Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2023 Jul 1.
Published in final edited form as: J Affect Disord. 2022 Apr 19;308:421–431. doi: 10.1016/j.jad.2022.04.061

Prevalence of stressful life events and associations with symptoms of depression, anxiety, and post-traumatic stress disorder among people entering care for HIV in Cameroon

Lindsey M Filiatreau a,b,c,*, Peter Vanes Ebasone d, Anastase Dzudie d, Rogers Ajeh d, Brian W Pence e, Milton Wainberg f, Denis Nash g, Marcel Yotebieng h, Kathryn Anastos h,i, Eric Pefura-Yone j, Denis Nsame k, Angela M Parcesepe c,l
PMCID: PMC9520993  NIHMSID: NIHMS1837717  PMID: 35452755

Abstract

Background:

Exposure to stressors increases the risk of mental health disorders. People living with HIV (PLWH) are particularly affected by poor mental health which can contribute to adverse HIV treatment outcomes.

Methods:

We estimated the prevalence of recent stressful life events (modified Life Events Survey) among a cohort of PLWH entering HIV care at three public health care facilities in Cameroon and quantified the association of seven types of stressful life events with symptoms of depression (Patient Health Questionnaire-9 scores>9), anxiety (General Anxiety Disorder-7 scores>9), and PTSD (PTSD Checklist for DSM-5 scores>30) using separate log-binomial regression models.

Results:

Of 426 PLWH enrolling in care, a majority were women (59%), in relationships (58%), and aged 21 to 39 years (58%). Recent death of a family member (39%) and severe illness of a family member (34%) were the most commonly reported stressful life events. In multivariable analyses, more stressful life event types, a negative relationship change, death or illness of a friend/family member, experience of violence, work-related difficulties, and feeling unsafe in one's neighborhood were independently associated with at least one of the mental health outcomes assessed. The greatest magnitude of association was observed between work-related difficulties and PTSD (adjusted prevalence ratio: 3.1; 95% confidence interval: 2.0–4.8).

Limitations:

Given the design of our study, findings are subject to recall and social desirability bias.

Conclusions:

Stressful life events were common among this population of PLWH entering care in Cameroon. Evidence-based interventions that improve coping, stress management, and mental health are needed.

Keywords: Stressful life events, Depression, Anxiety, PTSD, HIV, Cameroon

1. Introduction

Mental health disorders were the second leading cause of years lived with disability globally in 2019, at nearly 15% (Institute for Health Metrics and Evaluation (IHME), 2019). These disorders contribute to an array of health issues, including social isolation (Brown et al., 2011; Elmer and Stadtfeld, 2020), increased substance use and substance use disorders (Conner et al., 2009; Worley et al., 2012), decreased quality of life (Penner-Goeke et al., 2015) and physical functioning (Penninx et al., 2000), cognitive decline (Paterniti et al., 2002), and increased risk of mortality (Walker et al., 2015). People living with HIV (PLWH) are particularly vulnerable to poor mental health outcomes (Ciesla and Roberts, 2001; Nanni et al., 2015; Remien et al., 2019; Too et al., 2021). A 2017 study of 270 adult Cameroonians estimated that nearly 34% of study participants with HIV (n = 169) had symptoms of moderate to severe depression compared to just 20% of participants who were HIV negative (n = 101) (Kanmogne et al., 2017). Similar trends have been observed across a range of settings, including South Africa, India, China, Canada, Uganda, and the United States (Bhatia and Munjal, 2014; Gaynes et al., 2008; Institute for Health Metrics and Evaluation (IHME), 2019; Jonsson et al., 2013; Kendall et al., 2014; Kinyanda et al., 2011a; Niu et al., 2016; Remien et al., 2019).

Among PLWH, evidence suggests symptoms of common mental disorders (i.e., anxiety, depression, post-traumatic stress disorder [PTSD]) may contribute to sub-optimal treatment outcomes at each stage in the HIV care continuum (e.g., delayed linkage to care, delayed antiretroviral treatment [ART] initiation, suboptimal ART adherence, and viral non-suppression) (Nguyen et al., 2021; Regan et al., 2021; Uthman et al., 2014). In a study of 3996 adults newly initiating ART in Tanzania, the risk of viral non-suppression among women with depression at both ART initiation and 6 months after ART initiation was 1.94 times that in women who did not have depression at either time point (Regan et al., 2021). Similarly, the risk of viral non-suppression among men in the top tertile for depressive symptoms was 1.58 times the risk among those with symptoms in the bottom tertile (Regan et al., 2021). In settings such as sub-Saharan Africa, which bears a disproportionate burden of the HIV epidemic and has limited capacity for formal mental healthcare, these relationships are of particular concern (Abas et al., 2014; Remien et al., 2019).

Biopsychosocial stressors directly linked to HIV infection (e.g., HIV-associated stigma, discrimination, and shame, treatment side effects, symptoms of HIV infection, HIV disclosure) are consistently associated with suboptimal mental health outcomes among PLWH, including PLWH in sub-Saharan Africa (Abas et al., 2014; Ayano et al., 2018; Bennett et al., 2016; Duko et al., 2018; Feuillet et al., 2017; Gibbie et al., 2006; Huang et al., 2020; Nanni et al., 2015; Rong et al., 2017; Too et al., 2021). In a systematic review and meta-analysis of depression among PLWH in east Africa, opportunistic infections and perceived stigma were each noted as correlates of depression (Ayano et al., 2018).

Exposure to stress has been shown to induce an adaptive biological response in which allostatic mechanisms (i.e., fight-or-flight) are activated in the short term (Korte et al., 2005; McEwen, 2004, 2003, 1998). However, when an individual experiences prolonged exposure to stress, these biological mechanisms often “over-compensate” and ultimately collapse, placing an individual at increased risk of stress- and mood-related disorders (Juster et al., 2010; Korte et al., 2005; McEwen, 2004, 2003, 1998). As such, stressful life events have been shown to contribute to poor mental health, including increased risk for, or prevalence of, depression (Assari and Lankarani, 2015; Burger et al., 2017; Hadley et al., 2008; Hassanzadeh et al., 2017; Holmes and Rahe, 1967; Mazure, 1998; Paykel, 2003; Seok et al., 2020; Tennant, 2002), anxiety (Blazer et al., 1987; Hadley et al., 2008; Hassanzadeh et al., 2017; McLaughlin and Hatzenbuehler, 2009; Seok et al., 2020), PTSD (El-Khodary and Samara, 2018; Hadley et al., 2008), self-harm (Kinyanda et al., 2005), and heightened distress (Hadley et al., 2008; Tesfaye and Bune, 2014). Existing evidence spans a range of settings, including low- and middle-income countries (LMIC) (El-Khodary and Samara, 2018; Hassanzadeh et al., 2017), and sub-Saharan Africa specifically (Burger et al., 2017; Hadley et al., 2008; Kinyanda et al., 2005; Tesfaye and Bune, 2014).

The bulk of the existing research on stressful life events among PLWH centers on identifying the negative HIV-related effects (e.g., ART non-adherence, symptoms of HIV, low quality of life, etc.) of these events (Corless et al., 2013; Koopman et al., 2002; J. Leserman et al., 2008; Jane Leserman et al., 2008). Few studies have explored the association between stressful life events that may or may not be directly linked to HIV infection (e.g., the death of a friend or family member, job and relationship changes, and experiences of physical and sexual violence), and sub-optimal mental health outcomes among PLWH (Elliott-Desorbo et al., 2009; Jiang et al., 2019). Evidence is especially limited in sub-Saharan Africa (Burger et al., 2017; Kemppainen et al., 2017; Pence et al., 2012b).

Characterizing the prevalence of stressful life events and their mental health implications among PLWH is important to inform the adaptation, implementation, and scale up of evidence-based stress management interventions and mental health care for PLWH. This is particularly relevant in LMIC and humanitarian settings where individuals are often exposed to multiple stressors (Tol et al., 2014). The World Health Organization Mental Health Gap Action Program (mhGAP) has prioritized identification and provision of evidence-based stress management and mental health care, highlighting a specific need for stress management research and capacity building in LMIC (Barbui et al., 2020; Murray and Jordans, 2016). Substantial work remains in improving stress management in these settings, especially for populations at increased risk of sub-optimal mental health outcomes such as PLWH. In this analysis, we estimate the prevalence of specific stressful life events among PLWH newly entering HIV care in Cameroon and quantify the association between specific types of stressful life events and symptoms of depression, anxiety, and PTSD, separately.

2. Methods

2.1. Setting

This study, previously described (Filiatreau et al., 2021; Parcesepe et al., 2021), was conducted in three public sector health care facilities located in the North-West, South-West, and Central (Yaoundé) regions of Cameroon. These areas have an estimated HIV prevalence of 5.1%, 3.6%, and 4.4%, respectively (Cameroon Population-based HIV Impact Assessment Project, 2018). In 2019, the estimated prevalence of mental health disorders in the total population in Cameroon was nearly 11% (Institute for Health Metrics and Evaluation (IHME), 2019). Each study site serves as part of the Central Africa (CA) International epidemiology Databases to Evaluate AIDS (IeDEA) (ca-iedea.org) (Chammartin et al., 2020) and provides HIV care services free of charge as is the national standard. Access to formal mental health care services and provision of psychiatric medications is highly variable in Cameroon over time and by clinic.

2.2. Study population

We collected data from a cohort of people newly entering care for HIV in the three public sector health facilities described above between June 2019 and March 2020. To be eligible for participation individuals had to be 21 years of age or older (as required by the local ethical review board), newly entering HIV care at one of the study sites, and provide written informed consent. Individuals previously enrolled in HIV care were ineligible.

2.3. Data collection

Research assistants fluent in French and English administered a structured quantitative interview to eligible and consenting individuals. Interviews were conducted in the participant's language of choice (French or English) in a private setting within the health care facility. Questions captured data on participants' socio-demographic and economic backgrounds, symptoms of mental health and substance use disorders, and exposure to stressful life events in the prior three months. Ethical approval for this study was obtained from the University of North Carolina's Institutional Review Board and the National Ethical Committee of Research for Human Health at Yaoundé.

2.4. Measures

2.4.1. Stressful life events

We used a modified version of the Life Events Survey to measure exposure to 12 specific stressful life events in the three months prior to study enrollment (Jane Leserman et al., 2008; Reif et al., 2011; Sarason et al., 1978). Events of interest included negative relationship changes (e.g., getting divorced or separated, estrangement from a family member, an increase in arguments with a partner), death or severe illness of a family member or close friend, work-related difficulties (e.g., unable to find work, losing job or income), motor vehicle accidents, physical attacks or threats on one's life, robberies, hospitalizations, major new illnesses, and safety concerns in one's neighborhood. These events were selected from the original Life Events Survey as each was considered moderately to severely stressful (Reif et al., 2011) and relevant to the study setting. For analytic purposes, similar events were further combined such that seven distinct event types were considered: death of a family member or close friend, illness of a family member or close friend, experiences of violence, negative relationship changes, work-related difficulties, vehicle accidents, and feeling unsafe in one's neighborhood. Major new illnesses and hospitalizations were not included in the current analysis as the study population was comprised of PLWH newly initiating HIV care, many of whom may have been recently diagnosed with HIV. We also created a dichotomous variable to represent individuals who were and were not in the top tertile of number of different types of stressful life events reported. Those in the top, middle, and bottom tertiles reported three or more event types, two event types, and no or one event type, respectively.

