered was used for the study's objectives. All of the information gathered throughout the study was kept private, available only to the research team, and utilized only for that reason. Their medical record numbers were utilized instead of personal identifiers for the purpose of gathering data. The study incorporated active depression management for participants scoring PHQ-9 ≥ 5, including immediate referrals when indicated. This protocol was approved by the Jinka University IRB (ref: jcu/1149/14) and implemented in partnership with local health authorities. The study was carried out in compliance with the applicable rules, laws, and Helsinki Declaration principles.

Consent for publication

Not applicable.

Human or animal rights

The study design, study execution, and results distribution did not involve patients or general public.

Competing interests

The authors declare that the study was held in the absence of any commercial or financial support that could be constructed as a potential conflict of interest.