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Kaggwa MM, Najjuka SM, Bongomin F, Mamun MA, Griffiths MD. Prevalence of depression in Uganda: A systematic review and meta-analysis. PLoS One 2022; 17:e0276552. [PMID: 36264962 PMCID: PMC9584512 DOI: 10.1371/journal.pone.0276552] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/09/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Depression is one of the most studied mental health disorders, with varying prevalence rates reported across study populations in Uganda. A systematic review and meta-analysis was carried out to determine the pooled prevalence of depression and the prevalence of depression across different study populations in the country. METHODS Papers for the review were retrieved from PubMed, Scopus, PsycINFO, African Journal OnLine, and Google Scholar databases. All included papers were observational studies regarding depression prevalence in Uganda, published before September 2021. The Joanna Briggs Institute Checklist for Prevalence Studies was used to evaluate the risk of bias and quality of the included papers, and depression pooled prevalence was determined using a random-effects meta-analysis. RESULTS A total of 127 studies comprising 123,859 individuals were identified. Most studies were conducted among individuals living with HIV (n = 43; 33.9%), and the most frequently used instrument for assessing depression was the Depression sub-section of the Hopkins Symptom Checklist (n = 34). The pooled prevalence of depression was 30.2% (95% confidence interval [CI]: 26.7-34.1, I2 = 99.80, p<0.001). The prevalence of depression was higher during the COVID-19 pandemic than during the pre-pandemic period (48.1% vs. 29.3%, p = 0.021). Refugees had the highest prevalence of depression (67.6%; eight studies), followed by war victims (36.0%; 12 studies), individuals living with HIV (28.2%; 43 studies), postpartum or pregnant mothers (26.9%; seven studies), university students (26.9%; four studies), children and adolescents (23.6%; 10 studies), and caregivers of patients (18.5%; six studies). LIMITATION Significantly high levels of heterogeneity among the studies included. CONCLUSION Almost one in three individuals in Uganda has depression, with the refugee population being disproportionately affected. Targeted models for depression screening and management across various populations across the country are recommended. TRIAL REGISTRATION Protocol registered with PROSPERO (CRD42022310122).
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Affiliation(s)
- Mark Mohan Kaggwa
- Department of Psychiatry, Mbarara University of Science & Technology, Mbarara, Uganda
- African Centre for Suicide Prevention and Research, Mbarara, Uganda
- Department of Psychiatry and Behavioural Neurosciences, Forensic Psychiatry Program, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Maria Najjuka
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Mohammed A. Mamun
- CHINTA Research Bangladesh, Savar, Dhaka, Bangladesh
- Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka, Bangladesh
| | - Mark D. Griffiths
- Psychology Department, Nottingham Trent University, Nottingham, United Kingdom
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Mwangala PN, Nasambu C, Wagner RG, Newton CR, Abubakar A. Prevalence and factors associated with mild depressive and anxiety symptoms in older adults living with HIV from the Kenyan coast. J Int AIDS Soc 2022; 25 Suppl 4:e25977. [PMID: 36176027 PMCID: PMC9522642 DOI: 10.1002/jia2.25977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 07/31/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Empirical research on the burden and determinants of common mental disorders (CMDs), especially depression and anxiety, among older adults living with HIV (OALWH) in sub-Saharan Africa is inadequate. To bridge the gap in Kenya we: (1) determined the prevalence of CMDs among OALWH on routine HIV care compared to HIV-negative peers; (2) investigated HIV status as an independent predictor of CMDs in older adults; and (3) investigated CMD determinants. METHODS In a cross-sectional study conducted between 2020 and 2021, the prevalence of CMDs and associated determinants were investigated at the Kenyan coast among 440 adults aged ≥50 years (257 OALWH). The Patient Health Questionnaire and Generalized Anxiety Disorder scale were administered alongside measures capturing biopsychosocial information. Logistic regression was used to examine the correlates of CMDs. RESULTS No significant differences were found in the prevalence of mild depressive symptoms, 23.8% versus 18.2% (p = 0.16) and mild anxiety symptoms, 11.7% versus 7.2% (p = 0.12) among OALWH compared to HIV-negative peers, respectively. HIV status was not independently predictive of CMDs. Among OALWH, higher perceived HIV-related stigma, ageism, increasing household HIV burden, loneliness, increasing functional disability, sleeping