2.4.2. Depressive symptoms

The Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001), which has been validated and used among PLWH in sub-Saharan Africa, including in Cameroon (Chibanda et al., 2016; Cholera et al., 2014; Monahan et al., 2009; Pence et al., 2012a), was used to assess depressive symptoms. Scores range from 0 to 27 with scores greater than 9 considered indicative of symptoms of moderate to severe depression (Manea et al., 2012). Cronbach's alpha from the current study was 0.81.

2.4.3. Anxiety symptoms

Anxiety symptoms were assessed using the 7-item General Anxiety Disorder-7 (GAD-7) scale (Spitzer et al., 2006), which has been validated in a high HIV prevalence population in sub-Saharan Africa (Chibanda et al., 2016), and used among PLWH in Cameroon (Pefura-Yone et al., 2013). Scores range from 0 to 21 with scores greater than 9 considered indicative of moderate to severe anxiety symptoms (Chibanda et al., 2016; Spitzer et al., 2006). Cronbach's alpha from the current study was 0.82.

2.4.4. Post-traumatic stress disorder

PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5) (Blevins et al., 2015; Weathers et al., 2013) which has been validated and used in high HIV prevalence populations in sub-Saharan Africa (Duko et al., 2020; Verhey et al., 2018). Scores range from 0 to 80 with scores greater than 30 considered indicative of probable PTSD (Weathers et al., 2013). Cronbach's alpha from the current study was 0.92.

2.4.5. Composite outcomes of interest

We created dichotomous outcomes to represent individuals with and without symptoms of any measured mental health disorder and those with and without symptoms of two or more mental health disorders (i.e., those with symptoms of one or no mental health disorder(s) = referent).

2.5. Missing data

A small number of individuals were missing data on individual mental health scale items (n = 13 for PCL-5; n = 6 for PHQ-9; n = 12 for GAD-7). For individuals missing data on less than 10% of items for any given scale (n = 13 for PCL-5; n = 6 for PHQ-9; n = 10 for GAD-7), the mean of the individual's non-missing scale responses was imputed for the missing item(s) (Shrive et al., 2006).

2.6. Statistical analyses

We used counts, proportions, medians, and interquartile ranges (IQR) to describe the study population overall and the occurrence of stressful life events among study participants by presence of mental health symptoms. Log binominal regression was used to estimate the association between each type of stressful life event and symptoms of each mental health disorder, separately, and our composite outcomes. Adjusted analyses controlled for gender and clinic, the a priori covariates of interest. Clinic was included as a fixed effect variable given the small number of clinics (n = 3) included in the study.

3. Results

A total of 426 PLWH were included in this analysis. A majority of participants were women (n = 250; 58.7%), aged 21-39 (n=249; 58.5%), in relationships (n = 249; 58.5%), and had at least one child (n = 345; 81.4%) (Table 1). Over 40% of participants had completed secondary school or higher (n = 177; 41.5%) (Table 1). Most were working for pay at the time of interview (n = 275; 64.6%) (Table 1).

Table 1.

Sociodemographic characteristics of 426 people living with HIV newly entering HIV care at three health care facilities in Cameroon, overall and stratified by mental health symptom status.a

Total
(n =
426)
N (col
%)		 No mental health
disorder symptoms
(n = 301)
N (col %)		 Symptoms of any mental
health disorder
(n = 123)
N (col %)
Gender
 Male 176 (41.3) 133 (44.2) 43 (35.0)
 Female 250 (58.7) 168 (55.8) 80 (65.0)
Age
 21–39 249 (58.5) 171 (56.8) 78 (63.4)
 40+ 177 (41.5) 130 (43.2) 45 (36.6)
Education
 None 31 (7.3) 15 (5.0) 15 (12.2)
 Primary 218 (51.2) 152 (50.5) 66 (53.7)
 ≥Secondary 177 (41.5) 134 (44.5) 42 (34.1)
Relationship status
 Single 177 (41.5) 116 (38.5) 60 (48.8)
 Partnered 249 (58.5) 185 (61.5) 63 (51.2)
Number of childrenb
 0 79 (18.6) 54 (17.9) 25 (20.7)
 ≥1 345 (81.4) 247 (82.1) 96 (79.3)
Employment status
 Not working for pay 151 (35.4) 103 (34.2) 48 (39.0)
 Working for pay 275 (64.6) 198 (65.8) 75 (61.0)
Open in a new tab

Abbreviations: HIV- human immunodeficiency virus; PTSD- post-traumatic stress disorder.

a

Individuals with symptoms of depression, anxiety, or post-traumatic stress disorder were considered to have symptoms of any mental health disorder while those without symptoms of depression, anxiety and post-traumatic stress disorder were considered to have no mental health disorder symptoms. Two individuals were missing data on mental health disorder symptoms status.

b

Number of children n = 2.

Recent death of a family member (n = 166; 39.0%), severe illness of a family member (n = 144; 33.8%), inability to find work despite looking for employment (n = 96; 22.5%), and an increase in arguments with a romantic partner (n = 92; 21.6%) were the most commonly reported stressful life events (Table 2). Median number of recent stressful life event types in the study population overall was 2 (Range: 0–7), with over one-third of participants (N = 147; 34.7%) reporting three or more stressful life event types (Table 3).

Table 2.

Prevalence of reported stressful life events in prior 3 months among 426 adults newly entering HIV care in Cameroon.

Event Total population (n =
426)
No
N (row
%)		 Yes
N (row
%)
Death
Death of family member 260 (61.0) 166 (39.0)
Death of close frienda 353 (83.3) 71 (16.7)
Illness
Serious illness of family member 282 (66.2) 144 (33.8)
Serious illness of close frienda 395 (92.9) 30 (7.1)
Violence
Physically attacked 376 (88.3) 50 (11.7)
Robbeda 386 (90.8) 39 (9.2)
Negative relationship change
Increase in serious arguments with partner 334 (78.4) 92 (21.6)
Divorced/separated 366 (85.9) 60 (14.1)
Major change in closeness to family member 346 (81.2) 80 (18.8)
Work-related difficulty
Unable to find work even though looking 330 (77.5) 96 (22.5)
Losing work or source of incomea 351 (82.6) 74 (17.4)
Trouble with employer (suspended/demoted/discriminated against) 400 (93.9) 26 (6.1)
Other stressful life events
Vehicle accident 395 (92.7) 31 (7.3)
Felt unsafe in neighborhood 353 (82.9) 73 (17.1)
Open in a new tab
a

Missing: death of close friend n = 2; serious illness of close friend n = 1; robbed n = 1; losing work or source of income n = 1.

Table 3.

Prevalence of reported stressful life event type exposures in prior 3 months among 426 adults newly entering HIV care in Cameroon, stratified by current mental health (MH) disorder symptoms.

Total PTSD Depression Anxietya Any MH disorder
symptoms		 Symptoms of 2+ MH
disorders
Overall
(n = 426)
N (col %)		 Yes
(n = 67)
N (row
%)		 No
(n = 359)
N (row
%)		 Yes
(n = 87)
N (row
%)		 No
(n = 339)
N (row
%)		 Yes
(n = 54)
N (row
%)		 No
(n = 370)
N (row
%)		 Yes
(n = 123)
N (row
%)		 No
(n = 301)
N (row
%)		 Yes
(n = 62)
N (row
%)		 No
(n = 362)
N (row
%)
Death of close friend/familya
 Yes 210 (49.4) 41 (19.5) 169 (80.5) 52 (24.8) 158 (75.2) 22 (10.6) 186 (89.4) 66 (31.7) 142 (68.3) 35 (16.8) 173 (83.2)
 No 215 (50.6) 26 (12.1) 189 (87.9) 34 (15.8) 181 (84.2) 32 (14.9) 183 (85.1) 56 (26.0) 159 (74.0) 27 (12.6) 188 (87.4)
Serious illness of close friend/family
 Yes 160 (37.6) 40 (25.0) 120 (75.0) 44 (27.5) 116 (72.5) 27 (17.0) 132 (83.0) 59 (37.1) 100 (62.9) 38 (23.9) 121 (76.1)
 No 266 (62.4) 27 (10.2) 239 (89.8) 43 (16.2) 223 (83.8) 27 (10.2) 238 (89.8) 64 (24.2) 201 (75.8) 24 (9.1) 241 (90.9)
Violent stressful life eventa
 Yes 77 (18.1) 20 (26.0) 57 (74.0) 22 (28.6) 55 (71.4) 8 (10.5) 68 (89.5) 30 (39.5) 46 (60.5) 14 (18.4) 62 (81.6)
 No 348 (81.9) 47 (13.5) 301 (86.5) 65 (18.7) 283 (81.3) 46 (13.3) 301 (86.7) 93 (26.8) 254 (73.2) 48 (13.8) 299 (86.2)
Negative relationship change
 Yes 171 (40.1) 40 (23.4) 131 (76.6) 52 (30.4) 119 (69.6) 36 (21.3) 133 (78.7) 70 (41.4) 99 (58.6) 41 (24.3) 128 (75.7)
 No 255 (59.9) 27 (10.6) 228 (89.4) 35 (13.7) 220 (86.3) 18 (7.1) 237 (92.9) 53 (20.8) 202 (79.2) 21 (8.2) 234 (91.8)
Work-related difficultya
 Yes 140 (32.9) 42 (30.0) 98 (70.0) 44 (31.4) 96 (68.6) 24 (17.1) 116 (82.9) 62 (44.3) 78 (55.7) 36 (25.7) 104 (74.3)
 No 285 (67.1) 24 (8.4) 261 (91.6) 42 (14.7) 243 (85.3) 29 (10.2) 254 (89.8) 60 (21.2) 223 (78.8) 25 (8.8) 258 (91.2)
Vehicle accident
 Yes 31 (7.3) 4 (12.9) 27 (87.1) 4 (12.9) 27 (87.1) 5 (16.1) 26 (83.9) 8 (25.8) 23 (74.2) 4 (12.9) 27 (87.1)
 No 395 (92.7) 63 (15.9) 332 (84.1) 83 (21.0) 312 (79.0) 49 (12.5) 344 (87.5) 115 (29.3) 278 (70.7) 58 (14.8) 335 (85.2)
Felt unsafe in neighborhood
 Yes 73 (17.1) 21 (28.8) 52 (71.2) 24 (32.9) 49 (67.1) 18 (25.0) 54 (75.0) 32 (44.4) 40 (55.6) 20 (27.8) 52 (72.2)
 No 353 (82.9) 46 (13.0) 307 (87.0) 63 (17.8) 290 (82.2) 36 (10.2) 316 (89.8) 91 (25.9) 261 (74.1) 42 (11.9) 310 (88.1)
Stressful life event type count
 Upper tertile (3+ event types) 147 (34.7) 44 (29.9) 103 (70.1) 52 (35.4) 95 (64.6) 27 (18.6) 118 (81.4) 66 (45.5) 79 (54.5) 41 (28.3) 104 (71.7)
 Middle tertile (2 event types) 112 (26.4) 16 (14.3) 96 (85.7) 18 (16.1) 94 (83.9) 14 (12.5) 98 (87.5) 29 (25.9) 83 (74.1) 13 (11.6) 99 (88.4)
 Lower tertile (0–1 event types) 165 (38.9) 7 (4.2) 158 (95.8) 16 (9.7) 149 (90.3) 13 (7.9) 152 (92.1) 27 (16.4) 138 (83.6) 8 (4.8) 157 (95.2)
Open in a new tab

Abbreviations: PTSD-post-traumatic stress disorder; MH- mental health.

a

Missing: anxiety n = 2; death of close friend/family member n = 1; violent stressful life event n = 1; work-related difficulty n = 1; stressful life event tertile n = 2.

