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Depression Increases the Risk of Disease Progression and Death in HIV-positive Women

Depression plays an important role in clinical disease progression and death in HIV-1-infected women in Sub-Saharan Africa, according to a study published// in the Journal of Acquired Immune Deficiency Syndromes. The study found that depression is common among HIV-infected Tanzanian women and recommends screening for depression and providing psychosocial interventions as part of a comprehensive HIV care.

There is increasing evidence that depression or stress may accelerate HIV disease progression. Depression might directly alter immune functions or might cause behavioral changes resulting in non-adherence to treatment regimes and a reduced food uptake.

The prevalence of psychiatric disorders among HIV-infected African women is not known. Although depression has been reported in 47% of Ugandan HIV-infected men and women and in about 30% of HIV-infected Rwandese women, there is a paucity of studies which link depression and HIV clinical disease progression in developing countries. A team of Tanzanian and US investigators has addressed this issue.

The study was nested within a randomized controlled trial of vitamin supplementation in pregnant women.

The primary end-points of the parent study included vertical transmission rates, pregnancy outcomes, HIV disease progression, and mortality among the women and their children born into the study. Nine hundred and ninety-six women with at least one depression measure taken during pregnancy or more than twelve months postpartum were eligible for the depression study. Post-partum depression was eliminated by excluding the depression data collected between delivery and twelve months postpartum.

The women were followed up monthly and later quarterly for approximately six to eight years after HIV diagnosis. Survival and mortality data were collected through tracing participants if a clinic visit was missed. A woman was classified as alive on the day of contact if a home visitor reported talking to or seeing her.

About two months after enrolment, every six months until 2001, and every twelve months thereafter, a psychosocial questionnaire was administered to assess depression /anxiety symptoms based on eight out of the 25-item scale of the Hopkins Symptoms Checklist (HSCL-25). A previous study in this population validated the usefulness of the eight point sub-scale for assessing depression. A social support scale, based on a ten-item questionnaire on emotional or affective (six) and material or instrumental (four) support, was used to assess social support among the patients.

A psychiatric nurse provided individual counseling in the clinic and facilitated a weekly peer support group for women who needed or required counseling for depressive or anxiety symptoms. Women were encouraged to visit the study clinic if they were ill or required counseling.

Depression is not only common but is an independent predictor of disease progression and death among HIV-infected African women, the authors conclude. This brings into sharp relief the urgent need for additional studies to assess the effectiveness of psychosocial interventions in preventing or delaying disease progression.

The policy implication is that, alongside antiretroviral drug treatment, management of depression and psychiatric disorders must be an integral part of the health care package provided to all HIV-infected patients.

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