difficulties, chronic fatigue and advanced age (>70 years) were associated with elevated CMDs. Among HIV-negative older adults, loneliness, increased medication burden and sleeping difficulties were associated with elevated depressive symptoms. Easier access to HIV care was the only factor associated with lower CMDs among OALWH. CONCLUSIONS On the Kenyan coast, the burden of moderate and severe CMDs among older adults is low; however, both OALWH and their HIV-negative peers have a similar relatively high burden of mild depressive and anxiety symptoms. Our results also suggest that determinants of CMDs among OALWH in this setting are predominantly psychosocial factors. These results highlight the need for psychosocial interventions (at the family, community and clinical levels) to mitigate the risks of mild CMDs as they are known to be potentially debilitating.
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Affiliation(s)
- Patrick N. Mwangala
- Centre for Geographic Medicine Research CoastKenya Medical Research Institute (KEMRI)KilifiKenya,School of Public HealthUniversity of the WitwatersrandParktownSouth Africa,Institute for Human DevelopmentAga Khan UniversityNairobiKenya
| | - Carophine Nasambu
- Centre for Geographic Medicine Research CoastKenya Medical Research Institute (KEMRI)KilifiKenya
| | - Ryan G. Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)Faculty of Health Sciences, University of the WitwatersrandJohannesburgSouth Africa
| | - Charles R. Newton
- Centre for Geographic Medicine Research CoastKenya Medical Research Institute (KEMRI)KilifiKenya,Institute for Human DevelopmentAga Khan UniversityNairobiKenya,Department of PsychiatryUniversity of OxfordWarneford HospitalOxfordUK,Department of Public HealthPwani UniversityKilifiKenya
| | - Amina Abubakar
- Centre for Geographic Medicine Research CoastKenya Medical Research Institute (KEMRI)KilifiKenya,Institute for Human DevelopmentAga Khan UniversityNairobiKenya,Department of PsychiatryUniversity of OxfordWarneford HospitalOxfordUK,Department of Public HealthPwani UniversityKilifiKenya
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Kamacooko O, Bagiire D, Kasujja FX, Mirembe M, Seeley J, King R. Prevalence of probable depression and factors associated with mean Hopkins Symptom Checklist (HSCL) depression score among young women at high risk aged 15-24 years in Kampala, Uganda. PLoS One 2022; 17:e0270544. [PMID: 35771894 PMCID: PMC9246240 DOI: 10.1371/journal.pone.0270544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/11/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In populations at high risk of HIV infection, rates of depression can be elevated with far-reaching effects on overall well-being. There is limited research on depression among young women engaged in high-risk sexual behaviour in low and middle-income settings. We investigated the prevalence, correlates and factors associated with mean HSCL depression score among young women at high risk (aged 15-24 years old) in Kampala, Uganda. METHODS We conducted a baseline analysis of a randomized controlled trial. Probable depression was measured using the 15-item Hopkins Symptoms Checklist for depression (HSCL). This checklist has been validated in Ugandan populations, and our reliability test gave a Cronbach alpha coefficient of 0.89. The test was administered to all the participants. Participants whose HSCL mean score was greater than 1.75 were categorized as having probable depression. Socio-demographics and behaviour data were collected and factors associated with mean HSCL depression score were analysed using multiple linear regression. RESULTS Data was available for 600 participants, mean age 20.4 (SD±2.44) years. The prevalence of probable depression was 56% (95% CI, 52%-60%). Probable depression symptoms were most prevalent among those who reported ever-experiencing violence from a sexual partner (64.7%), those aged between 20-24 years (58.2%) and those who reported more than 10 sexual exposures in the month prior to the interview (56.8%). At the adjusted analysis level, condom use during their last sexual intercourse prior to the survey decreased probable depression symptoms by 0.147 units compared to those who never used condoms (β = -0.147, 95% CI -0.266-0.027). Having experienced physical violence by a sexual partners increased mean HSCL depression score by 0.183 units compared to those who have never experienced violence (β = 0.183, 95% CI 0.068-0.300). Participants who reported ever using drugs of addiction had their mean HSCL depression scoreincrease by 0.20 units compared to those who have never used (β = 0.20,95% CI 0.083-0.317). CONCLUSIONS Probable depression is high in this population and increased mean HSCL depression score is related to violence. Periodic screening for depression and interventions targeting depression, partner violence and risky sexual behaviours are recommended.