Nearly 30% of participants (n = 123) reported symptoms of at least one mental health disorder, with 62 (14.6%) reporting symptoms of two or more mental health disorders (Table 3). Approximately 20% (n = 87) reported moderate to severe depressive symptoms, 16% (n = 67) reported symptoms of probable PTSD, and 13% (n = 54) reported moderate to severe anxiety symptoms (Table 3).

In bivariable analyses, reporting symptoms of any mental health disorder was associated with reporting: serious illness of a friend or family member, a violent experience, a negative relationship change, a work-related difficulty, and feeling unsafe in one's neighborhood (Table 4). Reporting symptoms of two or more mental health disorders was associated with reporting: serious illness of a friend or family member, a negative relationship change, a work-related difficulty, and feeling unsafe in one's neighborhood (Table 4). Specifically, probable PTSD and moderate to severe depressive symptoms were each associated with reporting: death of a friend or family member, severe illness of a friend or family member, a violent experience, a negative relationship change, a work-related difficulty, and feeling unsafe in one's neighborhood (Table 4). Moderate to severe anxiety symptoms was associated with reporting: serious illness of a friend or family member, a negative relationship change, a work-related difficulty, and feeling unsafe in one's neighborhood (Table 4). Each of the mental health outcomes explored was associated with reporting experiences of three or more stressful life event types.

Table 4.

Crude and adjusted associations between reported stressful life events in prior 3 months and current symptoms of mental health (MH) disorders among 426 adults newly entering HIV care in Cameroon.

PTSD Depression Anxietya Any MH symptoms Symptoms of 2+ MH
disorders
uPR (95%
CI)		 aPR (95%
CI)b 		uPR (95%
CI)		 aPR (95%
CI)b 		uPR (95%
CI)		 aPR (95%
CI)b 		uPR (95%
CI)		 aPR (95%
CI)b 		uPR (95%
CI)		 aPR (95%
CI)b
Death of close friend/familya,c 1.6 (1.0, 2.5) 1.6 (1.0, 2.4) 1.6 (1.1, 2.3) 1.4 (1.0, 2.0) 0.7 (0.4, 1.2) 0.7 (0.4, 1.1) 1.2 (0.9, 1.6) 1.2 (0.9, 1.5) 1.3 (0.8, 2.1) 1.2 (0.8, 19)
Serious illness of close friend/familyc 2.5 (1.6, 3.9) 2.1 (1.3, 3.1) 1.7 (1.2, 2.5) 1.4 (1.0, 19) 1.7 (1.0, 2.7) 1.4 (0.9, 2.3) 1.5 (1.1, 2.1) 1.3 (1.0, 17) 2.6 (1.6, 4.2) 2.0 (1.3, 3.1)
Violent stressful life eventa,c 1.9 (1.2, 3.1) 2.1 (1.4, 3.2) 1.5 (1.0, 2.3) 1.7 (1.1, 2.4) 0.8 (0.4, 1.6) 0.8 (0.4, 1.6) 1.5 (1.1, 2.0) 1.7 (1.3, 2.4) 1.3 (0.8, 2.3) 1.5 (0.9, 2.4)
Negative relationship changec 2.2 (1.4, 3.5) 1.8 (1.2, 2.8) 2.2 (1.5, 3.2) 1.8 (1.2, 2.5) 3.0 (1.8, 5.1) 2.5 (1.5, 4.2) 2.0 (1.5, 2.7) 1.6 (1.2, 2.2) 2.9 (1.8, 4.8) 2.2 (1.4, 3.6)
Work-related difficultya,c 3.6 (2.3, 5.6) 3.1 (2.0, 4.8) 2.1 (1.5, 3.1) 1.7 (1.2, 2.4) 1.7 (1.0, 2.8) 1.4 (0.8, 2.3) 2.1 (1.6, 2.8) 1.8 (1.4, 2.3) 2.9 (1.8, 4.6) 2.3 (1.5, 3.5)
Vehicle accidentc 0.8 (0.3, 2.1) 1.3 (0.5, 3.4) 0.6 (0.2, 1.6) 0.8 (0.3, 2.2) 1.3 (0.6, 3.0) 1.8 (0.7, 4.2) 0.9 (0.5, 1.6) 1.1 (0.6, 2.1) 0.9 (0.3, 2.2) 1.3 (0.5, 3.4)
Felt unsafe in neighborhoodc 2.2 (1.4, 3.5) 1.4 (0.9, 2.2) 1.8 (1.2, 2.7) 1.2 (0.8, 17) 2.4 (1.5, 4.1) 1.8 (1.1, 3.0) 1.7 (1.3, 2.4) 1.2 (0.9, 17) 2.3 (1.5, 3.7) 1.4 (0.9, 2.2)
Upper tertile of event types (i.e.,3+ event types)a,d 3.6 (2.3, 5.7) 2.8 (1.8, 4.4) 2.9 (2.0, 4.2) 2.0 (1.4, 2.8) 1.9 (1.2, 3.1) 1.4 (0.9, 2.3) 2.3 (1.7, 3.0) 1.7 (1.3, 2.3) 3.7 (2.3, 6.1) 2.5 (1.6, 3.9)
Open in a new tab

Abbreviations: MH - mental health; PTSD - post-traumatic stress disorder; uPR - unadjusted prevalence ratio; aPR - adjusted prevalence ratio; CI - confidence interval.

a

Missing: anxiety n = 2, death of close friend/family member n = 1; violent stressful life event n = 1; work-related difficulty n = 1; stressful life event tertile n = 2.

b

Adjusted models include the specific event type of interest but no other event types, gender, and clinic.

c

Referent group is those who did not report exposure to the specific event listed.

d

Referent group is those in the lower two tertiles of event types.

In multivariable analyses, the prevalence of any mental health disorder symptoms, and symptoms of two or more mental health disorders was higher among those reporting a serious illness of a friend or family member, negative relationship change, work-related difficulty, and three or more stressful life events as compared to those who did not (Table 4). The prevalence of any mental health disorder symptoms was also associated with reporting a violent stressful life event as compared to those who did not (Table 4). More specifically, the prevalence of probable PTSD and moderate to severe depressive symptoms was significantly higher among individuals who reported three or more stressful life event types compared to those reporting up to two event types (Table 4). The prevalence of probable PTSD and moderate to severe depressive symptoms was also higher among those reporting a recent violent stressful life event (PTSD adjusted prevalence ratio [aPR]: 2.1 [95% CI: 1.4, 3.2]; depressive symptoms aPR: 1.7 [95% CI: 1.1, 2.4]), those reporting a work-related difficulty (PTSD aPR: 3.1 [95% CI: 2.0, 4.8]; depressive symptoms aPR: 1.7 [95% CI: 1.2, 2.4]), those reporting a recent negative relationship change (PTSD aPR: 1.8 [95% CI: 1.2, 2.8]; depressive symptoms aPR: 1.8 [95% CI: 1.2, 2.5]), those reporting a recent death of a friend or framily member (PTSD aPR: 1.6 [95% CI: 1.0, 2.4]; depressive symptoms aPR: 1.4 [95% CI: 1.0, 2.0]), and those reporting serious illness of a friend or family member (PTSD aPR: 2.1 [95% CI: 1.3, 3.1]; depressive symptoms aPR: 1.4 [95% CI: 1.0, 1.9]), compared to those who did not report exposure to each (Table 4). The prevalence of moderate to severe anxiety symptoms among those who reported feeling unsafe in their neighborhood was 1.8 (95% CI: 1.1, 3.0) times that of those who did not report feeling unsafe in their neighborhood and the prevalence among those reporting a negative relationship change was 2.5 times (95% CI: 1.5, 4.2) the prevalence among those who did not (Table 4).

4. Discussion

This study quantifies the occurrence of stressful life events and the association of specific types of stressful life events with symptoms of common mental disorders among PLWH newly entering HIV care in Cameroon. Overall, recent stressful life events were common among PLWH entering care in this setting with participants reporting a median of two types of stressful events in past three months. The total number of stressful life event types, as well as unique event types were associated with unique mental health disorder symptoms, though some event types were associated with symptoms of multiple mental health disorders. Individuals who reported three or more stressful life event types (i.e., those in the top tertile for reported number of event types) were more likely to report symptoms of any mental health disorder, symptoms of two or more mental health disorders, probable PTSD, and moderate to severe depressive symptoms.

These findings are consistent with studies that have assessed the association between stressful life events and sub-optimal mental health outcomes in other settings, including parts of sub-Saharan Africa (Ayano et al., 2018; Duko et al., 2020; Kemppainen et al., 2017; Kinyanda et al., 2011a; Nyongesa et al., 2021; Olley et al., 2006, 2004; Tesfaw et al., 2016). For example, in a study of 205 PLWH in Southern Ethiopia, reports of negative life events were significantly associated with probable PTSD (adjusted odds ratio = 1.76, 95% CI [1.41, 6.98]). In another study from Ethiopia, the odds of major depressive disorder among PLWH who had experienced 6–10 negative life events or 11 or more negative life events were significantly higher than that among those who had experienced 1–5 negative life events (odds ratios of 3.66 [95% CI: 1.51, 8.86] and 8.27 [95% CI: 3.18, 21.46], respectively) (Kinyanda et al., 2011a).

Additional resources are needed to improve stress management and coping among PLWH newly entering HIV care in Cameroon to minimize the negative mental health effects of stressful life events. Some existing evidence-based interventions have been shown to significantly improve coping skills and mental health outcomes among PLWH in LMIC and sub-Saharan Africa, specifically (Aweto et al., 2016; Nakimuli-Mpungu et al., 2020; Nakimuli-Mpungu et al., 2021; Sikkema et al., 2015). For example, in a study of 361 pregnant women newly diagnosed with HIV in South Africa, active coping was significantly higher and avoidant coping was significantly lower among individuals enrolled in a 10-session psychosocial support group intervention compared to those in the control group (Mundell et al., 2011). In a cluster randomized trial conducted among 1140 PLWH in Uganda, the odds of major depression was significantly lower among those receiving group support therapy compared to those receiving group HIV education only (adjusted odds ratio: 0.01; 95% CI: 0.003–0.012) (Nakimuli-Mpungu et al., 2020). Such interventions, particularly those which can be implemented by lay health workers and place minimal strain on health care infrastructure, could be implemented in Cameroon to improve the mental health of PLWH with comorbid mental disorders.

