Abstract
Depression is associated with suboptimal HIV care outcomes. Little is known about the extent to which the prevalence of depressive symptoms varies across the HIV care continuum. Also, the relationship among gender, HIV disclosure, HIV care stage, and depressive symptoms in PLWH remains poorly understood. We analyzed cross-sectional data from 12,507 PLWH at enrollment in International epidemiology Databases to Evaluate AIDS (IeDEA) Cameroon between 2016 and 2020. Recent depressive symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2). A score of three or greater on the PHQ-2 was considered indicative of likely major depressive disorder. We estimated the prevalence of depressive symptoms across three stages of HIV care: those not yet on antiretroviral therapy (ART), recent ART initiators (ART initiation ≤ 30 days prior), and ART users (ART initiation > 30 days prior). Adjusted prevalence differences (aPD) of depressive symptoms were estimated comparing recent ART initiators and ART users. Disclosure and gender were examined as effect measure modifiers of the relationship between HIV care stage and depressive symptoms. The prevalence of depressive symptoms was 11.9%, 22.0%, and 8.7% among PLWH not yet on ART, recent ART initiators, and ART users, respectively. ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD − 0.09 [95% CI − 0.11, − 0.08]). Neither gender nor HIV disclosure modified the effect measure of the relationship between HIV care stage and depressive symptoms. Depressive symptoms were commonly reported among this group of PLWH and were associated with recent ART initiation. Integration of screening and treatment of depression into HIV care should be prioritized and may be particularly relevant for PLWH initiating ART.
Keywords: Depression, HIV, Disclosure, Gender, Cameroon
Introduction
Depression is among the most common mental health disorders globally and among PLWH [1]. Estimates of the prevalence of depression among PLWH vary. A systematic review of depression among PLWH in sub-Saharan Africa estimated the prevalence of depression to be 12–19% when assessed via diagnostic interview and 13–24% when assessed through screening tools [2]. The prevalence of depressive symptoms among PLWH in Cameroon has been estimated to be 20–29% [3–5]. It has been estimated that within a decade, HIV and depression will be the two leading causes of disability globally, measured by disability-adjusted life years [6]. Gender has been consistently associated with depression among PLWH, with women at increased risk of depression compared to men [1, 2]. A number of psychosocial stressors have also been associated with depression among PLWH including food insecurity, material hardship, migration, HIV-related stigma, engagement in sex work, and alcohol and other substance use [2, 7–9].
Mental health disorders have been associated with suboptimal HIV care continuum outcomes throughout the HIV care cascade, including delayed care entry, suboptimal antiretroviral therapy (ART) adherence, lack of viral suppression, and mortality [10–12]. While the relationship between depression and HIV care continuum outcomes has been well documented, less is known about the extent to which the prevalence of depression varies meaningfully across key stages of the HIV care continuum, including engagement in HIV care, ART initiation, and retention in care. The prevalence of depressive symptoms may be higher among individuals initiating HIV care, particularly those newly diagnosed, and lower among PLWH engaged in HIV care for many years. On the other hand, given the chronic nature of depression, its prevalence may not vary meaningfully across HIV care continuum stages, particularly for those whose depression onset preceded HIV diagnosis. Most studies on the prevalence of depression among PLWH have included individuals in one stage of the HIV care continuum (i.e., ART initiation or care engagement) or included PLWH across care continuum stages without exploring differences by stage. A greater understanding of the prevalence of depressive symptoms among PLWH across key stages of the care continuum may help identify windows of vulnerability in which screening and enhanced mental health supports could be particularly beneficial.
HIV status disclosure is encouraged within the context of HIV treatment and had been hypothesized to improve the mental health of PLWH, largely through increased social support and reduced stress which may result from disclosure [13–16]. However, disclosure may also worsen mental health, particularly if it results in rejection, violence, or other stigmatizing experiences [17, 18]. Research on the relationship between disclosure and depressive symptoms among PLWH in sub-Saharan Africa remains equivocal. Research with PLWH in Kenya, Namibia, and Tanzania found that disclosure was associated with greater severity of depressive symptoms while research with PLWH in Nigeria found that HIV disclosure was associated with fewer depressive symptoms [19, 20]. A study with women living with HIV in Zimbabwe found that positive disclosure beliefs, but not number of disclosures, were associated with fewer depressive symptoms [21]. In addition, little is known about the extent to which the association between disclosure and depressive symptoms varies by HIV care stage.
Disclosure is often influenced by concerns related to stigma, discrimination, and physical and emotional safety. Research has consistently demonstrated differences in the prevalence of intimate partner violence, HIV-related stigma, and social support between men and women living with HIV [22–25]. Thus, the relationship between disclosure and depressive symptoms among PLWH may vary by gender.