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Affiliation(s)
| | | | | | | | - Janet Seeley
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rachel King
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America
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Mwangala PN, Mabrouk A, Wagner R, Newton CRJC, Abubakar AA. Mental health and well-being of older adults living with HIV in sub-Saharan Africa: a systematic review. BMJ Open 2021; 11:e052810. [PMID: 34551953 PMCID: PMC8461287 DOI: 10.1136/bmjopen-2021-052810] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/06/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE In this systematic review, we aimed to summarise the empirical evidence on common mental disorders (CMDs), cognitive impairment, frailty and health-related quality of life (HRQoL) among people living with HIV aged ≥50 years (PLWH50 +) residing in sub-Saharan Africa (SSA). Specifically, we document the prevalence and correlates of these outcomes. DESIGN, DATA SOURCES AND ELIGIBILITY CRITERIA The following online databases were systematically searched: PubMed, CINAHL, PsycINFO, Embase and Scopus up to January 2021. English-language publications on depression, anxiety, cognitive function, frailty and quality of life among PLWH50+ residing in SSA were included. DATA EXTRACTION AND SYNTHESIS We extracted information, including study characteristics and main findings. These were tabulated, and a narrative synthesis approach was adopted, given the substantial heterogeneity among included studies. RESULTS A total of 50 studies from fifteen SSA countries met the inclusion criteria. About two-thirds of these studies emanated from Ethiopia, Uganda and South Africa. Studies regarding depression predominated (n=26), followed by cognitive impairment (n=13). Overall, PLWH50+ exhibited varying prevalence of depression (6%-59%), cognitive impairments (4%-61%) and frailty (3%-15%). The correlates of CMDs, cognitive impairment, frailty and HRQoL were rarely investigated, but those reported were sociodemographic variables, many of which were inconsistent. CONCLUSIONS This review documented an increasing number of published studies on HIV and ageing from SSA. However, the current evidence on the mental and well-being outcomes in PLWH50+ is inadequate to characterise the public health dimension of these impairments in SSA, because of heterogeneous findings, few well-designed studies and substantial methodological limitations in many of the available studies. Future work should have sufficiently large samples of PLWH50+, engage appropriate comparison groups, harmonise the measurement of these outcomes using a standardised methodology to generate more robust prevalence estimates and confirm predictors. PROSPERO REGISTRATION NUMBER CRD42020145791.