Death of a friend or family member and serious illness of a friend or family member were among the most commonly reported types of stressful life events in this population of PLWH at 49% and 38%, respectively. Though higher than the estimated proportion of individuals in a cross-national survey of 21 countries (including 11 LMIC and two countries in sub-Saharan Africa) who had experienced the death of a loved one (30.5%) (Stein et al., 2010), these results were expected given the high rates of mortality and morbidity attributable to infectious diseases within Cameroon (Einterz and Bates, 2011; Institute for Health Metrics and Evaluation (IHME), 2019) and because PLWH may be more likely to have family or friends living with HIV and at increased risk of mortality (Perry et al., 1992; Sikkema et al., 2003, 2000). Reports of both the death and the serious illness of a close friend/family member were associated with probable PTSD and depression, but not with moderate to severe symptoms of anxiety.

Bereavement and the grief that often accompanies such loss are normal emotional, behavioral, and cognitive responses to the death of a loved one. However, bereavement and complicated grief have been shown to increase the risk of sub-optimal mental health outcomes in high-income settings (Kristensen et al., 2012; Moriarty et al., 2015). In an analysis using data from the Northern Ireland Longitudinal Study, the odds of mental health problems among bereaved caregivers was between 1.2 and 1.6 times that among non-bereaved non-caregivers (Moriarty et al., 2015). Coping with death can be particularly difficult among PLWH. These individuals may experience elevated grief reactions and psychological distress (including depressive symptoms, anxiety and stress) following the death of a loved one, particularly if the death was HIV-related (Sikkema et al., 2003, 2000; Wood et al., 2006). Yet, bereavement and grief are under-studied across sub-Saharan Africa broadly (Mutedzi et al., 2019; Thurman et al., 2017; Tol et al., 2014). While several cognitive behavioral therapy-based interventions for orphaned children have shown promise for improving adverse grief and mental health outcomes among participants (Kumakech et al., 2009; Thurman et al., 2017), additional research may be needed to identify culturally competent interventions that minimize lasting stress, grief, and PTSD symptoms associated with bereavement and grief among adult PLWH in Cameroon.

Experiences of violence and work-related difficulties were reported by 18% and 33% of participants, respectively. Both of these stressors were associated with probable PTSD and moderate to severe depressive symptoms. It is well known that physical violence contributes to poor mental health outcomes, including PTSD and depression, globally (Filiatreau et al., 2020; Mahenge et al., 2013; Pengpid and Peltzer, 2020; Tsai et al., 2016). In a population of youth living with HIV in South Africa, 24% of respondents reported a history of physical violence, and the prevalence of heightened depressive symptoms among those with a history of physical violence was 2.04 times (95% CI: 1.46, 2.85) the prevalence among those with no history of physical violence (Filiatreau et al., 2020). Similarly, unemployment, loss of income, and lower socioeconomic status, have been found to be associated with both PTSD and depression, globally (Kiernan, 2019; Lund et al., 2013; Posel et al., 2021; Rueda et al., 2012b, 2012a; Saraceno et al., 2005). The relationship between each of these stressors and adverse mental health outcomes is often cyclical (i.e., experiences of violence or unstable income often lead to poor mental health outcomes, which in turn can increase future risk of violence or loss of income) (Olesen et al., 2013; Prince et al., 2011). Interventions are critically needed to minimize violent crime (e.g., robbery, physical attacks) and improve economic stability in resource-limited settings such as Cameroon.

Across sub-Saharan Africa, economic empowerment interventions-some of which have been conducted among PLWH specifically- have yielded substantial improvements in mental health outcomes among participants (Cavazos-Rehg et al., 2021; Eyal and Burns, 2016; Kilburn et al., 2016; Ohrnberger et al., 2020; Zimmerman et al., 2021). In a 6-year randomized controlled trial of 702 adolescents living with HIV in Uganda, a subgroup of depressed participants randomized to an economic empowerment intervention arm had significantly lower scores on the Children's Depression Inventory at 36 months following enrollment when compared to the subgroup of depressed participants randomized to a control group (Cavazos-Rehg et al., 2021). While a handful of interventions have been shown reduce the occurrence of intimate partner violence (Kim et al., 2007; Kumakech et al., 2009; Pronyk et al., 2006; Wagman et al., 2015), little effort has been made to minimize interpersonal violence or violent crime more broadly in these settings (Hove et al., 2013). Furthermore, there is limited evidence to suggest effective intimate partner violence interventions yield improvements in participant mental health outcomes (Greene et al., 2019; Leight et al., 2020). As such, neighborhood strengthening and violent crime mitigation interventions should be explored.

Approximately 40% of our participants reported a negative relationship change in the prior three months. This was the only unique event type explored that was associated with all mental health outcomes assessed after adjustment and suggests maintenance of positive relationships may be of particular relevance to the mental health of PLWH newly entering HIV care in Cameroon. Alternatively, poor mental health may create challenges in maintaining positive relationships for PLWH (Segrin, 2013). Associations between poor family relationships or negative relationship changes and poor mental health outcomes have been observed in other settings in sub-Saharan Africa (Kinyanda et al., 2011b; Shenderovich et al., 2021; Tesfawet al., 2016). Similarly, higher levels of social support have been shown to improve the mental health of PLWH in sub-Saharan Africa (Cavazos-Rehg et al., 2020; Filiatreau et al., 2020; Seffren et al., 2018; Too et al., 2021). Evidenced-based interventions that incorporate psychosocial support groups or family or relationship-strengthening components (Betancourt et al., 2017, 2014; Nakimuli-Mpungu et al., 2020; Nakimuli-Mpungu et al., 2021; Thurman et al., 2018) may be particularly useful for improving the mental health of PLWH newly entering HIV care in this setting.

Feeling unsafe in one's neighborhood was reported by 17% of study participants and was significantly associated with symptoms of anxiety after adjustment. Evidence from high income settings, namely the United States, also suggests low perceived neighborhood safety is associated with symptoms of anxiety (Kreski et al., 2018; Slopen et al., 2012). Evidence from high income settings also suggests low perceived neighborhood safety is associated with depressive symptoms (Roh et al., 2011; Wilson-Genderson and Pruchno, 2013). While this is consistent with the point estimate from our study, our estimate did not reach statistical significance. The authors know of no other studies assessing the relationship between perceptions of neighborhood safety and mental health outcomes in sub-Saharan Africa. Instead, the bulk of the literature around neighborhood safety from this region assesses the effect of perceived neighborhood safety on physical activity or obesity (He et al., 2020; Malambo et al., 2018; Oyeyemi et al., 2012). While the observed relationship may be due to ongoing civil unrest throughout Cameroon (Chothia, 2018), more research is needed on the negative mental health effects of the built environment in Cameroon and other LMICs. Specifically, qualitative research illuminating what causes individuals to feel unsafe in their neighborhood could inform programs to improve both neighborhood safety (e.g., improved street lighting, traffic calming measures, etc.) (Haans and de Kort, 2012; Morrison and Thomson, 2004), and perceptions of neighborhood safety (e.g., social cohesion interventions, neighborhood associations) (De Jesus et al., 2010). Importantly, existing evidence-based interventions for improving neighborhood safety may be insufficient in settings such as Cameroon with ongoing political unrest. Thus, additional strategies may also be warranted.

Among study participants, no significant association was observed between reporting a motor vehicle accident in the prior three months and probable PTSD and moderate to severe depression or anxiety symptoms after adjustment. Significant associations between motor vehicle accidents and sub-optimal mental health outcomes, including depression and PTSD, have been observed in other settings in sub- Saharan Africa (Asuquo et al., 2017; Iteke et al., 2011). For example, in Nigeria, the prevalence of PTSD and depression was significantly higher among hospital patients involved in road traffic accidents than in controls (Asuquo et al., 2017). While participants were prompted to omit minor accidents with no resultant injury or significant damage, it is possible reported accidents resulted in no serious injury or that other stressful life events play a more significant role in influencing mental health outcomes in this setting because of the unique challenges faced among PLWH in Cameroon.

5. Limitations

This study has limitations worth noting. First, our findings are subject to recall bias, as is typical of studies of this nature with self-reported exposures or outcomes. To minimize this concern, we asked participants about exposure to stressful life events that occurred within the prior three months only as opposed to the prior year or throughout one's entire lifetime, as has been done in other studies (Duko et al., 2020; Nyongesa et al., 2021). In addition, because we asked individuals to respond to questions about potentially sensitive issues (e.g., symptoms of mental health disorders), social desirability bias may be of concern. To mitigate this concern, particularly sensitive questions were asked later in the study interview to allow time for participants to build rapport with the study interviewer. Next, small sample sizes limited our capacity to control for other potential confounders of interest (e.g., socio-economic status). As a result, we cannot make causal claims about the relationship between each of the explored events and mental disorders. Third, sub-optimal mental health can create tension in relations or lead to impulsive behaviors that put one at risk of heightened stress. Because of the cross-sectional nature of our study, we cannot make claims of direction of the observed association. Finally, we cannot draw conclusions about which events were or were not directly related to HIV (e.g., death of a family member/friend, severe illness of a family member/friend). This information is pertinent to ascertaining excess stress experienced among PLWH and to refining coping and mental health interventions specifically for PLWH.

6. Conclusions

Recent stressful life events were common among our study population of PLWH newly entering HIV care in Cameroon. Exposure to a high number of stressful life event types was associated with sub-optimal mental health outcomes, including probable PTSD and moderate to severe depressive symptoms. Negative relationship changes, death or illness of a close friend or family member, experiences of violence, work-related difficulties, and feeling unsafe in one's neighborhood were particularly associated with sub-optimal mental health.

Evidence-based interventions that identify those with recent stressful life events and work to improve coping and stress management are needed. Given the existing limitations of formal mental health care throughout the sub-Saharan Africa region, interventions that may be administered by lay health workers are particularly important.

Acknowledgements

The authors would like to thank all the individuals who participated in this study.

Role of funding source

This research was supported by NIMH grant K01 MH114721, NICHD grant P2C HD050924 (Carolina Population Center), NIAID grant P30 AI050410 (UNC Center for AIDS Research), NIMHD grant T37 MD014218, and NIAID grant U01AI096299. 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

Conflict of interest

The authors have no conflicts of interest to report.

Credit authorship contribution statement

LF: Conceptualization; Writing – original draft; Analysis; PVE: Project administration; Writing – review & editing; AD: Project administration; Supervision; Writing – review & editing; RA: Writing – review & editing; MW: Conceptualization; Writing – review & editing; BP: Conceptualization; Writing – review & editing; EP: Project administration; Writing – review & editing; MY: Writing – Review & editing; DNsame: Writing – Review & editing; KA: Writing – review & editing; DNash: Conceptualization; Writing – review & editing; AP: Conceptualization, funding, analysis, Writing – review & editing.