Since 2016 Cameroon has been implementing a national ‘treat all’ policy in which all PLWH are able to initiate ART immediately after diagnosis, similar to many countries in sub-Saharan Africa. ART is available free-of-charge at all levels of the health system in Cameroon. HIV prevalence among adults in Cameroon is approximately 3.7% and is higher among women than men in Cameroon (4.2% vs 2.0%, respectively) [26]. Compared to women, men living with HIV in Cameroon are less likely than women to be receiving ART (56% vs 67%, respectively) and are more likely to die from HIV-related causes [26].
The objectives of the current study are to investigate the relationship between depressive symptoms and HIV care stage and to examine to what extent the relationship between HIV care stage and depressive symptoms differs by HIV disclosure or gender among PLWH in Cameroon. A greater understanding of the association among HIV disclosure, HIV care stage, gender, and depressive symptoms can inform the development or adaptation of services to improve the mental health and well-being of PLWH.
Methods
This analysis used data from the Central Africa International epidemiology Databases to Evaluate AIDS (CA-IeDEA) Cameroon study. IeDEA is a research consortium established with funding from the National Institute of Allergy and Infectious Diseases to collect and harmonize global HIV data [27]. IeDEA Cameroon data are collected at three HIV treatment centers in Cameroon. The current analysis is restricted to data collected between January 2016 and March 2020. The IeDEA Cameroon study was approved by the national Ethical Committee of Research for Human Health in Yaoundé, Cameroon and the Institutional Review Board at Albert Einstein College of Medicine. All participants provided written informed consent.
Of the 12,774 people aged 18 or older who contributed data to IeDEA Cameroon from 2016 to 2020, 107 were excluded from the present analysis because they had two or more conflicting data points (Fig. 1). Four patients with missing dates of depression screening were eliminated. Additionally, 41 pregnant women were excluded due to meaningful differences between depression experienced during and outside the context of pregnancy. Finally, we removed 86 people with missing depression data, and 29 people with unclear ART treatment histories. We include cross-sectional data on 12,507 (97.9%) participants in IeDEA Cameroon.
Fig. 1.
Study inclusion flow chart
Measures
Depressive Symptoms
Depressive symptoms were ascertained using the two item Patient Health Questionnaire (PHQ-2) [28]. A score of three or greater was considered indicative of likely major depressive disorder. The PHQ-2 has been widely used throughout sub-Saharan Africa and has been validated among PLWH in Kenya [29]. The PHQ-2 has been found to have high sensitivity and specificity for identifying PLWH with any depressive disorder (sensitivity: 85%; specificity: 95%) and identifying PLWH with major depressive disorder (sensitivity: 91%; specificity: 77%) when validated with PLWH in Western Kenya [29]. The PHQ-2 was used as minimizing participant and staff burden in the HIV clinics in which this research was conducted was a top priority of clinic and study staff.
HIV Care Stage
Study participants were categorized into one of three HIV care stages: individuals who had not initiated ART at the time of depression screening (ART-non-users), individuals who initiated ART ≤ 30 days prior to the depression screening (recent ART initiators), and individuals who had initiated ART > 30 days prior to the depression screening (ART users). HIV care stage was determined using the dates of the depression screening and ART initiation. Date of ART initiation was obtained from participants’ medical records. Participants who had no ART initiation date or an ART initiation date after their depression screening were categorized as not yet on ART.
HIV Disclosure
Respondents were asked if they had ever shared their HIV status with anyone.
Advanced HIV Disease
Advanced HIV disease was defined as having a CD4 count of < 200 cells/cubic millimeter or having a WHO stage of 3 or 4.
Covariates of gender, age, education, income, employment, smoking status, and recent heavy episodic drinking were captured via self-report. We coded participants as having engaged in heavy episodic drinking if they reported a response of more frequently than never for either of the following questions: During the past three months, how often did you drink more than three bottles of beer in one sitting or During the past three months, how often did you drink more than six glasses of other alcoholic drinks (not beer) in one sitting? In Cameroon, beer is typically served in large bottles roughly equivalent to two standard drinks. If a participant was missing responses to these two questions, but responded “never” to the question What best describes how often you have a drink containing alcohol, they were categorized as not having engaged in heavy episodic drinking.
Statistical Analysis
Descriptive statistics were used to summarize demographic and behavioral characteristics of the cohort. Prevalence of depressive symptoms were calculated overall and stratified by HIV care stage, HIV disclosure status, and gender. We used binomial regression to assess the relationship between HIV care stage and depressive symptoms. We calculated the prevalence of depressive symptoms as well as the prevalence differences (PDs) and the corresponding 95% confidence intervals (CIs). In adjusted analyses, we controlled for age, education, smoking status, heavy episodic drinking, and clinical site. To assess how the association between HIV care stage and depressive symptoms differed by disclosure, we repeated the regression analysis separately among those who had and had not disclosed their HIV status. Similarly, to assess to what extent the association between HIV care stage and depressive symptoms differed between women and men, we repeated the regression analysis separately among women and men.