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Affiliation(s)
- Patrick Nzivo Mwangala
- Department of Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- University of the Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Adam Mabrouk
- Department of Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ryan Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Parkton, Gauteng, South Africa
| | - Charles R J C Newton
- Department of Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Amina A Abubakar
- Department of Clinical Research (Neurosciences), KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
- Department of Public Health, Pwani University, Kilifi, Kenya
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Xie J, Wang Z, Li Q, He Q, Xu G, Li Y, Zhou K, Li L, Gu J. Associations between antiretroviral therapy-related experiences and mental health status among people living with HIV in China: a prospective observational cohort study. AIDS Res Ther 2021; 18:60. [PMID: 34503529 PMCID: PMC8431891 DOI: 10.1186/s12981-021-00370-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 07/13/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Mental health problems (e.g., depression and anxiety) are among the most commonly reported comorbidities of HIV. Antiretroviral therapy (ART) coverage has increased sharply. The purposes of this prospective cohort study were to investigate the ART-related experiences and whether they were associated with mental health problems among a sample of people living with HIV undergoing ART in China. METHODS The participants were 400 people living with HIV who had started ART for the first time in Guangzhou city. They were followed-up 1-year after ART initiation. Probable depression and moderate/severe anxiety were measured at baseline and Month 12, while experiences related to ART (e.g., side effects and regained self-confidence) were measured at Month 6. Univariate and multivariate logistic regressions were used to explore the associations between baseline characteristics, ART-related experiences and mental health status. RESULTS Among the 300 participants (75.0%) who completed all three surveys, a significant decline in prevalence of probable depression (23.0% at baseline vs. 14.0% at Month 12, P = 0.002) and moderate/severe anxiety (14.7% at baseline vs. 8.7% at Month 12, P = 0.023) was observed during the follow-up period. After adjustment for mental health status and potential confounders at baseline, a number of ART-related experiences at Month 6 were associated with probable depression and/or moderate/severe anxiety measured at Month 12. Improved physical health, relationships with sexual partners, and self-confidence were associated with decreased mental health issues, while the side effects of ART, AIDS-related symptoms, and inconvenience in daily life due to ART use were associated with increased mental health issues. CONCLUSIONS ART-related experiences were associated with mental health problems, tailored mental health promotion interventions targeting these experiences are needed.
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Affiliation(s)
- Jinzhao Xie
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
| | - Zixin Wang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
- CUHK Shenzhen Research Institute (SZRI), Shenzhen, 518172, Guangdong, China
| | - Quanmin Li
- Department of Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, 510080, Guangdong, China
| | - Qiangsheng He
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
- Clinical Research Center, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, 518107, Guangdong, China
| | - Guohong Xu
- Department of Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, 510080, Guangdong, China
| | - Yonghong Li
- Department of Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, 510080, Guangdong, China
| | - Kai Zhou
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
- Dean's Office, Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, 510055, Guangdong, China
| | - Linghua Li
- Department of Infectious Diseases, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, 510080, Guangdong, China.
| | - Jing Gu
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China.
- Sun Yat-Sen Global Health Institute, School of Public Health and Institute of State Governance, Guangzhou, 510080, Guangdong, China.
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Nakasujja N, Vecchio AC, Saylor D, Lofgren S, Nakigozi G, Boulware DR, Kisakye A, Batte J, Mayanja R, Anok A, Reynolds SJ, Quinn TC, Pardo CA, Kumar A, Gray RH, Wawer MJ, Sacktor N, Rubin LH. Improvement in depressive symptoms after antiretroviral therapy initiation in people with HIV in Rakai, Uganda. J Neurovirol 2021; 27:519-530. [PMID: 34333739 PMCID: PMC8524346 DOI: 10.1007/s13365-020-00920-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/17/2020] [Accepted: 10/08/2020] [Indexed: 10/20/2022]
Abstract
Depression is common following HIV infection and often improves after ART initiation. We aimed to identify distinct dimensions of depression that change following ART initiation in persons with HIV (PWH) with minimal comorbidities (e.g., illicit substance use) and no psychiatric medication use. We expected that dimensional changes in improvements in depression would differ across PWH. In an observational cohort in Rakai, Uganda, 312 PWH (51% male; mean age = 35.6 years) completed the Center for Epidemiologic Studies-Depression (CES-D) scale before and up to 2 years after ART initiation. Twenty-two percent were depressed (CES-D scores ≥ 16) pre-ART that decreased to 8% after ART. All CES-D items were used in a latent class analysis to identify subgroups with similar change phenotypes. Two improvement phenotypes were identified: affective-symptom improvement (n = 58, 19%) and mixed-symptom improvement (effort, appetite, irritability; n = 41, 13%). The affect-improvement subgroup improved on the greatest proportion of symptoms (76%). A third subgroup was classified as no-symptom changes (n = 213, 68%) as they showed no difference is symptom manifestation from baseline (93% did not meet depression criteria) to post-ART. Factors associated with subgroup membership in the adjusted regression analysis included pre-ART self-reported functional capacity, CD4 count, underweight BMI, hypertension, female sex(P's < 0.05). In a subset of PWH with CSF, subgroup differences were seen on Aβ-42, IL-13, and IL-12. Findings support that depression generally improves following ART initiation; however, when improvement is seen the patterns of symptom improvement differ across PWH. Further exploration of this heterogeneity and its biological underpinning is needed to evaluate potential therapeutic implications of these differences.
