Depression due to HIV stigma common in Peruvian women with HIV

Over two-thirds of Peruvian women living with HIV and poverty are suffering from depression, according to a case series published in the August 1^st edition of the Journal of Acquired Immune Deficiency Syndromes. Although other studies have also explored this link, the current study found that depression is most significantly linked with HIV-related stigma and food scarcity - defined as not eating for at least a day in the past three months due to economic hardship. These findings highlight the burden of depression in this cohort of poor women and the need to incorporate mental health services as an integral part of HIV care.

In resource-poor settings, mental health among HIV–positive women is known to be worsened by poverty, and reported rates of depression among people with HIV living in poverty range from 21% to 57%. Depression can affect HIV outcomes both through non-adherence to antiretroviral therapy and effects on the immune system. The adverse effects of depression and HIV combined is worsened by poverty, and women may disproportionately bear the burden of these two illnesses. So a US and Peruvian team sought to measure the extent of depression and identify associated factors in a cohort of HIV-positive people living in impoverished settings in Lima, Peru.

Between November 2005 and August 2007, 159 adults, including 78 women, who were starting or about to start antiretroviral therapy based on World Health Organization guidelines, were enrolled in the study. In two hospitals, data were collected by patient interview and medical chart review including a one-to-one mental health assessment using the Hopkins Symptom Checklist-15, which has been validated in various populations.

Of 275 women identified as being eligible to start antiretroviral therapy during the study period, 91 were referred for psychosocial support and referred for the study but thirteen died before completing baseline interviews. Of the remaining 78 women, 68% were depressed. This rate is much higher than the prevalence of depression among women in Lima, Peru (13.5% lifetime), although the report acknowledges that the study design may have led to bias due to increased referrals. In addition, the questionnaire level used to diagnose depression has not been validated in this particular population.

Depression and suicidal ideation were diagnosed in only eleven women (24.5% of those affected) although the rate of suicidal ideation was 18%. In an analysis of multiple factors that might be associated with depression, food scarcity and stigma greater than the average reported by the cohort remained significantly associated with depression (adjusted odds ratios 3.95 [95% CI 1.23-12.69] and 4.81 [1.34-17.30], respectively).

The link between stigma and depression in people with HIV has been reported previously. Stigma and disclosure of diagnosis is thought to stress women’s relationships with partners and extended family, which limits their ability to utilise social support and fulfil their roles as carers. Women may also worry that their diagnosis may stigmatise their children. The authors' concern is that poverty limits the ability of people with HIV and AIDS to adopt healthy behaviours, such as medication adherence, avoiding breastfeeding, and practising safe sex. Food scarcity is not only linked with depression but also worsened HIV outcomes due to malnutrition and nutrient deficiencies.

In this cohort, the heavy burden of depression was mostly not communicated to healthcare providers and therefore remained undiagnosed and untreated. The investigators believe that this highlights the need to incorporate mental health services, and specifically the large evidence base on treating depression, as an integral component of HIV care. Although funding for global health has increased, mental health services are insufficiently funded, the authors conclude, so community-based services could be one cost-effective approach to expanding access to mental-health interventions.