Of the 12,507 people in the analytic sample, advanced HIV disease was missing for 38.2% of the sample (n = 4779). We performed two sensitivity analyses controlling for advanced HIV disease as a potential confounder of the association between HIV care stage and depressive symptoms. First, we replicated our analysis among the subset of individuals for whom data on advanced disease were available and adjusted for advanced HIV disease. Second, we used logistic regression to impute monotonically missing advanced HIV disease values and replicated our analyses using imputed values. Analyses using both the complete cases and the imputed values were not meaningfully different from our main results. Thus, we present results from the main analysis only which is not adjusted for advanced HIV disease.
Results
Of the 12,507 included participants, most were over 35 years old (Table 1). Two thirds (66.4%) of participants were female, 43.9% had received only a primary school education and most (63.7%) were employed.
Table 1.
Characteristics of PLWH in IeDEA Cameroon, 2016–2020
| Total sample N = 12,507 | With depressive symptomsa N = 1526 | |
|---|---|---|
| N(%) | % | |
| Age | ||
| 18–24 years | 520 (4.2) | 21.3 |
| 25–34 years | 2551 (20.6) | 15.9 |
| 35–44 years | 4365 (35.3) | 12.3 |
| > 44 years | 4937 (39.9) | 10.1 |
| Missing | 134 | – |
| Gender | ||
| Women | 8280 (66.4) | 12.0 |
| Men | 4196 (33.6) | 13.6 |
| Missing | 31 | – |
| Education | ||
| Noschooling | 1179 (9.5) | 13.0 |
| Primary | 5454 (43.9) | 10.9 |
| Secondary | 3614 (29.1) | 14.8 |
| High school or equivalent | 1183 (9.5) | 13.2 |
| University or equivalent | 1001 (8.1) | 12.2 |
| Missing | 76 | – |
| Employment | ||
| Student | 383 (3.1) | 20.5 |
| Employed | 7908 (63.7) | 11.8 |
| Retired | 372 (3.0) | 6.6 |
| Unemployed | 3759 (30.3) | 14.0 |
| Missing | 85 | – |
| Monthly income, in XAF (USD)b | ||
| None | 3369 (27.5) | 16.5 |
| < 50,000 (< 89) | 5832 (47.7) | 10.2 |
| 51,000–100,000 (91–178) | 1713 (14.0) | 12.6 |
| 101,000–200,000 (180–356) | 883 (7.2) | 12.6 |
| 201,000–300,00 (358–534) | 309 (2.5) | 11.9 |
| > 300,000 (> 534) | 125 (1.0) | 10.4 |
| Missing | 276 | – |
| Smoking status | ||
| Never | 10,485 (84.4) | 12.3 |
| Current | 418 (3.4) | 18.5 |
| Former | 1523 (12.3) | 12.8 |
| Missing | 81 | – |
| Heavy episodic drinking in prior | ||
| 3 months | ||
| Yes | 2042 (16.4) | 17.5 |
| No | 10,400 (83.6) | 11.6 |
| Missing | 65 | – |
Among those with non-missing covariates
Conversion from Central African Franc (XAD) to United States Dollar (USD) based on conversionrate on October 30th, 2020
Overall, 12.5% percent of participants screened positive for depressive symptoms, with a slightly higher proportion of men than women (13.6% vs 12.0%, respectively). Age was inversely related to prevalence of depressive symptoms. The prevalence of depressive symptoms among those 18–24 years of age was 21.3% compared 10.1% among those 45 years or older. Most (69.4%) participants were ART users and had been on ART for more than 12 months (60.8%) (Table 2). Among ART users, the mean time since ART initiation was 5.9 years (range 31 days to 43 years; standard deviation: 4 years). Approximately one-quarter (28.7%) of participants had recently initiated ART, mostly initiating ART the same day they were screened for depression (26.8%). Just 1.9% of participants had not yet initiated ART.
Table 2.