References

  1. Abas M, Ali GC, Nakimuli-Mpungu E, Chibanda D, 2014. Depression in people living with HIV in sub-saharan Africa: time to act. Trop. Med. Int. Heal 19, 1392–1396. 10.1111/tmi.12382. [DOI] [PubMed] [Google Scholar]
  2. Assari S, Lankarani MM, 2015. Association between stressful life events and depression; intersection of race and gender. J. Racial Ethn. Heal. Disparities 3, 349–356. 10.1007/s40615-015-0160-5. [DOI] [PubMed] [Google Scholar]
  3. Asuquo J, Edet B, Abang I, Essien E, Osakwe O, Aigbomain E, Chigbundu K, 2017. Depression and posttraumatic stress disorder among road traffic accident victims managed in a tertiary hospital in southern Nigeria. Niger. J. Clin. Pract 20, 170–175. 10.4103/1119-3077.196114. [DOI] [PubMed] [Google Scholar]
  4. Aweto HA, Aiyegbusi AI, Ugonabo AJ, Adeyemo TA, 2016. Effects of aerobic exercise on the pulmonary functions, respiratory symptoms and psychological status of people living with HIV. J. Res. Health Sci 16, 17–21. 10.34172/jrhs162488. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Ayano G, Solomon M, Abraha M, 2018. A systematic review and meta-analysis of epidemiology of depression in people living with HIV in East Africa. BMC Psychiatry 18, 254. 10.1186/s12888-018-1835-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Barbui C, Purgato M, Abdulmalik J, Acarturk C, Eaton J, Gastaldon C, Gureje O, Hanlon C, Jordans M, Lund C, Nosè M, Ostuzzi G, Papola D, Tedeschi F, Tol W, Turrini G, Patel V, Thornicroft G, 2020. Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review. Lancet Psychiatry 7, 162–172. 10.1016/S2215-0366(19)30511-5. [DOI] [PubMed] [Google Scholar]
  7. Bennett DS, Traub K, Mace L, Juarascio A, O’Hayer CV, 2016. Shame among people living with HIV: a literature review. AIDS Care 28, 87–91. 10.1080/09540121.2015.1066749. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Betancourt TS, Ng LC, Kirk CM, Munyanah M, Mushashi C, Ingabire C, Teta S, Beardslee WR, Brennan RT, Zahn I, Stulac S, Cyamatare FR, Sezibera V, 2014. Family-based prevention of mental health problems in children affected by HIV and AIDS: an open trial. AIDS 28, S359–S368. 10.1097/QAD.0000000000000336. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Betancourt TS, Ng LC, Kirk CM, Brennan RT, Beardslee WR, Stulac S, Mushashi C, Nduwimana E, Mukunzi S, Nyirandagijimana B, Kalisa G, Rwabukwisi CF, Sezibera V, 2017. Family-based promotion of mental health in children affected by HIV: a pilot randomized controlled trial. J. Child Psychol. Psychiatry Allied Discip 58, 922–930. 10.1111/jcpp.12729. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Bhatia MS, Munjal S, 2014. Prevalence of depression in people living with HIV/AIDS undergoing ART and factors associated with it. J. Clin. Diagnostic Res 8, WC01–WC04. 10.7860/JCDR/2014/7725.4927. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Blazer D, Hughes D, George LK, 1987. Stressful life events and the onset of a generalized anxiety syndrome. Am. J. Psychiatry 144, 1178–1183. 10.1176/ajp.144.9.1178. [DOI] [PubMed] [Google Scholar]
  12. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL, 2015. The posttraumatic stress disorder checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J. Trauma. Stress 28, 489–498. 10.1002/jts.22059. [DOI] [PubMed] [Google Scholar]
  13. Brown LH, Strauman T, Barrantes-Vidal N, Silvia PJ, Kwapil TR, 2011. An experience-sampling study of depressive symptoms and their social context. J. Nerv. Ment. Dis 199, 403–409. 10.1097/NMD.0b013e31821cd24b. [DOI] [PubMed] [Google Scholar]
  14. Burger R, Posel D, von Fintel M, 2017. The relationship between negative household events and depressive symptoms: evidence from South African longitudinal data. J. Affect. Disord 218, 170–175. 10.1016/j.jad.2017.04.031. [DOI] [PubMed] [Google Scholar]
  15. Cameroon Population-based HIV Impact Assessment Project, 2018. Cameroon Population-based HIV Impact Assessment 2017.
  16. Cavazos-Rehg P, Xu C, Kasson E, Byansi W, Bahar OS, Ssewamala FM, 2020. Social and economic equity and family cohesion as potential protective factors from depression among adolescents living with HIV in Uganda. AIDS Behav. 24, 2546–2554. 10.1007/s10461-020-02812-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Cavazos-Rehg P, Byansi W, Xu C, Nabunya P, Sensoy Bahar O, Borodovsky J, Kasson E, Anako N, Mellins C, Damulira C, Neilands T, Ssewamala FM, 2021. The impact of a family-based economic intervention on the mental health of HIV-infected adolescents in Uganda: results from Suubi + adherence. J. Adolesc. Health 68, 742–749. 10.1016/j.jadohealth.2020.07.022. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Chammartin F, Dao Ostinelli CH, Anastos K, Jaquet A, Brazier E, Brown S, Dabis F, Davies MA, Duda SN, Malateste K, Nash D, Wools-Kaloustian K, Von Groote PM, Egger M, 2020. International epidemiology databases to evaluate AIDS (IeDEA) in Sub-Saharan Africa, 2012–2019. BMJ Open. 10.1136/bmjopen-2019-035246. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Chibanda D, Verhey R, Gibson LJ, Munetsi E, Machando D, Rusakaniko S, Munjoma R, Araya R, Weiss HA, Abas M, 2016. Validation of screening tools for depression and anxiety disorders in a primary care population with high HIV prevalence in Zimbabwe. J. Affect. Disord 198, 50–55. 10.1016/j.jad.2016.03.006. [DOI] [PubMed] [Google Scholar]
  20. Cholera R, Gaynes BN, Pence BW, Bassett J, Qangule N, Macphail C, Bernhardt S, Pettifor A, Miller WC, 2014. Validity of the Patient Health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa. J. Affect. Disord 167, 160–166. 10.1016/j.jad.2014.06.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Chothia F, 2018. Cameroon's Anglophone crisis: Red Dragons and Tigers - the rebels fighting for independence [WWW Document]. BBC World Serv. https://www.bbc.com/news/world-africa-45723211 (accessed 7.5.21). [Google Scholar]
  22. Ciesla JA, Roberts JE, 2001. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am. J. Psychiatry 158, 725–730. 10.1176/appi.ajp.158.5.725. [DOI] [PubMed] [Google Scholar]
  23. Conner KR, Pinquart M, Gamble SA, 2009. Meta-analysis of depression and substance use among individuals with alcohol use disorders. J. Subst. Abus. Treat 37, 127–137. 10.1016/j.jsat.2008.11.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Corless IB, Voss J, Guarino AJ, Wantland D, Holzemer W, Jane Hamilton M, Sefcik E, Willard S, Kirksey K, Portillo C, Mendez MR, Rosa ME, Nicholas PK, Human S, Maryland M, Moezzi S, Robinson L, Cuca Y, 2013. The impact of stressful life events, symptom status, and adherence concerns on quality of life in people living with HIV. J. Assoc. Nurses AIDS Care 24, 478–490. 10.1016/j.jana.2012.11.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. De Jesus M, Puleo E, Shelton RC, Emmons KM, 2010. Associations between perceived social environment and neighborhood safety: health implications. Health Place 16, 1007–1013. 10.1016/j.healthplace.2010.06.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Duko B, Geja E, Zewude M, Mekonen S, 2018. Prevalence and associated factors of depression among patients with HIV/AIDS in Hawassa, Ethiopia, cross-sectional study. Ann. Gen. Psychiatry 17, 1–6. 10.1186/s12991-018-0215-l. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Duko B, Toma A, Abraham Y, Kebble P, 2020. Post-traumatic stress disorder and its correlates among people living with HIV in southern Ethiopia, an institutionally based cross-sectional study. Psychiatr. Q 91, 783–791. 10.1007/s11126-020-09735-4. [DOI] [PubMed] [Google Scholar]
  28. Einterz EM, Bates M, 2011. Causes and circumstances of death in a district hospital in northern Cameroon, 1993–2009. Rural Remote Health 11. 10.22605/rrh1623. [DOI] [PubMed] [Google Scholar]
  29. El-Khodary B, Samara M, 2018. The effect of exposure to war-traumatic events, stressful life events, and other variables on mental health of Palestinian children and adolescents in the 2012 Gaza war. Lancet 391, S6. 10.1016/s0140-6736(18)30331-3.29553455 [DOI] [Google Scholar]
  30. Elliott-Desorbo DK, Martin S, Wolters PL, 2009. Stressful life events and their relationship to psychological and medical functioning in children and adolescents with HIV infection. J. Acquir. Immune Defic. Syndr 52, 364–370. 10.1097/QAI.0b013e3181b73568. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Elmer T, Stadtfeld C, 2020. Depressive symptoms are associated with social isolation in face-to-face interaction networks. Sci. Rep 10, 1–12. 10.1038/S41598-020-58297-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Eyal K, Burns J, 2016. Up or Down? Intergenerational Mental Health Transmission and Cash Transfers in South Africa. SALDRU Work. Pap. In: University Cape Town, p. 165 https://econpapers.repec.org/paper/ldrwpaper/165.htm. [Google Scholar]
  33. Feuillet P, Lert F, Tron L, Aubriere C, Spire B, Dray-Spira R, Agence Nationale de Recherche sur le Sida et les Hepatites Virales (ANRS)-VIH: Enquete sur les personnes atteintes (VESPA2) Study Group, 2017. Prevalence of and factors associated with depression among people living with HIV in France. HIV Med. 18, 383–394. 10.1111/hiv.12438. [DOI] [PubMed] [Google Scholar]
  34. Filiatreau LM, Giovenco D, Twine R, Gómez-Olivé FX, Kahn K, Haberland N, Pettifor A, 2020. Examining the relationship between physical and sexual violence and psychosocial health in young people living with HIV in rural South Africa. J. Int. AIDS Soc 23 10.1002/jia2.25654. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Filiatreau LM, Ebasone PV, Dzudie A, Ajeh R, Pence B, Wainberg M, Nash D, Yotebieng M, Anastos K, Pefura-Yone E, Nsame D, Parcesepe AM, 2021. Correlates of self-reported history of mental health help-seeking: a cross-sectional study among individuals with symptoms of a mental or substance use disorder initiating care for HIV in Cameroon. BMC Psychiatry 211 (21), 1–12. 10.1186/S12888-021-03306-Y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Gaynes BN, Pence BW, Eron JJ, Miller WC, 2008. Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an hiv+ patient population. Psychosom. Med 70, 505–511. 10.1097/PSY.0b013e31816aa0cc. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Gibbie T, Mijch A, Ellen S, Hoy J, Hutchison C, Wright E, Chua P, Judd F, 2006. Depression and neurocognitive performance in individuals with HIV/AIDS: 2-year follow-up. HIV Med. 7, 112–121. 10.1111/j.1468-1293.2006.00350.x. [DOI] [PubMed] [Google Scholar]