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Affiliation(s)
| | - Alyssa C Vecchio
- Institute of Global Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Deanna Saylor
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/Meyer 6-113, Baltimore, MD, USA
| | - Sarah Lofgren
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | | | | | - James Batte
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | - Aggrey Anok
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - Steven J Reynolds
- Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
- Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas C Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, USA
- Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/Meyer 6-113, Baltimore, MD, USA
| | | | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Ned Sacktor
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/Meyer 6-113, Baltimore, MD, USA
| | - Leah H Rubin
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/Meyer 6-113, Baltimore, MD, USA.
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, USA.
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Foley JD, Sheinfil A, Woolf-King SE, Fatch R, Emenyonu NI, Muyindike WR, Kekibiina A, Ngabirano C, Samet JH, Cheng DM, Hahn JA. Assessing the interaction between depressive symptoms and alcohol use prior to antiretroviral therapy on viral suppression among people living with HIV in Rural Uganda. AIDS Care 2020; 32:1251-1257. [PMID: 32482097 DOI: 10.1080/09540121.2020.1770671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Although there is evidence of individual associations between depressive symptoms and hazardous alcohol use with suboptimal antiretroviral therapy (ART) adherence among people living with HIV (PLWH), few studies have established how the two risk factors may interact to predict viral suppression. We conducted secondary data analyses with two cohorts of Ugandan PLWH (N = 657) to investigate the hypothesized interaction between depressive symptoms (Center for Epidemiological Studies Depression Scale) and hazardous alcohol use (Alcohol Use Disorder Identification Test -Consumption and/or Phosphatidylethanol biomarker) prior to ART initiation with viral suppression (<550 copies/ml). We were unable to detect an interaction between depressive symptoms and hazardous alcohol use prior to ART initiation with viral suppression in the first two years (M = 19.9 months) after ART initiation (p = 0.75). There was also no evidence of a main effect association for depressive symptoms (Adjusted Odds Ratio [AOR] = 0.88, 95% Confidence Interval [CI]: 0.50, 1.55) or hazardous alcohol use (AOR = 1.37, 95% CI: 0.80, 2.33). PLWH with depressive symptoms and/or hazardous alcohol use appear to exhibit similar levels of viral suppression as others in care; further work is needed to determine effects on HIV testing and treatment engagement.
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Affiliation(s)
- Jacklyn D Foley
- Department of Psychology, Syracuse University, Syracuse University, Syracuse, NY, USA.,Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Harvard University, Boston, MA, USA
| | - Alan Sheinfil
- Department of Psychology, Syracuse University, Syracuse University, Syracuse, NY, USA
| | - Sarah E Woolf-King
- Department of Psychology, Syracuse University, Syracuse University, Syracuse, NY, USA
| | - Robin Fatch
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nneka I Emenyonu
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Allen Kekibiina
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | - Judith A Hahn
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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