Depressive symptoms, gender, and HIV Care Stage among PLWH in IeDEA Cameroon, 2016–2020
| Total sample N = 12,507 | With depressive symptoms N = 1570 | Men | Women | |||
|---|---|---|---|---|---|---|
| Total male sample N = 4196 | With depressive symptoms N = 566 | Total female sample N = 8280 | With depressive symptoms N = 995 | |||
| N(%) | N(%) | N(%) | N(%) | N(%) | N(%) | |
| ART users | 8675 (69.4) | 753 (8.7) | 2610 (62.2) | 223 (8.5) | 6050 (73.1) | 528 (8.7) |
| > 12 months since ART initiation | 7610 (60.8) | 611 (8.0) | 2223 (53.0) | 174 (7.8) | 5375 (64.9) | 435 (8.1) |
| 6–12 months since ART initiation | 568 (4.5) | 54 (9.5) | 205 (4.9) | 21 (10.2) | 361 (4.4) | 33 (9.1) |
| 31 days- < 6 months since ART initiation | 497 (4.0) | 88 (17.7) | 182 (4.3) | 28 (15.4) | 314 (3.8) | 60 (19.1) |
| Recent ART initiators | 3589 (28.7) | 788 (22.0) | 1499 (35.7) | 337 (22.5) | 2075 (25.1) | 445 (21.4) |
| Initiated ART 1–30 days after depression screening | 240 (1.9) | 57 (23.8) | 89 (2.1) | 19 (21.3) | 150 (1.8) | 37 (24.7) |
| ART initiation same day as depression screening | 3349 (26.8) | 731 (21.8) | 1410 (33.6) | 318 (22.6) | 1925 (23.2) | 408 (21.2) |
| ART non-users | 243 (1.9) | 29 (11.9) | 87 (2.1) | 6 (6.9) | 155 (1.9) | 22 (14.2) |
Depressive Symptoms and HIV Care Stage
The prevalence of depressive symptoms varied meaningfully by HIV care stage. The prevalence of depressive symptoms was 22.0%, 11.9%, and 8.7% among recent ART initiators, those not yet on ART, and ART users, respectively. Among recent ART initiators, the prevalence of depressive symptoms was 23.8% among those who had initiated in the 30 days prior to depression screening and 21.8% among those who initiated the same day they were screened for depression.
Among ART users, the prevalence of depressive symptoms decreased with time since ART initiation. The prevalence of depressive symptoms was 17.7%, 9.5% and 8.0% among participants who had initiated between 31 days and less than 6 months ago, from 6 to 12 months prior, and more than 12 months prior.
The prevalence of depressive symptoms did not differ meaningfully between men and women among ART users (8.5% vs. 8.7%, respectively) or recent ART initiators (22.5% vs 21.4%). Among those not on ART, the prevalence of depressive symptoms was higher among women compared to men (14.2% vs 6.9%).
HIV Disclosure, HIV Care Stage, and Depressive Symptoms
HIV disclosure was common among participants, with 90.4% having disclosed their HIV status (Table 3). HIV disclosure was significantly associated with HIV care stage: 96.2% of ART users had disclosed their HIV status compared to 86.3% of ART non-users and 76.6% of recent ART initiators. The prevalence of HIV disclosure was similar between women and men across HIV care stages.
Table 3.
Depressive symptoms, gender, HIV disclosure and HIV care stage among PLWH in IeDEA Cameroon, 2016–2020
| Total sample N = 12,507 | With depressive symptoms N = 1570 | Men | Women | |||
|---|---|---|---|---|---|---|
| Total male sample N = 4196 | With depressive symptoms N = 566 | Total female sample N = 8280 | With depressive symptoms N = 995 | |||
| N(%) | % | N(%) | % | N(%) | % | |
| Overall | ||||||
| Shared HIV status | 11,263 (90.4) | 11.8 | 3635 (86.9) | 12.4 | 7600 (92.2) | 11.4 |
| Has not shared HIV status | 1194 (9.6) | 19.9 | 548 (13.1) | 20.4 | 643 (7.8) | 19.6 |
| Missing | 50 | 13 | 37 | |||
| Longer time ART user (on ART for > 30 days) | ||||||
| Shared HIV status | 8315 (96.2) | 8.6 | 2485 (95.6) | 8.4 | 5815 (96.5) | 8.6 |
| Has not shared HIV status | 323 (3.7) | 11.7 | 115 (4.4) | 11.3 | 208 (3.5) | 12.0 |
| Missing | 37 | 10 | 27 | |||
| Recent ART initiator (on ART for ≤ 30 days) | ||||||
| Shared HIV status | 2741 (76.6) | 21.5 | 1076 (71.9) | 22.0 | 1653 (79.9) | 21.0 |
| Has not shared HIV status | 838 (23.4) | 23.3 | 420 (28.1) | 23.6 | 415 (20.1) | 23.1 |
| Missing | 10 | 3 | 7 | |||
| ART initiation same day as depression screening | ||||||
| Shared HIV status | 2529 (75.7) | 21.2 | 998 (70.9) | 22.0 | 1520 (79.2) | 20.5 |
| Has not shared HIV status | 811 (24.3) | 23.7 | 409 (29.1) | 23.7 | 399 (20.8) | 23.8 |
| Missing | 9 | 3 | 6 | |||
Among the entire sample, the prevalence of depressive symptoms was higher among those who had not disclosed compared to those who had (19.9% vs 11.8%, respectively). However, when examined specifically among recent ART initiators, the prevalence of depressive symptoms was similar between those who had and had not disclosed (21.5% vs 23.3%, respectively). Among those who initiated ART the same day as depression screening, the prevalence of depressive symptoms was also similar between those who had and had not disclosed their status (21.2% vs. 23.7%, respectively).