  38. Greene MC, Rees S, Likindikoki S, Bonz AG, Joscelyne A, Kaysen D, Nixon RDV, Njau T, Tankink MTA, Tiwari A, Ventevogel P, Mbwambo JKK, Tol WA, 2019. Developing an integrated intervention to address intimate partner violence and psychological distress in Congolese refugee women in Tanzania. Confl. Health 13, 1–16. 10.1186/s13031-019-0222-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Haans A, de Kort YAW, 2012. Light distribution in dynamic street lighting: two experimental studies on its effects on perceived safety, prospect, concealment, and escape. J. Environ. Psychol 32, 342–352. 10.1016/j.jenvp.2012.05.006. [DOI] [Google Scholar]
  40. Hadley C, Tegegn A, Tessema F, Cowan JA, Asefa M, Galea S, 2008. Food insecurity, stressful life events and symptoms of anxietry and depression in East Africa: evidence from the Gilgel Gibe growth and development study. J. Epidemiol. Community Health 62, 980–986. 10.1136/jech.2007.068460. [DOI] [PubMed] [Google Scholar]
  41. Hassanzadeh A, Heidari Z, Feizi A, Hassanzadeh Keshteli A, Roohafza H, Afshar H, Adibi P, 2017. Association of stressful life events with psychological problems: a large-scale community-based study using grouped outcomes latent factor regression with latent predictors. Comput. Math. Methods Med 2017 10.1155/2017/3457103. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. He Z, Ghose B, Yaya S, Cheng Z, Zhou Y, 2020. Perceived neighborhood safety and exercise behavior among community dwellers in Gauteng, South Africa. Medicine (Baltimore) 99, e23552. 10.1097/MD.0000000000023552. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Holmes TH, Rahe RH, 1967. The social readjustment rating scale. J. Psychosom. Res 11, 213–218. 10.1016/0022-3999(67)90010-4. [DOI] [PubMed] [Google Scholar]
  44. Hove M, Ngwerume ET, Muchemwa C, 2013. The urban crisis in sub-Saharan Africa: a threat to human security and sustainable development. Stability 2. 10.5334/sta.ap. [DOI] [Google Scholar]
  45. Huang Y, Luo D, Chen X, Zhang D, Huang Z, Xiao S, 2020. HIV-related stress experienced by newly diagnosed people living with HIV in China: a 1-year longitudinal study. Int. J. Environ. Res. Public Health 17. 10.3390/ijerph17082681. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Institute for Health Metrics and Evaluation (IHME), 2019. GBD compare data visualization [WWW Document]. Inst. Heal. Metrics Eval https://www.healthdata.org/data-visualization/gbd-compare. [Google Scholar]
  47. Iteke O, Bakare MO, Agomoh AO, Uwakwe R, Onwukwe JU, 2011. Road traffic accidents and posttraumatic stress disorder in an orthopedic setting in South-Eastern Nigeria: a controlled study. Scand. J. Trauma. Resusc. Emerg. Med 19, 1–6. 10.1186/1757-7241-19-39. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Jiang H, Tan Z, Cheng W, Xu M, Lin P, Huang X, Huang R, Liu J, Yang F, Li Y, Gao Y, Yang Y, 2019. Negative life events and major depressive disorder among HIV-positive individuals in Guangdong, China: a cross-sectional study. Medicine (United States) 98. 10.1097/MD.0000000000017174. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Jonsson G, Davies N, Freeman C, Joska J, Pahad S, Thom R, Thompson K, Woollett N, Furin J, Meintjes G, 2013. Guideline: management of mental health disorders in HIV-positive patients. S. Afr. J. HIV Med 14, 155–165. 10.7196/SAJHIVMED.995. [DOI] [Google Scholar]
  50. Juster RP, McEwen BS, Lupien SJ, 2010. Allostatic load biomarkers of chronic stress and impact on health and cognition. Neurosci. Biobehav. Rev 35, 2–16. 10.1016/j.neubiorev.2009.10.002. [DOI] [PubMed] [Google Scholar]
  51. Kanmogne GD, Qiu F, Ntone FE, Fonsah JY, Njamnshi DM, Kuate CT, Doh RF, Kengne AM, Tagny CT, Nchindap E, Kenmogne L, Mbanya D, Cherner M, Heaton RK, Njamnshi AK, 2017. Depressive symptoms in HIV-infected and seronegative control subjects in Cameroon: effect of age, education and gender. PLoS One 12, e0171956. 10.1371/journal.pone.0171956. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Kemppainen JK, MacKain S, Alexander M, Reid P, Jackson MP, 2017. Posttraumatic stress disorder and stressful life events among rural women with HIV disease. J. Assoc. Nurses AIDS Care 28, 216–225. 10.1016/j.jana.2016.06.001. [DOI] [PubMed] [Google Scholar]
  53. Kendall CE, Wong J, Taljaard M, Glazier RH, Hogg W, Younger J, Manuel DG, 2014. A cross-sectional, population-based study measuring comorbidity among people living with HIV in Ontario. BMC Public Health 14, 1–9. 10.1186/1471-2458-14-161. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Kiernan FM, 2019. Income loss and the mental health of young mothers: evidence from the recession in Ireland. J. Ment. Health Policy Econ 22, 131–149. [PubMed] [Google Scholar]
  55. Kilburn K, Thirumurthy H, Halpern CT, Pettifor A, Handa S, 2016. Effects of a large-scale unconditional cash transfer program on mental health outcomes of young people in Kenya. J. Adolesc. Health 58, 223–229. 10.1016/j.jadohealth.2015.09.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Kim JC, Watts CH, Hargreaves JR, Ndhlovu LX, Phetla G, Morison LA, Busza J, Porter JDH, Pronyk P, 2007. Understanding the impact of a microfinance-based intervention on women’s empowerment and the reduction of intimate partner violence in South Africa. Am. J. Public Health 97, 1794–1802. 10.2105/AJPH.2006.095521. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Kinyanda E, Hjelmeland H, Musisi S, 2005. Negative life events associated with deliberate self-harm in an african population in Uganda. Crisis 26, 4–11. 10.1027/0227-5910.26.1.4. [DOI] [PubMed] [Google Scholar]
  58. Kinyanda E, Hoskins S, Nakku J, Nawaz S, Patel V, 2011a. Prevalence and risk factors of major depressive disorder in HIV/AIDS as seen in semi-urban Entebbe district, Uganda. BMC Psychiatry 11, 1–9. 10.1186/1471-244X-11-205. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Kinyanda E, Woodburn P, Tugumisirize J, Kagugube J, Ndyanabangi S, Patel V, 2011b. Poverty, life events and the risk for depression in Uganda. Soc. Psychiatry Psychiatr. Epidemiol 46, 35–44. 10.1007/s00127-009-0164-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Koopman C, Gore-Felton C, Azimi N, O’Shea K, Ashton E, Power R, De Maria S, Israelski D, Spiegel D, 2002. Acute stress reactions to recent life events among women and men living with HIV/AIDS. Int. J. Psychiatry Med 32, 361–378. 10.2190/CK2N-33NV-3PVF-GLVR. [DOI] [PubMed] [Google Scholar]
  61. Korte SM, Koolhaas JM, Wingfield JC, McEwen BS, 2005. The Darwinian concept of stress: benefits of allostasis and costs of allostatic load and the trade-offs in health and disease. Neurosci. Biobehav. Rev 29, 3–38. 10.1016/j.neubiorev.2004.08.009. [DOI] [PubMed] [Google Scholar]
  62. Kreski NT, Park SH, Safren SA, Goedel WC, Morganstein JG, Chaix B, Duncan DT, 2018. Is neighborhood safety associated with depression symptoms, anxiety symptoms, and psychological distress among gay, bisexual, and other men who have sex with men? J. Gay Lesbian Ment. Heal 22, 243–260. 10.1080/19359705.2018.1463583. [DOI] [Google Scholar]
  63. Kristensen P, Weisaeth L, Heir T, 2012. Bereavement and mental health after sudden and violent losses: a review. Psychiatry 75, 76–97. 10.1521/psyc.2012.75.1.76. [DOI] [PubMed] [Google Scholar]
  64. Kroenke K, Spitzer RL, Williams JBW, 2001. The PHQ-9: validity of a brief depression severity measure. J. Gen. Intern. Med 16, 606–613. 10.1046/j.1525-1497.2001.016009606.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Kumakech E, Cantor-Graae E, Maling S, Bajunirwe F, 2009. Peer-group support intervention improves the psychosocial well-being of AIDS orphans: cluster randomized trial. Soc. Sci. Med 68, 1038–1043. 10.1016/j.socscimed.2008.10.033. [DOI] [PubMed] [Google Scholar]
  66. Leight J, Deyessa N, Verani F, Tewolde S, Sharma V, 2020. An intimate partner violence prevention intervention for men, women, and couples in Ethiopia: additional findings on substance use and depressive symptoms from a cluster-randomized controlled trial. PLoS Med. 17, e1003131 10.1371/JOURNAL.PMED.1003131. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Leserman J, Barroso J, Pence BW, Salahuddin N, Harmon JL, 2008. Trauma, stressful life events and depression predict HIV-related fatigue. AIDS Care 20, 1258–1265. 10.1080/09540120801919410. [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Leserman Jane, Ironson G, O’Cleirigh C, Fordiani JM, Balbin E, 2008. Stressful life events and adherence in HIV. AIDS Patient Care STDs 22, 403–411. 10.1089/apc.2007.0175. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Lund C, Myer L, Stein DJ, Williams DR, Flisher AJ, 2013. Mental illness and lost income among adult South Africans. Soc. Psychiatry Psychiatr. Epidemiol 48, 845–851. 10.1007/s00127-012-0587-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Mahenge B, Likindikoki S, Stöckl H, Mbwambo J, 2013. Intimate partner violence during pregnancy and associated mental health symptoms among pregnant women in Tanzania: a cross-sectional study. BJOG Int. J. Obstet. Gynaecol 120, 940–947. 10.1111/1471-0528.12185. [DOI] [PubMed] [Google Scholar]
  71. Malambo P, De Villiers A, Lambert EV, Puoane T, Kengne AP, 2018. Associations of perceived neighbourhood safety from traffic and crime with overweight/obesity among South African adults of lowsocioeconomic status. PLoS One 13, e0206408. 10.1371/journal.pone.0206408. [DOI] [PMC free article] [PubMed] [Google Scholar]
  72. Manea L, Gilbody S, McMillan D, 2012. Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. CMAJ 184, E191. 10.1503/cmaj.110829. [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. Mazure CM, 1998. Life stressors as risk factors in depression. Clin. Psychol. Sci. Pract 5, 291–313. 10.1111/j.1468-2850.1998.tb00151.x. [DOI] [Google Scholar]
  74. McEwen BS, 1998. Protective and damaging effects of stress mediators. N. Engl. J. Med 338, 171–179. 10.1056/nejm199801153380307. [DOI] [PubMed] [Google Scholar]
  75. McEwen BS, 2003. Mood disorders and allostatic load. Biol. Psychiatry 54, 200–207. 10.1016/S0006-3223(03)00177-X. [DOI] [PubMed] [Google Scholar]
  76. McEwen BS, 2004. Protection and damage from acute and chronic stress: allostasis and allostatic overload and relevance to the pathophysiology of psychiatric disorders. In: Annals of the New York Academy of Sciences. New York Academy of Sciences, pp. 1–7. 10.1196/annals.1314.001. [DOI] [PubMed] [Google Scholar]
  77. McLaughlin KA, Hatzenbuehler ML, 2009. Stressful life events, anxiety sensitivity, and internalizing symptoms in adolescents. J. Abnorm. Psychol 118, 659–669. 10.1037/a0016499. [DOI] [PMC free article] [PubMed] [Google Scholar]
  78. Monahan PO, Shacham E, Reece M, Kroenke K, Ong’Or WO, Omollo O, Yebei VN, Ojwang C, 2009. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in Western Kenya. J. Gen. Intern. Med 24, 189–197. 10.1007/s11606-008-0846-z (accessed 7.5.21). [DOI] [PMC free article] [PubMed] [Google Scholar]
  79. Moriarty J, Maguire A, O’Reilly D, McCann M, 2015. Bereavement after informal caregiving: assessing mental health burden using linked population data. Am. J. Public Health 105, 1630–1637. 10.2105/AJPH.2015.302597. [DOI] [PMC free article] [PubMed] [Google Scholar]
  80. Morrison DS, Thomson H, 2004. Evaluation of the health effects of a neighbourhood traffic calming scheme. J. Epidemiol. Community Health 58, 837–840. 10.1136/jech.2003.017509. [DOI] [PMC free article] [PubMed] [Google Scholar]
  81. Mundell JP, Visser MJ, Makin JD, Kershaw TS, Forsyth BWC, Jeffery B, Sikkema KJ, 2011. The impact of structured support groups for pregnant South African women recently diagnosed HIV positive. Women Heal. 51, 546–565. 10.1080/03630242.2011.606356. [DOI] [PMC free article] [PubMed] [Google Scholar]
  82. Murray LK, Jordans MJD, 2016. Rethinking the service delivery system of psychological interventions in low and middle income countries. BMC Psychiatry 16, 1–6. 10.1186/s12888-016-0938-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  83. Mutedzi B, Langhaug L, Hunt J, Nkhoma K, Harding R, 2019. Improving bereavement outcomes in Zimbabwe: protocol for a feasibility cluster trial of the 9-cell bereavement tool. Pilot Feasibility Stud. 5 10.1186/s40814-019-0450-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  84. Nakimuli-Mpungu E, Musisi S, Wamala K, Okello J, Ndyanabangi S, Birungi J, Nanfuka M, Etukoit M, Mayora C, Ssengooba F, Mojtabai R, Nachega JB, Harari O, Mills EJ, 2020. Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster-randomised trial. Lancet Glob. Heal 8, e387–e398. 10.1016/S2214-109X(19)30548-0. [DOI] [PubMed] [Google Scholar]
  85. Nakimuli-Mpungu E, Musisi S, Smith CM, Von Isenburg M, Akimana B, Shakarishvili A, Nachega JB, Mills EJ, Chibanda D, Ribeiro M, Williams VA, Joska JA, 2021. Mental health interventions for persons living with HIV in low- and middle-income countries: a systematic review. J. Int. AIDS Soc 24, e25722 10.1002/jia2.25722. [DOI] [PMC free article] [PubMed] [Google Scholar]
  86. Nanni MG, Caruso R, Mitchell AJ, Meggiolaro E, Grassi L, 2015. Depression in HIV infected patients: a review. Curr. Psychiatry Rep 10.1007/s11920-014-0530-4. [DOI] [PubMed] [Google Scholar]
  87. Nguyen MX, McNaughton Reyes HL, Pence BW, Muessig K, Hutton HE, Latkin CA, Dowdy D, Chander G, Lancaster KE, Frangakis C, Sripaipan T, Ha Tran V, Go VF, 2021. The longitudinal association between depression, anxiety symptoms and HIV outcomes, and the modifying effect of alcohol dependence among ART clients with hazardous alcohol use in Vietnam. J. Int. AIDS Soc 24, e25746 10.1002/jia2.25746. [DOI] [PMC free article] [PubMed] [Google Scholar]
  88. Niu L, Luo D, Liu Y, Silenzio VMB, Xiao S, 2016. The mental health of people living with HIV in China, 1998–2014: a systematic review. PLoS One. 10.1371/journal.pone.0153489. [DOI] [PMC free article] [PubMed] [Google Scholar]
  89. Nyongesa MK, Mwangi P, Kinuthia M, Hassan AS, Koot HM, Cuijpers P, Newton CRJC, Abubakar A, 2021. Prevalence, risk and protective indicators of common mental disorders among young people living with HIV compared to their uninfected peers from the Kenyan coast: a cross-sectional study. BMC Psychiatry 21, 1–17. 10.1186/s12888-021-03079-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  90. Ohrnberger J, Fichera E, Sutton M, Anselmi L, 2020. The effect of cash transfers on mental health-new evidence from South Africa. BMC Public Health 20, 1–13. 10.1186/s12889-020-08596-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  91. Olesen SC, Butterworth P, Leach LS, Kelaher M, Pirkis J, 2013. Mental health affects future employment as job loss affects mental health: findings from a longitudinal population study. BMC Psychiatry 13, 1–9. 10.1186/1471-244X-13-144. [DOI] [PMC free article] [PubMed] [Google Scholar]
  92. Olley BO, Seedat S, Nei DG, 2004. Predictors of major depression in recently diagnosed patients with HIV/AIDS in South Africa. AIDS Patient Care STDS 18 (8), 481–487. 10.1089/1087291041703700. [DOI] [PubMed] [Google Scholar]
  93. Olley BO, Seedat S, Stein DJ, 2006. Persistence of psychiatric disorders in a cohort of HIV/AIDS patients in South Africa: a 6-month follow-up study. J. Psychosom. Res 61, 479–484. 10.1016/j.jpsychores.2006.03.010. [DOI] [PubMed] [Google Scholar]
  94. Oyeyemi AL, Adegoke BO, Oyeyemi AY, Deforche B, Bourdeaudhuij ID, Sallis JF, 2012. Environmental factors associated with overweight among adults in Nigeria. Int. J. Behav. Nutr. Phys. Act 9, 1–9. 10.1186/1479-5868-9-32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  95. Parcesepe AM, Filiatreau LM, Ebasone PV, Dzudie A, Ajeh R, Wainberg M, Pence B, Pefura-Yone E, Yotebieng M, Nsame D, Anastos K, Nash D, 2021. Gender, mental health, and entry into care with advanced HIV among people living with HIV in Cameroon under a national ‘Treat all’ policy. AIDS Behav. 1, 3. 10.1007/s10461-021-03328-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  96. Paterniti S, Verdier-Taillefer MH, Dufouil C, Alpérovitch A, 2002. Depressive symptoms and cognitive decline in elderly people: longitudinal study. Br. J. Psychiatry 181, 406–410. 10.1192/bjp.181.5.406. [DOI] [PubMed] [Google Scholar]
  97. Paykel ES, 2003. Life events and affective disorders. Acta Psychiatr. Scand 108, 61–66. 10.1034/j.1600-0447.108.s418.13.x. [DOI] [PubMed] [Google Scholar]
  98. Pefura-Yone EW, Soh E, Kengne AP, Balkissou AD, Kuaban C, 2013. Non-adherence to antiretroviral therapy in Yaoundé: prevalence, determinants and the concordance of two screening criteria. J. Infect. Public Health 6, 307–315. 10.1016/j.jiph.2013.02.003. [DOI] [PubMed] [Google Scholar]
  99. Pence BW, Gaynes BN, Atashili J, O’Donnell JK, Tayong G, Kats D, Whetten R, Whetten K, Njamnshi AK, Ndumbe PM, 2012a. Validity of an interviewer- administered patient health questionnaire-9 to screen for depression in HIV-infected patients in Cameroon. J. Affect. Disord 143, 208–213. 10.1016/j.jad.2012.05.056. [DOI] [PMC free article] [PubMed] [Google Scholar]
  100. Pence BW, Shirey K, Whetten K, Agala B, Itemba D, Adams J, Whetten R, Yao J, Shao J, 2012b. Prevalence of psychological trauma and association with current health and functioning in a sample of HIV-infected and HIV-uninfected Tanzanian adults. PLoS One 7, e36304. 10.1371/journal.pone.0036304. [DOI] [PMC free article] [PubMed] [Google Scholar]
  101. Pengpid S, Peltzer K, 2020. Associations of physical partner violence and sexual violence victimization on health risk behaviours and mental health among university students from 25 countries. BMC Public Health 20, 1–10. 10.1186/s12889-020-09064-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  102. Penner-Goeke K, Henriksen CA, Chateau D, Latimer E, Sareen J, Katz LY, 2015. Reductions in quality of life associated with common mental disorders: results from a nationally representative sample. J. Clin. Psychiatry 76, 1506–1512. 10.4088/JCP.14m09271. [DOI] [PubMed] [Google Scholar]
  103. Penninx BWJH, Deeg DJH, Van Eijk JTM, Beekman ATF, Guralnik JM, 2000. Changes in depression and physical decline in older adults: a longitudinal perspective. J. Affect. Disord 61, 1–12. 10.1016/S0165-0327(00)00152-X. [DOI] [PubMed] [Google Scholar]
  104. Perry S, Fishman B, Jacobsberg L, Frances A, 1992. Relationships over 1 year between lymphocyte subsets and psychosocial variables among adults with infection by Human Immunodeficiency Virus. Arch. Gen. Psychiatry 49, 396–401. 10.1001/ARCHPSYC.1992.01820050060010. [DOI] [PubMed] [Google Scholar]
  105. Posel D, Oyenubi A, Kollamparambil U, 2021. Job loss and mental health during the COVID-19 lockdown: evidence from South Africa. PLoS One 16, e0249352. 10.1371/journal.pone.0249352. [DOI] [PMC free article] [PubMed] [Google Scholar]
  106. Prince M, Lahti E, Jennings LC, Murdoch DR, 2011. No health without mental health. Lancet 377, 1264–1275. 10.1016/S0140. [DOI] [PMC free article] [PubMed] [Google Scholar]
  107. Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, Busza J, Porter JD, 2006. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 368, 1973–1983. 10.1016/S0140-6736(06)69744-4. [DOI] [PubMed] [Google Scholar]
  108. Regan M, Muhihi A, Nagu T, Aboud S, Ulenga N, Kaaya S, Fawzi MCS, Yousafzai AK, Mugusi F, Fawzi WW, Saxena S, Koenen K, Sudfeld CR, 2021. Depression and viral suppression among adults living with HIV in Tanzania. AIDS Behav. 1, 3. 10.1007/s10461-021-03187-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  109. Reif S, Mugavero M, Raper J, Thielman N, Leserman J, Whetten K, Pence BW, 2011. Highly stressed: stressful and traumatic experiences among individuals with HIV/AIDS in the Deep South. AIDS Care 23, 152–162. 10.1080/09540121.2010.498872. [DOI] [PMC free article] [PubMed] [Google Scholar]