In contrast, among ART users, the prevalence of depressive symptoms was lower among those who had disclosed compared to those who had not (8.6% vs 11.7%, respectively). A similar pattern between HIV disclosure, HIV care stage, and depressive symptoms was observed when examined separately by gender.
Among the entire sample, in multivariable analyses, ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD −0.09 [95% CI − 0.11, − 0.08]) (Table 4). This relationship persisted when stratified by disclosure. Among those who had not disclosed, ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD − 0.07, 95% [CI − 0.14, − 0.01)]). Similarly, among those who had disclosed, ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD − 0.09, 95% [CI − 0.11, − 0.07)]. The relationship between HIV care stage and depressive symptoms also persisted when stratified by gender. Among men, ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPR − 0.09, 95% [CI − 0.11, − 0.07)]. Similarly, among women, ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD − 0.10, 95% [CI − 0.12, − 0.08)].
Table 4.
Multivariable analyses of the relationship among gender, HIV disclosure, HIV care stage, and depressive symptoms among PLWH in HIV care in IeDEA Cameroon, 2016–2020
| Exposure | Overall | ||
|---|---|---|---|
| Prevalence of depression (95% CI) | Unadjusted prevalence difference (95% CI) | Adjusted prevalence difference (95% CI) | |
| Overall | |||
| Longer time ART user (on ART for > 30 days) | 0.09 (0.08, 0.09) | − 0.13 (− 0.15, − 0.12) | − 0.09 (− 0.11, − 0.08)a |
| Recent ART initiator (on ART for ≤ 30 days) | 0.22 (0.21, 0.23) | Ref | Ref |
| Have not disclosed HIV status | |||
| Longer time ART user (on ART for > 30 days) | 0.12 (0.08, 0.15) | − 0.11 (− 0.16, − 0.07) | − 0.07 (− 0.14, − 0.01)a |
| Recent ART initiator (on ART for ≤ 30 days) | 0.23 (0.20, 0.26) | Ref | Ref |
| Have disclosed HIV status | |||
| Longer time ART user (on ART for > 30 days) | 0.09 (0.08, 0.09) | − 0.13 (− 0.15, − 0.11) | − 0.09 (− 0.11, − 0.07)a |
| Recent ART initiator (on ART for ≤ 30 days) | 0.22 (0.20, 0.23) | Ref | Ref |
| Men | |||
| Longer time ART user (on ART for > 30 days) | 0.09 (0.08, 0.10) | − 0.14 (− 0.16, − 0.12) | − 0.09 (− 0.11, − 0.07)b |
| Recent ART initiator (on ART for ≤ 30 days) | 0.23 (0.20, 0.25) | Ref | Ref |
| Women | |||
| Longer time ART user (on ART for > 30 days) | 0.09 (0.08, 0.09) | − 0.13 (− 0.15, − 0.11) | − 0.10 (− 0.12, − 0.08)b |
| Recent ART initiator (on ART for ≤ 30 days) | 0.21 (0.20, 0.23) | Ref | Ref |
Adjusted for age, gender, education, smoking, clinic and heavy episodic drinking
Adjusted for age, education, smoking, clinic, and heavy episodic drinking
Discussion
Overall, depressive symptoms were reported by 12.5% of this sample of PLWH in HIV care in Cameroon. Individuals who recently initiated ART reported significantly higher prevalence of depressive symptoms compared to longer-term ART users. The association between HIV care stage and depressive symptoms was not modified by gender or HIV disclosure.
While data are limited, the prevalence of depressive symptoms in the current study is lower than previous estimates with PLWH in Cameroon. For example, studies of PLWH on ART in Cameroon have estimated that 27–29% screened positive for depressive symptoms while a study of PLWH in Yaounde found that 21% of participants screened positive for depressive symptoms [4, 5, 30]. Among ART users, the prevalence of depressive symptoms was 8.7%. This is also lower than findings from a previous meta-analysis which estimated the pooled prevalence of depressive symptoms among PLWH on ART in sub-Saharan Africa to be 12–17% and lower than has been previously estimated among PLWH on ART in Cameroon [2, 30, 31]. Caution is warranted when comparing estimates across studies due to differences in screening instruments, sampling, and timing of assessments.
Depressive symptoms were significantly higher among individuals who had recently initiated ART compared to longer-term ART users. Research on the relationship between ART use and depressive symptoms remains equivocal. One meta-analysis of PLWH in sub-Saharan Africa estimated the pooled prevalence of depressive symptoms to be 17% among individuals on ART compared to 38% among samples comprised of PLWH who were treatment-naïve or samples comprised of treated and untreated PLWH [31]. However, another meta-analysis of depressive symptoms among PLWH in sub-Saharan Africa did not find a meaningful difference between the prevalence of depressive symptoms among PLWH on ART and those who were treatment-naïve or samples of treatment and untreated PLWH [2]. Importantly, neither meta-analysis examined the prevalence of depressive symptoms by time on ART.
HIV diagnosis has been found to be an acute stressor and associated with poor mental health. Because Cameroon began implementing a national ‘treat all’ policy in 2016, in which all PLWH are eligible to initiate ART immediately following diagnosis, it is possible that some portion of PLWH who initiated ART the same day as they were screened for depression were also newly diagnosed with HIV. Because date of first HIV-positive diagnosis was unavailable for participants, we were unable to compare the prevalence of depression symptoms between those who were and were not newly diagnosed. However, among those for whom depression screening was conducted on the same day as ART initiation most (75.7%) reported having disclosed their HIV status to someone, suggesting that these individuals had likely been previously diagnosed. Among those for whom depression screening was conducted on the same day as ART initiation, the prevalence of depression was similar between those who had and had not disclosed their HIV status. Thus, it does not appear that the prevalence of depression among those who initiated ART on the same day as depression screening was meaningfully influenced by an acute shock of diagnosis.
In the current analyses, ART users who had initiated ART between 31 days and 6 months prior had a higher prevalence of depressive symptoms compared to those who initiated ART longer ago. Research with PLWH in Uganda found that the prevalence of depressive symptoms decreased substantially between ART initiation and both 3 and 6 months after ART initiation [32]. A longitudinal study of PLWH in Kenya and Uganda similarly found that depressive symptoms decreased 6 months after ART initiation [33]. Prior research with PLWH in Cameroon found that time on ART was not associated with prevalence of depressive symptoms [4]. However, this research compared the prevalence of depressive symptoms among those who were on ART for more or less than 2 years [4]. Dichotomizing ART duration at two years may have precluded researchers’ ability to observe differences in the prevalence of depressive symptoms by time on ART. In the current analyses, the prevalence of depressive symptoms was similar between participants who initiated ART 6–12 months prior and more than 12 months prior.
Current findings suggest that the period surrounding ART initiation may be a window of particular vulnerability for depression among PLWH. HIV treatment centers should consider screening PLWH initiating ART for depressive symptoms and referring individuals to care, where indicated. Similar to many regions in sub-Saharan Africa, integration of screening and treatment for mental health disorders into HIV clinics remains limited throughout Cameroon [34]. Patient, provider, and health facility-level barriers and facilitators to sustainable integration of mental health and HIV care in resource-limited settings should be explored, and implementation strategies to address these resource limitations should be evaluated.
Because we analyzed a cross-sectional snapshot of IeDEA Cameroon data, it is unclear whether PLWH with depressive symptoms at ART initiation were more likely to disengage from care or whether depressive symptoms at ART initiation improved with time in care. Research with PLWH in South Africa found that depression at HIV diagnosis was not associated with subsequent engagement in HIV care [35]. Similarly, research with PLWH in Malawi found that depression at ART initiation was not associated with HIV care engagement six months later [36]. However, research with PLWH in Rwanda found depression to be associated with subsequent attrition from HIV care [37]. In addition, a study with PLWH with depression in Uganda found that the alleviation of depression symptoms was associated with improved clinic attendance at 12 months [38]. Additional longitudinal analyses are needed to better understand the trajectory and persistence of depressive symptoms over time among PLWH and the extent to which depressive symptoms among PLWH prior to or at ART initiation are associated with subsequent disengagement from HIV care. Future research should also explore the extent to which the relationship between depressive symptoms and care engagement differs between those with pre-existing depression and those with depression onset subsequent to HIV diagnosis.
HIV disclosure was very common among study participants with 90% of participants reporting having disclosed their HIV status to at least one person. This is similar to previous research with PLWH initiating ART in Cameroon between 2008 and 2011 which found that 87% of study participants had disclosed their HIV status to at least one person [39]. Similarly, research with women living with HIV in Cameroon found that 86% had disclosed their HIV status to their main sexual partner [40]. Cultural and contextual factors that influence high levels of HIV disclosure in Cameroon warrant further investigation.
HIV disclosure was associated with the prevalence of depressive symptoms and HIV care stage. However, disclosure did not modify the association between HIV care stage and depressive symptoms. Research on the relationship between disclosure and depressive symptoms among PLWH in sub-Saharan Africa remains equivocal. For example, research with PLWH in Kenya, Namibia, and Tanzania found that disclosure was positively associated with severity of depressive symptoms while research with PLWH in Nigeria found that HIV disclosure was inversely associated with depressive symptoms [19, 20]. However, neither study disaggregated findings by HIV care stage. Our findings highlight the importance of examining the relationship between HIV disclosure and depressive symptoms separately by HIV care stage and suggest that interventions to promote HIV disclosure may be insufficient to improve depressive symptoms among PLWH in Cameroon or other low-resource settings.
Gender did not modify the association between depressive symptoms and HIV care stage. The authors are not aware of previous research that examined the extent to which gender modifies the relationship between depressive symptoms and HIV care stage. Women often experience a higher prevalence of depression than men [41, 42]. However, in this study of PLWH in Cameroon, we found a slightly lower prevalence of depressive symptoms among women compared to men. Women were also more likely to be ART users compared to men. Among those not on ART, the prevalence of depressive symptoms was higher among women than men. Given the small sample size of ART non-users (n = 243), we remain hesitant to draw conclusions from these data. Further, because this study was conducted during implementation of a national ‘treat all’ policy, it is likely that ART users and non-users are meaningfully different. Greater understanding is needed surrounding factors that influence ART non-use in the context of national ‘treat all’ policy implementation and the relationships among gender, depression, and ART non-use in this context.
Given consistent gender differences in the prevalence of depressive symptoms and HIV care continuum outcomes, more research is needed to understand the relationship among gender, depressive symptoms, and HIV care continuum outcomes. Longitudinal research may yield important insights into the ways in which gender, depression, and HIV care engagement intersect.
While not a primary focus of our study, it is worth noting that there was an inverse relationship between age and prevalence of depressive symptoms. This is contrary to previous research which has found a positive relationship between age and prevalence of depressive symptoms among PLWH in sub-Saharan Africa [43, 44]. Additional research to understand the relationship between age and depressive symptoms among PLWH in Cameroon is warranted.
This study has limitations worth noting. Depressive symptoms were assessed using the PHQ-2. The PHQ-2 is a screening tool for possible depression and cannot be considered diagnostic of depression. In addition, date of first HIV positive diagnosis was unavailable for participants. As such, we are unable to distinguish between those who were and were not newly diagnosed with HIV at the time of depression screening. Data were collected from three public HIV treatment clinics participating in IeDEA Cameroon and may not be generalizable to other populations or settings. Because IeDEA sites routinely contribute electronic data to the IeDEA consortium, these sites may function at a higher level than HIV treatment sites in Cameroon not participating in IeDEA.
Conclusion
This study of PLWH in HIV care in Cameroon found that depressive symptoms were commonly reported among this group of PLWH and associated with HIV care stage. Integration of screening and treatment of depression into HIV care should be prioritized and may be particularly relevant for PLWH initiating ART.
Acknowledgements
The authors would like to thank the following individuals for their support and collaboration in IeDEA Central Africa: Nimbona Pélagie, Association Nationale de Soutien aux Séropositifs et Malade du Sida (ANSS), Burundi; Patrick Gateretse, Jeanine Munezero, Valentin Nitereka, Théodore Niyongabo, Christelle Twizere, Centre National de Référence en Matière de VIH/SIDA, Burundi; Hélène Bukuru, Thierry Nahimana, Centre de Prise en Charge Ambulatoire et Multidisciplinaire des PVVIH/SIDA du Centre Hospitalo-Universitaire de Kamenge (CPAMP-CHUK), Burundi; Elysée Baransaka, Patrice Barasukana, Eugene Kabanda, Martin Manirakiza, François Ndikumwenayo, CHUK/Burundi National University, Burundi; Jérémie Biziragusenyuka, Ange Marie Michelline Munezero, Centre de Prise en Charge Ambulatoire et Multidisciplinaire des PVVIH/SIDA de l’Hôpital Prince Régent Charles (CPAMP-HPRC), Burundi; Denis Nsame Nforniwe, Bamenda Hospital, Cameroon; Rogers Ajeh, Marc Lionel Ngamani, Clinical Research Education and Consultancy (CRENC), Cameroon; Anastase Dzudie, CRENC and Douala General Hospital, Cameroon; Akindeh Mbuh, CRENC and University of Yaoundé, Cameroon; Djenabou Amadou, Eric Walter Pefura Yone, Jamot Hospital, Cameroon; Ernestine Kendowo, Limbe Regional Hospital, Cameroon; Catherine Akele, Akili Clever, Faustin Kitetele, Patricia Lelo, Martine Tabala, Kalembelembe Pediatric Hospital, Democratic Republic of Congo; Cherubin Ekembe, Didine Kaba, Kinshasa School of Public Health, Democratic Republic of Congo; Merlin Diafouka, Martin Herbas Ekat, Dominique Mahambou Nsonde, CTA Brazzaville, Republic of Congo; Adolphe Mafoua, Massamba Ndala Christ, CTA Pointe-Noire, Republic of Congo; Jules Igirimbabazi, Nicole Ayinkamiye, Bethsaida Health Center, Rwanda; Providance Uwineza, Emmanuel Ndamijimana, Busanza Health Center, Rwanda; Emmanuel Habarurema, Marie Luise Nyiraneza, Gahanga Health Center, Rwanda; Marie Louise Nyiransabimana, Liliane Tuyisenge, Gikondo Health Center, Rwanda; Christian Shyaka, Catherine Kankindi, Kabuga Health Center, Rwanda; Bonheur Uwakijijwe, Marie Grace Ingabire, Kicukiro Health Center, Rwanda; Jules Ndumuhire, Marie Goretti Nyirabahutu, Masaka Health Center, Rwanda; Fred Muyango, Jean Christophe Bihibindi, Nyagasambu Health Center, Rwanda; Oliver Uwamahoro, Yvette Ndoli, Nyarugunga Health Center, Rwanda; Sabin Nsanzimana, Placidie Mugwaneza, Eric Remera, Esperance Umumararungu, Gallican Nshogoza Rwibasira, Dominique Savio Habimana, Rwanda Biomedical Center, Rwanda; Josephine Gasana, Faustin Kanyabwisha, Gallican Kubwimana, Benjamin Muhoza, Athanase Munyaneza, Gad Murenzi, Francoise Musabyimana, Francine Umwiza, Charles Ingabire, Patrick Tuyisenge, Alex M. Butera, Jules Kabahizi, Ephrem Rurangwa, Rwanda Military Hospital, Rwanda; Rosine Feza, Eugenie Mukashyaka, Shyorongi Health Center, Rwanda; Chantal Benekigeri, Jacqueline Musaninyange, WE-ACTx Health Center, Rwanda; Adebola Adedimeji, Kathryn Anastos, Madeline Dilorenzo, Lynn Murchison, Jonathan Ross, Marcel Yotebieng, Albert Einstein College of Medicine, USA; Diane Addison, Ellen Brazier, Heidi Jones, Elizabeth Kelvin, Sarah Kulkarni, Denis Nash, Matthew Romo, Olga Tymejczyk, Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York (CUNY), USA; Batya Elul, Columbia University, USA; Xiatao Cai, Allan Dong, Don Hoover, Hae-Young Kim, Chunshan Li, Qiuhu Shi, Data Solutions, USA; Kathryn Lancaster, The Ohio State University, USA; Mark Kuniholm, University at Albany, State University of New York, USA; Andrew Edmonds, Jess Edwards, University of North Carolina at Chapel Hill, USA; Olivia Keiser, University of Geneva; Stephany Duda; Vanderbilt University School of Medicine, USA; April Kimmel, Virginia Commonwealth University School of Medicine, USA.
Funding
Central Africa IeDEA is supported by the National Institutes of Health’s National Institute of Allergy and Infectious Diseases (NIAID), the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), the National Cancer Institute (NCI), the National Institute on Drug Abuse (NIDA), the National Heart, Lung, and Blood Institute (NHLBI), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the Fogarty International Center (FIC), the National Library of Medicine (NLM), and the Office of the Director (OD) under Award Number U01AI096299 (Central Africa- IeDEA). This research was also supported by NIMH Grant K01 MH114721, and NICHD Grant P2C HD050924 (Carolina Population Center). This work is solely the responsibility of the authors and does not necessarily represent the official views of any of the institutions mentioned above.
Footnotes
Code Availability All analyses were conducted using SAS. SAS code could be made available from the first author (AMP) on reasonable request.
Conflict of interest Authors declare that they have no conflict of interest.
Ethical Approval This study was approved by the Institutional Review Board at Albert Einstein College of Medicine and the National Ethical Committee of Research for Human Health in Cameroon.
Consent to Participate All participants provided written informed consent.
Data Availability
The dataset contains sensitive information and is not publicly available. However, it could be made available on reasonable request, with approval from the IRB at the Albert Einstein College of Medicine to maintain confidentiality.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The dataset contains sensitive information and is not publicly available. However, it could be made available on reasonable request, with approval from the IRB at the Albert Einstein College of Medicine to maintain confidentiality.