  110. Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, Mellins CA, 2019. Mental health and HIV/AIDS: the need for an integrated response. AIDS 33, 1411–1420. 10.1097/QAD.0000000000002227. [DOI] [PMC free article] [PubMed] [Google Scholar]
  111. Roh S, Jang Y, Chiriboga DA, Kwag KH, Cho S, Bernstein K, 2011. Perceived neighborhood environment affecting physical and mental health: a study with Korean American older adults in New York City. J. Immigr. Minor. Health 13, 1005–1012. 10.1007/s10903-011-9492-3. [DOI] [PubMed] [Google Scholar]
  112. Rong H, Nianhua X, Jun X, Lianguo R, Si W, Sheng W, Heng G, Xia W, 2017. Prevalence of and risk factors for depressive symptoms among people living with HIV/AIDS receiving antiretroviral treatment in Wuhan, China: a short report. AIDS Care 29, 1524–1528. 10.1080/09540121.2017.1327649. [DOI] [PubMed] [Google Scholar]
  113. Rueda S, Raboud J, Plankey M, Ostrow D, Mustard C, Rourke SB, Jacobson LP, Bekele T, Bayoumi A, Lavis J, Detels R, Silvestre AJ, 2012a. Labor force participation and health-related quality of life in HIV-positive men who have sex with men: the multicenter AIDS cohort study. AIDS Behav. 16, 2350–2360. 10.1007/s10461-012-0257-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  114. Rueda S, Raboud J, Rourke SB, Bekele T, Bayoumi A, Lavis J, Cairney J, Mustard C, 2012b. Influence of employment and job security on physical and mental health in adults living with HIV: cross-sectional analysis. Open Med. 6, 118–126. [PMC free article] [PubMed] [Google Scholar]
  115. Saraceno B, Levav I, Kohn R, 2005. The public mental health significance of research on socio-economic factors in schizophrenia and major depression. World Psychiatry 4, 181–185. [PMC free article] [PubMed] [Google Scholar]
  116. Sarason IG, Johnson JH, Siegel JM, 1978. Assessing the impact of life changes: development of the life experiences survey. J. Consult. Clin. Psychol 46, 932–946. 10.1037/0022-006X.46.5.932. [DOI] [PubMed] [Google Scholar]
  117. Seffren V, Familiar I, Murray SM, Augustinavicius J, Boivin MJ, Nakasujja N, Opoka R, Bass J, 2018. Association between coping strategies, social support, and depression and anxiety symptoms among rural Ugandan women living with HIV/AIDS. AIDS Care 30, 888–895. 10.1080/09540121.2018.1441969. [DOI] [PMC free article] [PubMed] [Google Scholar]
  118. Segrin C, 2013. Disrupted interpersonal relationships and mental health problems. In: The Dark Side of Close Relationships, pp. 327–365. 10.4324/9781410601117-21. [DOI] [Google Scholar]
  119. Seok BJ, Jeon S, Lee J, Cho SJ, Lee YJ, Kim SJ, 2020. Effects of early trauma and recent stressors on depression, anxiety, and anger. Front. Psychiatry 11. 10.3389/fpsyt.2020.00744. [DOI] [PMC free article] [PubMed] [Google Scholar]
  120. Shenderovich Y, Boyes M, Esposti MD, Casale M, Toska E, Roberts KJ, Cluver L, 2021. Relationships with caregivers and mental health outcomes among adolescents living with HIV: a prospective cohort study in South Africa. BMC Public Health 21, 1–11. 10.1186/s12889-020-10147-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  121. Shrive FM, Stuart H, Quan H, Ghali WA, 2006. Dealing with missing data in a multi-question depression scale: a comparison of imputation methods. BMC Med. Res. Methodol 6, 57. 10.1186/1471-2288-6-57. [DOI] [PMC free article] [PubMed] [Google Scholar]
  122. Sikkema KJ, Kalichman SC, Hoffmann R, Koob JJ, Kelly JA, Heckman TG, 2000. Coping strategies and emotional wellbeing among HIV-infected men and women experiencing AIDS-related bereavement. AIDS Care 12, 613–624. 10.1080/095401200750003798. [DOI] [PubMed] [Google Scholar]
  123. Sikkema KJ, Kochman A, DiFranceisco W, Kelly JA, Hoffmann RG, 2003. AIDS-related grief and coping with loss among HIV-positive men and women. J. Behav. Med 26, 165–181. 10.1023/A:1023086723137. [DOI] [PubMed] [Google Scholar]
  124. Sikkema KJ, Dennis AC, Watt MH, Choi KW, Yemeke TT, Joska JA, 2015. Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries. Glob. Ment. Health 2, 1–23. 10.1017/gmh.2015.17. [DOI] [PMC free article] [PubMed] [Google Scholar]
  125. Slopen N, Fitzmaurice GM, Williams DR, Gilman SE, 2012. Common patterns of violence experiences and depression and anxiety among adolescents. Soc. Psychiatry Psychiatr. Epidemiol 47, 1591–1605. 10.1007/s00127-011-0466-5. [DOI] [PubMed] [Google Scholar]
  126. Spitzer RL, Kroenke K, Williams JBW, Löwe B, 2006. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch. Intern. Med 166, 1092–1097. 10.1001/archinte.166.10.1092. [DOI] [PubMed] [Google Scholar]
  127. Stein DJ, Chiu WT, Hwang I, Kessler RC, Sampson N, Alonso J, Borges G, Bromet E, Bruffaerts R, de Girolamo G, Florescu S, Gureje O, He Y, Kovess-Masfety V, Levinson D, Matschinger H, Mneimneh Z, Nakamura Y, Ormel J, Posada-Villa J, Sagar R, Scott KM, Tomov T, Viana MC, Williams DR, Nock MK, 2010. Cross-national analysis of the associations between traumatic events and suicidal behavior: findings from the WHO world mental health surveys. PLoS One 5, e10574. 10.1371/journal.pone.0010574. [DOI] [PMC free article] [PubMed] [Google Scholar]
  128. Tennant C, 2002. Life events, stress and depression: a review of recent findings. Aust. N. Z. J. Psychiatry 36, 173–182. 10.1046/j.1440-1614.2002.01007.x. [DOI] [PubMed] [Google Scholar]
  129. Tesfaw G, Ayano G, Awoke T, Assefa D, Birhanu Z, Miheretie G, Abebe G, 2016. Prevalence and correlates of depression and anxiety among patients with HIV on-follow up at Alert Hospital, Addis Ababa, Ethiopia. BMC Psychiatry 16, 1–7. 10.1186/s12888-016-1037-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  130. Tesfaye SH, Bune GT, 2014. Generalized psychological distress among HIV-infected patients enrolled in antiretroviral treatment in Dilla University Hospital, Gedeo zone, Ethiopia. Glob. Health Action 7, 23882. 10.3402/gha.v7.23882. [DOI] [PMC free article] [PubMed] [Google Scholar]
  131. Thurman TR, Luckett BG, Nice J, Spyrelis A, Taylor TM, 2017. Effect of a bereavement support group on female adolescents' psychological health: a randomised controlled trial in South Africa. Lancet Glob. Heal 5, e604–e614. 10.1016/S2214-109X(17)30146-8. [DOI] [PubMed] [Google Scholar]
  132. Thurman TR, Nice J, Luckett B, Visser M, 2018. Can family-centered programing mitigate HIV risk factors among orphaned and vulnerable adolescents? Results from a pilot study in South Africa. AIDS Care 30, 1135–1143. 10.1080/09540121.2018.1455957. [DOI] [PubMed] [Google Scholar]
  133. Tol WA, Barbui C, Bisson J, Cohen J, Hijazi Z, Jones L, de Jong JTVM, Magrini N, Omigbodun O, Seedat S, Silove D, Souza R, Sumathipala A, Vijayakumar L, Weissbecker I, Zatzick D, van Ommeren M, 2014. World Health Organization guidelines for management of acute stress, PTSD, and bereavement: key challenges on the road ahead. PLoS Med. 11, e1001769 10.1371/journal.pmed.1001769. [DOI] [PMC free article] [PubMed] [Google Scholar]
  134. Too EK, Abubakar A, Nasambu C, Koot HM, Cuijpers P, Newton CR, Nyongesa MK, 2021. Prevalence and factors associated with common mental disorders in young people living with HIV in sub-Saharan Africa: a systematic review. J. Int. AIDS Soc 10.1002/jia2.25705. [DOI] [PMC free article] [PubMed] [Google Scholar]
  135. Tsai AC, Tomlinson M, Comulada WS, Rotheram-Borus MJ, 2016. Intimate partner violence and depression symptom severity among South African women during pregnancy and postpartum: population-based prospective cohort study. PLoS Med. 13 10.1371/journal.pmed.1001943. [DOI] [PMC free article] [PubMed] [Google Scholar]
  136. Uthman OA, Magidson JF, Safren SA, Nachega JB, 2014. Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: a systematic review and meta-analysis. Curr. HIV/AIDS Rep 11, 291–307. 10.1007/s11904-014-0220-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  137. Verhey R, Chibanda D, Gibson L, Brakarsh J, Seedat S, 2018. Validation of the posttraumatic stress disorder checklist - 5 (PCL-5) in a primary care population with high HIV prevalence in Zimbabwe. BMC Psychiatry 18. 10.1186/s12888-018-1688-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  138. Wagman JA, Gray RH, Campbell JC, Thoma M, Ndyanabo A, Ssekasanvu J, Nalugoda F, Kagaayi J, Nakigozi G, Serwadda D, Brahmbhatt H, 2015. Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort. Lancet Glob. Heal 3, e23–e33. 10.1016/S2214-109X(14)70344-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  139. Walker ER, McGee RE, Druss BG, 2015. Mortality in mental disorders and global disease burden implications a systematic review and meta-analysis. JAMA Psychiatry 72, 334–341. 10.1001/jamapsychiatry.2014.2502. [DOI] [PMC free article] [PubMed] [Google Scholar]
  140. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP, 2013. The PTSD Checklist for DSM-5 (PCL-5). [Google Scholar]
  141. Wilson-Genderson M, Pruchno R, 2013. Effects of neighborhood violence and perceptions of neighborhood safety on depressive symptoms of older adults. Soc. Sci. Med 85, 43–49. 10.1016/j.socscimed.2013.02.028. [DOI] [PubMed] [Google Scholar]
  142. Wood K, Chase E, Aggleton P, 2006. “Telling the truth is the best thing”: teenage orphans' experiences of parental AIDS-related illness and bereavement in Zimbabwe. Soc. Sci. Med 63, 1923–1933. 10.1016/j.socscimed.2006.04.027. [DOI] [PubMed] [Google Scholar]
  143. Worley MJ, Trim RS, Roesch SC, Mrnak-Meyer J, Tate SR, Brown SA, 2012. Comorbid depression and substance use disorder: longitudinal associations between symptoms in a controlled trial. J. Subst. Abus. Treat 43, 291–302. 10.1016/j.jsat.2011.12.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  144. Zimmerman A, Garman E, Avendano-Pabon M, Araya R, Evans-Lacko S, McDaid D, Park A.La, Hessel P, Diaz Y, Matijasevich A, Ziebold C, Bauer A, Paula CS, Lund C, 2021. The impact of cash transfers on mental health in children and young people in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Glob. Health 10.1136/bmjgh-2020-004661. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES