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Du J, Li J, Liang H, Wang F, Lin Y, Shao B. State of mental health, sleep status, and the interaction with health-related quality of life in HIV-infected Chinese patients during the COVID-19 pandemic. BMC Public Health 2024; 24:1445. [PMID: 38816790 PMCID: PMC11137900 DOI: 10.1186/s12889-024-18929-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 05/22/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVE To describe how mental health and sleep status influence the health-related quality of life (HRQOL) of people living with HIV/AIDS (PLWHA) during the novel coronavirus disease 2019 (COVID-19) pandemic, and to apply targeted interventions to improve the HRQOL. METHODS A web-based online questionnaire survey was administered. Descriptive analysis was used to depict the mental health and sleep status. Correlation analysis and the structural equation model (SEM) method were used to analyze the influence of mental health and sleep status on HRQOL in PLWHA. RESULTS After excluding 24 unqualified questionnaires, a total of 490 participants in this survey were included in the statistical analysis. Of the participants, 66.1% and 55.1% reported mild or worse symptoms of depression and anxiety, respectively. Overall, 70.0% had varying degrees of sleep problems. Correlation analysis showed that anxiety had the strongest correlation with sleep disturbances and sleep quality (R = 0.588 and 0.551, respectively), while depression had the strongest correlation with the HRQOL psychological and physical domains (R = - 0.759 and - 0.682, respectively). SEM analysis showed that depression, sleep quality, and psychological domains had the greatest item load on mental health, sleep status, and HRQOL (093, 0.82, and 0.89, respectively). Mental health had a more significant influence than sleep status on HRQOL, as indicated by factor loading (- 0.75 and - 0.15, respectively). CONCLUSIONS There were more severe mental health and sleep problems among PLWHA during the COVID-19 pandemic, thus, mental health intervention, especially to relieve depression symptoms, may be the most important approach to improve the HRQOL among PLWHA.
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Affiliation(s)
- Juan Du
- School of Pharmacy, Jilin medical university, Jilin, China
| | - Jin Li
- Department of AIDS, Changchun Infectious Disease Hospital, Changchun, China
| | - Han Liang
- Department of infectious diseases, Jilin Infectious Disease Hospital, Jilin, China
| | - Fuxiang Wang
- The Third Department of Infection, Shenzhen Third People's Hospital, Shenzhen, China
| | - Yuanlong Lin
- The Third Department of Infection, Shenzhen Third People's Hospital, Shenzhen, China.
| | - Bing Shao
- School of Public Health, Jilin Medical University, Jilin, China.
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Chen WT, Huang F, Shiu CS, Lin SH, Tun MS, Nwe TW, Oo YTN, Oo HN. Can social support mediate stigma and perceived stress in people live with human immunodeficiency virus? AIDS Care 2024; 36:255-262. [PMID: 37674375 PMCID: PMC10842375 DOI: 10.1080/09540121.2023.2254545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/25/2023] [Indexed: 09/08/2023]
Abstract
Stigma has heavily impacted People Living with HIV (PLWH). Limited studies report on how social support affects HIV-related stigma and perceived stress, especially in Myanmar. During first seven months of 2020, a random sample of 248 eligible PLWH were contacted from a private, closed Facebook group with more than 18,000 Myanmar people, where 90% of the members were PLWH. Variables collected included demographics data, perceived stress, social support, and HIV stigma. After controlling for the effects of demographic variables, the path from HIV stigma to perceived stress (direct effect β = 0.40) and though the mediation of social support was significant (indirect effect β = 0.014). However, the mediating effect of social support was non-significant between HIV stigma and perceived stress. This exploratory study shows that social support did not have the expected effect of decreasing perceived stress in PLWH in Myanmar. Interventions to reduce HIV stigma to decrease perceived stress should consider other strategies, e.g., spirituality-based practice, to reduce perceived stress in Myanmar PLWH.
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Affiliation(s)
- Wei-Ti Chen
- School of Nursing, University of California Los Angeles, Los Angeles, CA, USA
| | - Feifei Huang
- School of Nursing, Fujian Medical University, Fuzhou, China
| | - Cheng-Shi Shiu
- Department of Social Work, National Taiwan University, Taipei, Taiwan
| | - Sai Htun Lin
- Human Rights & Technical Services Department, Secretariat Office, Myanmar Positive Group (MPG), Yangon, Myanmar
| | - Min San Tun
- Human Rights & Technical Services Department, Secretariat Office, Myanmar Positive Group (MPG), Yangon, Myanmar
| | - Thet Wai Nwe
- National AIDS Program, Department of Public Health, Ministry of Health and Sports, Naypyidaw, Myanmar
| | - Yin Thet Nu Oo
- Health System Research Division, Department of Medical Research, Yangon, Myanmar
| | - Htun Nyunt Oo
- National AIDS Program, Department of Public Health, Ministry of Health and Sports, Naypyidaw, Myanmar
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Fu J, Chen X, Dai Z, Huang Y, Xiao W, Wang H, Si M, Wu Y, Zhang L, Jing S, Liu X, Yu F, Mi G, Su XY. HIV-related stigma, depression and suicidal ideation among HIV-positive MSM in China: a moderated mediation model. BMC Public Health 2023; 23:2117. [PMID: 37891525 PMCID: PMC10612198 DOI: 10.1186/s12889-023-17047-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND As the HIV epidemic among MSM in China continues, Chinese men who have sex with men (MSM) face various mental health difficulties, including suicide ideation, depression, and stigma. The current study aims to assess the mechanisms between HIV-related stigma, depression, and suicidal ideation among MSM in China. METHODS This national cross-sectional study was completed on the geosocial networking application (GSN) app, Blued, from December 2020 to March 2021. We used the HIV Stigma Scale and the Center for Epidemiologic Studies Depression Scale (CES-D10) to measure HIV stigma and depression, respectively. Suicidal ideation was measured by the suicidal ideation-related item. Descriptive analyses, logistic regression, and structural equation modeling (SEM) were used for data analysis. RESULTS A total of 244 HIV-positive MSM were included in the analysis. The mediation model revealed that the direct pathway of perceived HIV-related stigma on suicidal ideation was significant (standardized pathway coefficient = 0.07), and the indirect pathway of perceived HIV-related stigma on suicidal ideation via depression was also significant (standardized pathway coefficient = 0.04). There was a partial mediating effect of depression in the association between perceived HIV-related stigma and suicidal ideation. CONCLUSIONS Our study found that both perceived HIV-related stigma and depression were associated with suicidal ideation among HIV-positive MSM in China, and that depression could serve as a mediator between HIV-related stigma and suicidal ideation. Targeted interventions regarding HIV-related stigma and depression should be taken into account to reduce suicidal ideation among HIV-positive MSM in China.
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Affiliation(s)
- Jiaqi Fu
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xu Chen
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhenwei Dai
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yiman Huang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weijun Xiao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hao Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mingyu Si
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yijin Wu
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ling Zhang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shu Jing
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin Liu
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fei Yu
- Danlan Public Welfare, Beijing, China
| | | | - Xiao-You Su
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Li X, Liu Y, Han J, Lin K, Bai X, Lu F. Trajectories of depressive symptoms in young and middle-aged men who have sex with men with new HIV-diagnosis: a 1-year prospective cohort study in Beijing, China. Front Public Health 2023; 11:1244624. [PMID: 37915822 PMCID: PMC10616961 DOI: 10.3389/fpubh.2023.1244624] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/29/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Due to the sexual orientation and HIV diagnosis, young and middle-aged men who have sex with men (MSM) with new HIV-diagnosis may experience more depressive syndromes and face greater psychological stress. The study explored trajectories of depressive symptoms of young and middle-aged MSM within 1 year after new HIV-diagnosis and analyze the related factors. Methods From January 2021 to March 2021, 372 young and middle-aged MSM who were newly diagnosed as HIV-infection were recruited in two hospitals in Beijing. Self-rating Depression Scale was used to measure the participants' depressive symptom in 1st month, 3rd month, 6th month, 9th month and 12th month after HIV diagnosis. The latent class growth model was used to identify trajectories of the participants' depressive symptoms. Multinomial logistic regression was used to analyse factors related with the trajectories. Results Three hundred and twenty-eight young and middle-aged MSM with new HIV-diagnosis completed the research. Depressive symptom in 328 young and middle-aged MSM was divided into three latent categories: non-depression group (56.4%), chronic-mild depression group (28.1%), and persistent moderate-severe depression group (15.5%). The participants assessed as non-depression (non-depression group) or mild depression (chronic-mild depression group) at the baseline were in a non-depression state or had a downward trend within one-year, and the participants assessed as moderate and severe depression (persistent moderate-severe depression group) at the time of diagnosis were in a depression state continuously within 1-year. Multinomial logistic regression analysis showed that, compared with the non-depression group, monthly income of 5,000 ~ 10,000 RMB (equal to 690 ~ 1,380 USD) was the risk factor for the chronic-mild depression group, and self-rating status being fair/good and self-disclosure of HIV infection were protective factors for the persistent moderate-severe depression group while HIV-related symptoms was the risk factor. Conclusion Depressive symptoms in young and middle-aged MSM is divided into three latent categories. Extra care must be given to young and middle-aged MSM assessed as moderate or severe depression at the time of HIV-diagnosis, especially to those who had poor self-rating health status, did not tell others about their HIV-infection and experienced HIV-related symptoms.
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Affiliation(s)
- Xiao Li
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yu Liu
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Han
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Keke Lin
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoyan Bai
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Fengling Lu
- School of Medicine, Qingdao Huanghai University, Qingdao, China
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Brody LA, Kamalyan L, Karcher K, Guarena LA, Bender AA, McKenna BS, Umlauf A, Franklin D, Marquine MJ, Heaton RK. NIH Toolbox Emotion Battery Findings Among People with HIV: Normative Comparisons and Clinical Associations. Patient Relat Outcome Meas 2023; 14:15-30. [PMID: 36814680 PMCID: PMC9939807 DOI: 10.2147/prom.s391113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/28/2023] [Indexed: 02/16/2023] Open
Abstract
Purpose Depression and other aspects of emotional health in people with HIV (PWH) can affect functional independence, disease progression, and overall life quality. This study used the NIH Toolbox Emotion Battery (NIHTB-EB), which assesses many features of emotional health, to more comprehensively investigate differences among adults living with and without HIV, and to identify factors associated with emotional health for PWH. Patients and Methods Participants (n=1451; age: M=50.19, SD=16.84; 47.90% women) included 433 PWH living in southern California seen from 2003 to 2021 (64.72% AIDS, 92.25% on antiretroviral therapy) and 1018 healthy participants from NIHTB-EB national normative cohort. Participants completed the NIHTB-EB and PWH underwent comprehensive HIV disease and psychiatric evaluations. We investigated differences in emotional health by HIV status via independent samples t-tests (continuous scores) and Chi2 tests ("problematic" emotional health scores). Multivariable linear regression models examined correlates of emotional health among PWH. Results PWH had significantly worse emotional health than people without HIV across Social Satisfaction (Cohen's d=0.71, p<0.001), Psychological Well-Being (Cohen's d=0.49, p<0.001) and Negative Affect (Cohen's d=0.19, p<0.01) summary T-scores, and most component scales. PWH also had higher rates of "problematic" emotional health, particularly in Social Satisfaction (45% vs 17%, p<0.0001). Poor emotional health among PWH was associated with lifetime Major Depressive and Substance Use Disorders, relationship status (lost relationship versus in relationship), unemployment, and cognitive difficulties and loss of functional independence. Conclusion The NIHTB-EB identified that difficulties with multiple aspects of emotional health are common among PWH, and appear to be relatively independent of cognitive impairment as well as HIV disease and treatment history, but are strongly associated with everyday functioning. Given the cross-sectional nature of this study, longitudinal studies should be employed to evaluate causality pertaining to predictors of emotional health in PWH. These findings may inform interventions to promote emotional wellbeing in PWH.
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Affiliation(s)
- Lilla A Brody
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, NY, USA
- Department of Psychiatry, HIV Neurobehavioral Research Program, San Diego, CA, USA
| | - Lily Kamalyan
- Department of Psychiatry, HIV Neurobehavioral Research Program, San Diego, CA, USA
- Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA, USA
| | - Kayle Karcher
- Department of Psychiatry, HIV Neurobehavioral Research Program, San Diego, CA, USA
| | - Lesley A Guarena
- Department of Psychiatry, HIV Neurobehavioral Research Program, San Diego, CA, USA
| | - Alexis A Bender
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Benjamin S McKenna
- Department of Psychiatry, HIV Neurobehavioral Research Program, San Diego, CA, USA
| | - Anya Umlauf
- Department of Psychiatry, HIV Neurobehavioral Research Program, San Diego, CA, USA
| | - Donald Franklin
- Department of Psychiatry, HIV Neurobehavioral Research Program, San Diego, CA, USA
| | - Maria J Marquine
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Robert K Heaton
- Department of Psychiatry, HIV Neurobehavioral Research Program, San Diego, CA, USA
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Kechine T, Ali T, Worku T, Abdisa L, Assebe Yadeta T. Anxiety and Associated Factors Among Clients on Highly Active Antiretroviral Therapy (HAART) in Public Hospitals of Southern Ethiopia: A Multi-Center Cross-Sectional Study. Psychol Res Behav Manag 2022; 15:3889-3900. [PMID: 36605175 PMCID: PMC9809403 DOI: 10.2147/prbm.s385630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/16/2022] [Indexed: 12/30/2022] Open
Abstract
Background Anxiety is an unpleasant feeling of fear, apprehension, and nervousness without any apparent stimulus. Anxiety is one of the co-morbidities that are often overlooked in treating patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Anxiety is worse among people with HIV/AIDS than the general population. Few studies have been conducted on prevalence of anxiety in people receiving antiretroviral treatment and limited evidence is available on its associated factors. Therefore, the objective of this study was to investigate the magnitude and associated factors of anxiety among clients on highly active antiretroviral therapy in public hospitals of Southern Ethiopia. Methods An institution-based cross-sectional study was conducted in public hospitals of Southern Ethiopia. Simple random sampling method was used to recruit study participants. Data collection was done by using a structured questionnaire regarding medical data related to HIV/AIDS. Seven items of the Hospital Anxiety and Depression Scale (HADS) were also used to measure the anxiety level. Oslo social support scale and perceived stigma scale were used to measure social support and stigma respectively. Bivariate and multivariate logistic regression analyses were computed with 95% CI to identify different explanatory variables. Significance was declared at p<0.05. Multi-collinearity was checked by variance inflation factors and Hosmer-Lemeshow test was used to check model fitness. Results Prevalence of anxiety among clients on HAART in selected public hospitals of Southern Ethiopia was found to be 25.6%. Females (AOR=3.24, 95% CI [1.32, 7.97]), being widowed (AOR=5.47, 95% CI [1.08, 29.72], monthly income 1425-2280 Ethiopian birr (AOR=7.29, 95% CI [2.55, 20.88]), comorbid conditions (AOR=5.47, 95% CI [1.92, 15.62]), perceived stigma (AOR=8.34, 95% CI [3.49, 19.91]) were factors associated with anxiety. Conclusion Approximately one-fourth of participants living with HIV/AIDS had anxiety. Being female, widowed, medium income, comorbid conditions, and perceived stigma were significantly associated with anxiety. This finding highlights the importance of mental health assessment, early detection and treatment of anxiety as an integral component of HIV/AIDS care.
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Affiliation(s)
- Temesgen Kechine
- School of Nursing, College of Medicine and Health Science, Wachemo University, Hosaena, Ethiopia
| | - Tilahun Ali
- Department of Psychiatry, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia,Correspondence: Tilahun Ali, Department of Psychiatry, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia, Email
| | - Teshager Worku
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Lemesa Abdisa
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Tesfaye Assebe Yadeta
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Mohamad Fisal ZA, Minhat HS, Mohd Zulkefli NA, Ahmad N. Biopsychosocial approach to understanding determinants of depression among men who have sex with men living with HIV: A systematic review. PLoS One 2022; 17:e0264636. [PMID: 35286312 PMCID: PMC8920233 DOI: 10.1371/journal.pone.0264636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 02/14/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Men who have sex with men (MSM) living with HIV are more likely to be depressed than MSM without HIV. The AIDS epidemic will not end if the needs of people living with HIV and the determinants of health are not being addressed. Compared to HIV individuals without depression, depressed HIV individuals have worse clinical outcomes and higher mortality risk. Depression is caused by a complex combination of social, psychological, and biological variables. This systematic review, thereby motivated by the need to address this gap in the literature, aims to articulate determinants of depression among MSM living with HIV according to the biopsychosocial approach. METHODOLOGY We systematically searched four databases from 2011 to 2021. We searched for observational studies on determinants of depression among MSM living with HIV. The outcome is depression based on the categorical or numerical outcome. Two reviewers independently extracted data and assessed study risks of bias. Any disagreements are consulted with the third reviewer. RESULTS We identified 533 articles, of which only eight studies are included. A total of 3,172 MSMs are included in the studies. We found the determinants of depression and categorized them according to biological, psychological, and social approaches. CONCLUSION The determinants of depression with the strongest evidence across studies were enacted HIV-related stigma, unemployment, sleep disturbance, current smoker, black ethnicity, born overseas, ART initiation, and access to mental health care. Despite weaker evidence, the other relevant determinants to be included were older age, internalized stigma, self-efficacy, and social support. Efforts to improve or prevent depression among MSM living with HIV could benefit from addressing the determinants of depression based on the biopsychosocial approach immediately after HIV diagnosis. Integrating mental health screening and care into HIV treatment settings would strengthen HIV prevention and care outcomes and improve access to mental healthcare.
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Affiliation(s)
- Zul Aizat Mohamad Fisal
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- * E-mail:
| | - Halimatus Sakdiah Minhat
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Nor Afiah Mohd Zulkefli
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Norliza Ahmad
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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Chen S, Hong H, Xu G. Prevalence and related factors of depressive symptoms among HIV/AIDS in Ningbo, China: A cross-sectional study. Front Psychiatry 2022; 13:1004318. [PMID: 36299546 PMCID: PMC9592111 DOI: 10.3389/fpsyt.2022.1004318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/22/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Depressive symptoms were common among HIV/AIDS patients. Previous studies had shown that HIV-infected patients were twice as likely to be diagnosed with depression as the general population. However, only few studies have explored the prevalence and related factors of depressive symptoms among HIV/AIDS in China. MATERIALS AND METHODS A cross-sectional study was conducted to study the prevalence of depressive symptoms among HIV/AIDS from January to December 2021 through the database of HIV/AIDS antiretroviral therapy and psychological evaluation system in Ningbo, China. The Patient Health Questionnaire-2 (PHQ-2) was used to screen for depressive symptoms (PHQ-2 > 0), the Patient Health Questionnaire-9 (PHQ-9) was used to diagnose depressive symptoms, and multivariate Logistic regression model was carried on to evaluate the related factors. RESULTS A total of 3,939 HIV/AIDS patients were enrolled, and the age of initiation of antiretroviral therapy was 37.15 (IQR = 28.41-48.73) years. Among them, 3,230 (82.00%) were male, 3,844 (97.59%) were Han nationality, 1,391 (35.49%) were unmarried, 1,665 (42.27%) were homosexual transmission, and 2,194 (55.70%) were HIV-infected patients. There were 265 patients (6.73%) with depressive symptoms, and the proportion of mild, moderate, moderate and severe depressive symptoms was 4.01% (158/3939), 1.65% (65/3939), 0.76% (30/3939), and 0.30% (12/3939), respectively. Multivariate analysis showed that married [odds ratio (OR) = 0.675, 95% CI = 0.501-0.908], divorced or widowed (OR = 0.571, 95% CI = 0.380-0.860), homosexual transmission (OR = 1.793, 95% CI = 1.349-2.396) were associated with depressive symptoms among HIV/AIDS. CONCLUSION The prevalence of depressive symptoms among HIV/AIDS patients was 6.73% in Ningbo, China. More attention should be paid to the psychological status of unmarried and homosexual HIV/AIDS patients in Ningbo and timely psychological intervention or treatment should be given to those patients with depressive symptoms.
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Affiliation(s)
- Suting Chen
- School of Medicine, Ningbo University, Ningbo, China
| | - Hang Hong
- Ningbo Municipal Center for Disease Control and Prevention, Ningbo, China
| | - Guozhang Xu
- Ningbo Municipal Center for Disease Control and Prevention, Ningbo, China
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Rahmati J, Ahmadi S, Rezaei S, Hosseinifard H, Dehnad A, Shabaninejad H, Aryankhesal A, Ghasemyani S, Alihosseini S, Mansour Kiaee Z, Noorani Mejareh Z, Aghalou S, Ghashghaee A, Shoghi M, Ahmadi Nasab M, Khajehvand A. The worldwide prevalence of anxiety in acquired immune deficiency syndrome patients: A systematic review and meta-analysis. Med J Islam Repub Iran 2021; 35:101. [PMID: 34956947 PMCID: PMC8683796 DOI: 10.47176/mjiri.35.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Anxiety affects social, economic, and physical aspects of daily life in patients with AIDS. Therefore, it is necessary to take preventive measures and design plans to maintain their general health. The present study was the first comprehensive systematic literature review research that examined the worldwide prevalence rate of anxiety in patients with AIDS.
Methods: We searched for papers published in the English language in the major databases including Embase, PubMed, Web of Science, Scopus, Cochrane, and Google Scholar from 2000 to October 2018. There were 40 studies which found to be eligible. These studies were independently evaluated and the collected data were entered in a data extraction form, which was then analyzed by two authors and a third author if necessary. Der Simonian-Laird model was used to estimate the prevalence rate on a Forest plot at the interval confidence of 95%.
Results: The total sample size was 24111, and the total number of people with anxiety was 5546. The results based on the random-effects model showed that the rate of anxiety prevalence in the patients was 25% (CI: 95%, 21% -30%) with heterogeneity of 97.9% and a significance level of p<0.001. The South America continent with a prevalence of 38% (95% CI, 34%-42%) had the highest anxiety prevalence rates and Africa with 19% (95% CI, 12% -29%) had the lowest anxiety prevalence rates.
Conclusion: Based on findings, the prevalence of anxiety in developed countries was partially higher than in underdeveloped countries and the obtained mean in the present study. It can be a significant point for policymakers. Therefore, WHO and the world community should have special plans for these countries.
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Affiliation(s)
- Jeiran Rahmati
- Student Research Committee, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Saba Ahmadi
- Student Research Committee, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Sepideh Rezaei
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Hosseinifard
- Department of Biostatistics, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Afsaneh Dehnad
- Department of Foreign Languages, School of Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hosein Shabaninejad
- Population Health Sciences Institute (PHSI), Newcastle University, Newcastle, UK
| | - Aidin Aryankhesal
- Health Management and Economics Research Centre, Iran University of Medical Sciences, Tehran, Iran.,Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Shabnam Ghasemyani
- Student Research Committee, Faculty of Health Management and Information Sciences Branch, Iran University of Medical Sciences, Tehran, Iran
| | | | - Zahra Mansour Kiaee
- School of Health Management & Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Noorani Mejareh
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Sepideh Aghalou
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Ghashghaee
- School of Public Health, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Mahnaz Shoghi
- Nursing care research center, Nursing and midwifery school, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ahmadi Nasab
- Student Research Committee, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Anahita Khajehvand
- Student Research Committee, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
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10
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Wang N, Wang M, Xin X, Zhang T, Wu H, Huang X, Liu H. Exploring the Relationship Between Anxiety, Depression, and Sleep Disturbance Among HIV Patients in China From a Network Perspective. Front Psychiatry 2021; 12:764246. [PMID: 34744844 PMCID: PMC8569919 DOI: 10.3389/fpsyt.2021.764246] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/22/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Mental disorder of people living with HIV (PLWH) has become a common and increasing worldwide public health concern. We aimed to explore the relationship between anxiety, depression, and sleep disturbance for PLWH from a network perspective. Methods: The network model featured 28 symptoms on the Hospital Anxiety and Depression scale questionnaire and Pittsburgh Sleep Quality Index questionnaire in a sample of 4,091 HIV-infected persons. Node predictability and strength were computed to assess the importance of items. We estimated and compared 20 different networks based on subpopulations such as males and females to analyze similarities and differences in network structure, connections, and symptoms. Results: Several consistent patterns and interesting differences emerged across subgroups. Pertaining to the connections, some symptoms such as S12-S13 ("sleepy"-"without enthusiasm") shown a strong positive relationship, indicating that feeling sleepy was a good predictor of lacking enthusiasm, and vice versa. While other symptoms, such as A3-D3 ("worried"-"cheerful"), were negatively related in all networks, revealing that nodes A3 and D3 were bridge symptoms between anxiety and depression. Across all subgroups, the most central symptom was A7 "panic" and S2 "awake", which had the greatest potential to affect an individual's mental state. While S3 "bathroom" and S5 "cough or snore" shown consistent lower node importance, which would be of limited therapeutic use. Conclusions: Mental conditions of PLWH varied considerably among subgroups, inspiring psychiatrists and clinicians that personalized invention to a particular subgroup was essential and might be more effective during treatment than adopting the same therapeutic schedule.
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Affiliation(s)
- Ni Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Muyu Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Xin Xin
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Tong Zhang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Honglei Liu
- School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
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11
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Fu H, Feng T, Wang T, Wu X, Cai Y, Yang T. Reported prevalence of depression or depressive symptoms among men who have sex with men in China, 2004-2018: A systematic review and meta-analysis. J Affect Disord 2020; 277:192-203. [PMID: 32829195 DOI: 10.1016/j.jad.2020.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Depression is a major mental disorder that imposes a considerable burden on health. Men who have sex with men (MSM) are at high risk for depression. Numerous studies have reported the prevalence of depression or depressive symptoms among MSM in China. However, the estimates have varied substantially between studies. This meta-analysis aimed to establish the pooled prevalence of depression or depressive symptoms among Chinese MSM to attract public attention. METHOD A systematic search of several electronic databases and a subsequent manual search was performed to identify relevant studies. A random effects model was adopted to calculate the pooled prevalence of depression or depressive symptoms. Heterogeneity between studies and publication bias was also assessed. RESULTS A total of 54 articles with a sample size of 21,950 MSM were analysed. The pooled prevalence of depression or depressive symptoms among MSM was 40.0% (95% CI: 37.9%-45.0%). Substantial heterogeneity was observed across individual studies. The pooled summary estimate stratified by screening instruments and cutoff scores ranged from 19.0% to 60.2%. Subgroup analysis indicated that survey dates, sampling method, HIV infection status and occupation can partially contribute to the between-study heterogeneity. LIMITATIONS The findings should be interpreted with caution because of several limitations related to the heterogeneity across studies, sampling method and quality assessment. CONCLUSIONS Overall, the reported prevalence of depression or depressive symptoms among Chinese MSM was fairly high. The study suggested that more attention and effective intervention programmes are urgently provided to prevent and improve mental health issues among Chinese MSM.
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Affiliation(s)
- Hanlin Fu
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, Hunan Province 410078, China; HIV/AIDS Prevention and Control Division, Shenzhen Center for Disease Control and Prevention, Shenzhen, Guangdong Province 518000, China
| | - Tiejian Feng
- HIV/AIDS Prevention and Control Division, Shenzhen Center for Disease Control and Prevention, Shenzhen, Guangdong Province 518000, China
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, Hunan Province 410078, China
| | - Xiaobing Wu
- Department of STD control and prevention, Shenzhen Center for Chronic Disease Control, Shenzhen, Guangdong Province 518020, China
| | - Yumao Cai
- Department of STD control and prevention, Shenzhen Center for Chronic Disease Control, Shenzhen, Guangdong Province 518020, China
| | - Tubao Yang
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, Hunan Province 410078, China.
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12
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Xiao L, Qi H, Wang YY, Wang D, Wilkinson M, Hall BJ, Ungvari GS, Wang G, Xiang YT. The prevalence of depression in men who have sex with men (MSM) living with HIV: A meta-analysis of comparative and epidemiological studies. Gen Hosp Psychiatry 2020; 66:112-119. [PMID: 32818791 DOI: 10.1016/j.genhosppsych.2020.04.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Men who have sex with men (MSM) living with Human Immunodeficiency Virus (HIV) are more likely to suffer from depressive symptoms (depression hereafter). This is a comprehensive meta-analysis of the prevalence of depression in HIV-infected MSM. METHODS Relevant publications were systematically searched in PubMed, PsycINFO, EMBASE, Cochrane Library and Web of Science. Comparative and epidemiological studies with prevalence of depression as measured by the Center for Epidemiological Studies Depression Scale (CES-D) were included. The prevalence of depression was pooled using the random-effects model. RESULTS A total of 18 studies with 7653 MSM with HIV and 3395 MSM without HIV were included in the meta-analysis. The pooled prevalence of depression in MSM living with HIV was 43% (95%CI: 32%-53%). Compared to MSM without HIV, MSM living with HIV were more likely to be depressed (OR = 1.46, 1.05-2.03). Subgroup and meta-regression analyses revealed that different CES-D cut-off values and survey year had significant moderating effects on the prevalence of depression. CONCLUSIONS Depression was common in MSM living with HIV. Considering the negative effects of depression on health outcomes and wellbeing, regular screening for depression and effective treatment and interventions should be developed for this vulnerable population.
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Affiliation(s)
- Le Xiao
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Han Qi
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Yuan-Yuan Wang
- Division of Psychology, Faculty of Health and Life Sciences, De Montford University, Leicester, UK
| | - Di Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Meredith Wilkinson
- Division of Psychology, Faculty of Health and Life Sciences, De Montford University, Leicester, UK
| | - Brian J Hall
- Global and Community Mental Health Research Group, Department of Psychology, University of Macau, Macao SAR, China; Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gabor S Ungvari
- Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia; The University of Notre Dame Australia, Fremantle, Australia
| | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
| | - Yu-Tao Xiang
- Center for Cognition and Brain Sciences, University of Macau, Macao SAR, China.
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13
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Sun S, Pachankis JE, Li X, Operario D. Addressing Minority Stress and Mental Health among Men Who Have Sex with Men (MSM) in China. Curr HIV/AIDS Rep 2020; 17:35-62. [PMID: 31950336 PMCID: PMC7050812 DOI: 10.1007/s11904-019-00479-w] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Men who have sex with men (MSM) in China experience elevated risks of mental health issues in comparison to the general population in China, which contribute to vulnerability to HIV/STI risks and can comprise the effectiveness of HIV prevention efforts. A conceptual framework for understanding this mental health disparity is minority stress theory, which posits that experiences of external prejudice events (i.e., distal stressors) and internal stress processes such as internalized homophobia and concealment (i.e., proximal stressors) contribute to sexual minorities' elevated risk of psychological distress. To deepen the understanding of mental health among Chinese MSM and explore the potential utility of minority stress theory in this population, this paper synthesizes research evidence regarding prevalent mental health issues as well as how minority stress may be linked to psychological health in Chinese MSM. RECENT FINDINGS Results indicate that Chinese MSM experience a high prevalence of several mental health issues including depression, anxiety, suicidal behaviors, and alcohol dependence. This review further reveals minority stress to be an important determinant of psychological distress among Chinese MSM, though evidence is mixed regarding the relationship between proximal minority stress and psychological health. Nonetheless, there is a lack of mental health services and interventions focusing on MSM in China. Culturally relevant, competent, and LGBT-affirmative mental health interventions are needed for Chinese MSM. To guide future intervention research, we provide considerations for reducing minority stress and promoting psychological health among Chinese MSM.
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Affiliation(s)
- Shufang Sun
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, 167 Point St, Providence, RI, 02906, USA.
| | - John E Pachankis
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, University of South Carolina Arnold School of Public Health, Columbia, SC, 29208, USA
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown School of Public Health, Providence, RI, USA
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14
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Yan H, Li X, Li J, Wang W, Yang Y, Yao X, Yang N, Li S. Association between perceived HIV stigma, social support, resilience, self-esteem, and depressive symptoms among HIV-positive men who have sex with men (MSM) in Nanjing, China. AIDS Care 2019; 31:1069-1076. [PMID: 30942086 DOI: 10.1080/09540121.2019.1601677] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Among Chinese HIV-positive men who have sex with men (MSM), high levels of depression are common. The association between HIV and depression is attributed to several factors, particularly HIV-related stigma. However, to date, how HIV-related stigma leads to depression among Chinese HIV-positive MSM is still unclear. As such, this study aims to examine the relationships between perceived HIV stigma, social support, resilience, self-esteem, and depressive symptoms among HIV-positive MSM in China. We conducted a cross-sectional survey study among 347 HIV-positive MSM from July to August 2016 in Nanjing, China. Measurements were sociodemographic and psychological constructs including perceived HIV stigma, social support, resilience, self-esteem, and depressive symptoms. Structural equation modeling (SEM) was used to examine the relationships among these constructs. Overall,134 (38.6%) participants had depressive symptoms. Perceived stigma was directly associated with depressive symptoms (β = .196, p < .001). Perceived stigma also indirectly affected depressive symptoms (β = .200, p < .001)through social support and self-esteem. Social support (β = -.124, p = .004) and self-esteem (β = -.536, p = .001), but not resilience, were direct predictors of depressive symptoms. Resilience was directly associated with self-esteem (β = .512, p < .001). Perceived HIV stigma could directly and indirectly impact depressive symptoms in HIV-positive MSM. Improving personal self-esteem, resilience and social support might reduce impact of perceived stigma on depressive symptoms among HIV-positive MSM in China.
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Affiliation(s)
- Hong Yan
- a School of Health Sciences , Wuhan University , Wuhan , People's Republic of China
| | - Xiaoyan Li
- a School of Health Sciences , Wuhan University , Wuhan , People's Republic of China
| | - Jingjing Li
- b Behavioral Sciences and Health Education, Rollins School of Public Health , Emory University , Atlanta , USA
| | - Wei Wang
- a School of Health Sciences , Wuhan University , Wuhan , People's Republic of China
| | - Yinmei Yang
- a School of Health Sciences , Wuhan University , Wuhan , People's Republic of China
| | - Xing Yao
- a School of Health Sciences , Wuhan University , Wuhan , People's Republic of China
| | - Ningxi Yang
- a School of Health Sciences , Wuhan University , Wuhan , People's Republic of China
| | - Shiyue Li
- a School of Health Sciences , Wuhan University , Wuhan , People's Republic of China
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15
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A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries. BMC Med 2019; 17:17. [PMID: 30764819 PMCID: PMC6376728 DOI: 10.1186/s12916-019-1250-8] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/02/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions. METHODS We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations. RESULTS Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes. CONCLUSIONS Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.
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16
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Wang T, Fu H, Kaminga AC, Li Z, Guo G, Chen L, Li Q. Prevalence of depression or depressive symptoms among people living with HIV/AIDS in China: a systematic review and meta-analysis. BMC Psychiatry 2018; 18:160. [PMID: 29855289 PMCID: PMC5984474 DOI: 10.1186/s12888-018-1741-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/11/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The number of people living with HIV/AIDS (PLHA) in China continues to increase. Depression, a common mental disorder in this population, may confer a higher likelihood of worse health outcomes. An estimate of the prevalence of this disorder among PLHA is required to guide public health policy, but the published results vary widely and lack accuracy in China. The goal of this study was to estimate the pooled prevalence of depression or depressive symptoms among PLHA in China. METHODS A systematic literature search of several databases was conducted from inception to June 2017, focusing on studies reporting on depression or depressive symptoms among PLHA in China. The risk of bias of individual studies was assessed using a modified version of the Newcastle-Ottawa scale. The overall prevalence estimates were pooled using random-effects meta-analysis. Differences according to study-level characteristics were examined using stratified meta-analysis and meta-regression. RESULTS Seventy-four observational studies including a total of 20,635 PLHA were included. The pooled prevalence of depression or depressive symptoms was 50.8% (95% CI: 46.0-55.5%) among general PLHA, 43.9% (95% CI: 36.2-51.9%) among HIV-positive men who have sex with men, 85.6% (95% CI: 64.1-95.2%) among HIV-positive former blood/plasma donors, and 51.6% (95% CI: 31.9-70.8%) among other HIV-positive populations. Significant heterogeneity was detected across studies regarding these prevalence estimates. Heterogeneity in the prevalence of depression among the general population of PLHA was partially explained by the geographic location and baseline survey year. CONCLUSIONS Because of the significant heterogeneity detected across studies regarding these prevalence estimates of depression or depressive symptoms, the results must be interpreted with caution. Our findings suggest that the estimates of depression or depressive symptoms among PLHA in China are considerable, which highlights the need to integrate screening and providing treatment for mental disorders in the treatment package offered to PLHA, which would ultimately lead to better health outcomes in PLHA.
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Affiliation(s)
- Tingting Wang
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan Province China
| | - Hanlin Fu
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan Province China
| | - Atipatsa Chiwanda Kaminga
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan Province China ,grid.442592.cDepartment of Mathematics, Mzuzu University, Mzuzu 2, Malawi
| | - Zhanzhan Li
- 0000 0001 0379 7164grid.216417.7Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan Province China
| | - Guiping Guo
- 0000 0004 1803 0208grid.452708.cDepartment of Medical Psychology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province China
| | - Lizhang Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China.
| | - Qiongxuan Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China.
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17
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Chen WT, Shiu C, Yang JP, Li CSR, Wang K, Zhang L, Zhang J, Bao M, Aung MN, Chen LC, Zhao H, Lu H. Substance use, anxiety, and self-management efficacy in HIV-positive individuals: A mediation analysis. JOURNAL OF SUBSTANCE USE 2018; 23:408-414. [PMID: 30906222 DOI: 10.1080/14659891.2018.1436603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Context In China, the social stigma of both substance use and HIV remains major barriers. HIV+ individuals have been demonstrated to have higher psychosocial distress in the literature. To ensure quality of life among HIV+ Chinese individuals, self-efficacy in HIV-related management including substance use and anxiety is the key to suppress viral load and maintain healthy lives. Objectives We examine the mediation relationship among substance use, anxiety, and self-management efficacy. Method A cross-sectional study design was used. 137 HIV+ individuals were recruited from two premier Chinese hospitals: Beijing's Ditan Hospital and Shanghai's Public Health Clinic Center (SPHCC). Results HIV+ substance users had significantly lower HIV-management efficacy and higher anxiety scores. About a third of the relations between substance use and anxiety was mediated by HIV-management self-efficacy. Those who used substances in the previous week had higher anxiety levels suggesting the presence of a recent effect. Their higher levels of anxiety could be largely explained by their lower HIV-management efficacy. Conclusion It is useful for healthcare providers to assess substance use behaviors in HIV+ individuals as well as provide support in managing anxiety in this population. Meanwhile, enhancing self-management efficacy to ensure healthy lifestyles may support achieving optimal lives with HIV.
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Affiliation(s)
- Wei-Ti Chen
- School of Nursing, University of California Los Angeles, Los Angeles, CA
| | - Chengshi Shiu
- School of Nursing, University of California Los Angeles, Los Angeles, CA
| | - Joyce P Yang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Chiang-Shan Ray Li
- Psychiatry and of Neuroscience, School of Medicine, Yale University, New Haven, CT
| | - Kerong Wang
- Ditan Hospital, Capital Medical University, Beijing, China
| | - Lin Zhang
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Jing Zhang
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Meijuan Bao
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | | | - Li-Chen Chen
- National Cheng Kung University, School of Nursing, Tainan, Taiwan
| | - Hongxin Zhao
- Ditan Hospital, Capital Medical University, Beijing, China
| | - Hongzhou Lu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
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18
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Huang X, Meyers K, Liu X, Li X, Zhang T, Xia W, Hou J, Song A, He H, Li C, He S, Cai W, Zhong H, Huang C, Liu S, Wang H, Ling X, Ma P, Ye R, Xiao G, Li T, Ding D, Yaffe K, Chen H, Chen Y, Wu H. The Double Burdens of Mental Health Among AIDS Patients With Fully Successful Immune Restoration: A Cross-Sectional Study of Anxiety and Depression in China. Front Psychiatry 2018; 9:384. [PMID: 30197608 PMCID: PMC6117419 DOI: 10.3389/fpsyt.2018.00384] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/30/2018] [Indexed: 12/31/2022] Open
Abstract
Background: Anxiety and depression continue to be significant comorbidities for people with HIV infection. We investigated the prevalence of and factors associated with anxiety and depression among adult HIV-infected patients across China. Methods: In this cross-sectional study, we described clinical and psychosocial variables related to depression and anxiety in 4103 HIV-infected persons. Doctors assessed anxiety and depression by asking patients whether they had experienced anxiety or depression in the prior month. Patients also self-administered the Hospital Anxiety and Depression (HAD) scale; those with score ≥8 on HAD-A/D were considered to be at high risk of anxiety or depression. Results: Associations between socio-demographic, psychosocial, and ART-related clinical factors and risk of depression or anxiety were investigated using multivariable logistic regression. Among patients assessed between 9/2014 and 11/2015, 27.4% had symptoms of anxiety, 32.9% had symptoms of depression, and 19.0% had both. Recentness of HIV diagnoses (P = 0.046) was associated with elevated odds of anxiety. Older age (P = 0.004), higher educational attainment (P < 0.001), employment (P = 0.001), support from family / friends (P < 0.001), and sleep disturbance (P < 0.001), and number of ART regimen switches (P = 0.046) were associated with risk of depression, while neither sex nor transmission route showed any associations. There were no significant associations with HIV-specific clinical factors including current CD4+ T cell count and current viral load. Conclusions: Prevalence of symptoms of anxiety and depression is high in this cohort of treatment-experienced HIV patients. Psychological and social-demographic factors, rather than HIV disease status, were associated with risk of depression and anxiety. This finding highlights the need to deliver interventions to address the mental health issues affecting HIV-infected persons with fully successful immune restoration across China.
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Affiliation(s)
- Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Kathrine Meyers
- The Aaron Diamond AIDS Research Center, The Rockefeller University, New York, NY, United States
| | - Xinchao Liu
- Infectious Diseases Department, Peking Union Medical College Hospital, Beijing, China
| | - Xia Li
- Infectious Diseases Department, Yunnan AIDS Care Center, Kunming, China
| | - Tong Zhang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Wei Xia
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Jiahua Hou
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Aixin Song
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Haolan He
- Institute of Infectious Diseases, The Eighth People's Hospital of Guangzhou, Guangzhou, China
| | - Chongxi Li
- Infectious Diseases Department, The Third People's Hospital of Kunming, Kunming, China
| | - Shenghua He
- Institute of Infectious Diseases, The Eighth People's Hospital of Guangzhou, Guangzhou, China
| | - Weiping Cai
- Institute of Infectious Diseases, The Eighth People's Hospital of Guangzhou, Guangzhou, China
| | - Huolin Zhong
- Institute of Infectious Diseases, The Eighth People's Hospital of Guangzhou, Guangzhou, China
| | - Chengyu Huang
- Department of Infectious Diseases, Chongqing Infectious Disease Medical Center, Chongqing, China
| | - Shuiqing Liu
- Department of Infectious Diseases, Guiyang Public Health Clinical Center, Guiyang, China
| | - Hui Wang
- Department of Clinical AIDS Research, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Xuemei Ling
- Department of Hematology, The Third People's Hospital of Hengyang, Hengyang, China
| | - Ping Ma
- Department of Infectious Disease, The Second Affiliated Hospital of Medical School of the Southeast University, Tianjin, China
| | - Rongxia Ye
- Department of Infectious Diseases, The Sixth People's Hospital of Hangzhou, Hangzhou, China
| | - Gang Xiao
- Department of Infectious Diseases, The First Hospital of Changsha, Changsha, China
| | - Taisheng Li
- Infectious Diseases Department, Peking Union Medical College Hospital, Beijing, China
| | - Ding Ding
- Shanghai Public Health Clinical Center, Shanghai, China
| | - Kristine Yaffe
- Department of Psychiatric and Neurology and Department of Epidemiology and Statistics, University of California, San Francisco, San Francisco, CA, United States
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Yaokai Chen
- Department of Infectious Diseases, Chongqing Infectious Disease Medical Center, Chongqing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
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19
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Huang X, Li H, Meyers K, Xia W, Meng Z, Li C, Bai J, He S, Cai W, Huang C, Liu S, Wang H, Ling X, Ma P, Tan D, Wang F, Ruan L, Zhao H, Wei H, Liu Y, Yu J, Lu H, Wang M, Zhang T, Chen H, Wu H. Burden of sleep disturbances and associated risk factors: A cross-sectional survey among HIV-infected persons on antiretroviral therapy across China. Sci Rep 2017. [PMID: 28623361 PMCID: PMC5473875 DOI: 10.1038/s41598-017-03968-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This study evaluated the prevalence and factors associated with sleep disturbance in a large cohort of HIV-infected patients across China. A cross-sectional study was conducted among HIV-infected patients on antiretroviral therapy at 20 AIDS clinics. The Pittsburgh Sleep Quality Index was self-administered by subjects. Socio-demographic characteristics, medical history and HIV-related clinical data were collected. 4103 patients had complete data for analysis. Sleep disturbances were observed in 43.1% of patients. Associated factors in multivariable analysis included psychological factors: anxiety (odds ratio [OR], 3.13; 95% confidence interval [CI], 2.44–4.00; P < 0.001), depression (OR, 2.09; 95% CI, 1.70–2.57; P < 0.001), and both anxiety and depression (OR, 5.90; 95% CI, 4.86–7.16; P < 0.001); sociodemographic factors: MSM (OR, 1.26; 95% CI, 1.04–1.52; P = 0.018), being single (OR, 1.45; 95%CI 1.21–1.74; P < 0.001), higher education (OR, 1.25; 95% CI, 1.03–1.53; P = 0.025); and clinical factors: suboptimal adherence (OR,1.51; 95% CI,1.23–1.85; P < 0.001), regimen-switching (OR, 1.94; 95% CI, 1.12–3.35; P = 0.018), and antidepressant use (OR, 1.98; 95% CI, 1.47–2.67; P = 0.044). Prevalence of sleep disturbance is high in this large Chinese cohort. Associated factors appear related to psychological and social-demographic factors. Health workers may consider routinely assessing sleep disturbances among HIV-infected patients, especially in the first three months after HIV diagnosis, and referring for mental health services, which may positively impact adherence to treatment.
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Affiliation(s)
- Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China
| | - Huiqin Li
- Infectious Diseases Department, Yunnan AIDS Caring Center, Kunming, Yunnan, 650301, China
| | - Kathrine Meyers
- The Aaron Diamond AIDS Research Center, New York, NY, 10016, United States
| | - Wei Xia
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China
| | - Zhihao Meng
- Infectious Diseases Department, Longtan Hospital of Guangxi, Liuzhou, Guangxi, 545005, China
| | - Chongxi Li
- Infectious Diseases Department, the Third People's Hospital of Kunming, Kunming, Yunnan, 650041, China
| | - Jinsong Bai
- Infectious Diseases Department, the Third People's Hospital of Kunming, Kunming, Yunnan, 650041, China
| | - Shenghua He
- Infectious Diseases Department, the Infectious Diseases Hospital of Chengdu, Chengdu, Sichuan, 610061, China
| | - Weiping Cai
- Institute of Infectious Diseases, the Eighth People's Hospital of Guangzhou, Guangzhou, Guangdong, 510060, China
| | - Chengyu Huang
- Department of AIDS, Chongqing Infectious Disease Medical Center, Chongqing, 400039, China
| | - Shuiqing Liu
- Department of Infectious Diseases, the Fifth People's Hospital of Guiyang, Guiyang, Guizhou, 550004, China
| | - Hui Wang
- Department of Clinical AIDS Research, the Third People's Hospital of Shenzhen, Shenzhen, Guangdong, 518020, China
| | - Xuemei Ling
- Department of Hematology, the Third People's Hospital of Hengyang, Hengyang, Hunan, 421000, China
| | - Ping Ma
- Department of Infectious Diseases, the Second People's Hospital of Tianjin, Tianjin, 300193, China
| | - Daling Tan
- Department of Infectious Diseases, the People's Hospital of Luzhai, Liuzhou, Guangxi, 545600, China
| | - Fuxiang Wang
- Department of Infectious Diseases, the First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, 150001, China
| | - Lianguo Ruan
- Department of Infectious Diseases, Wuhan Medical Treatment Center, Wuhan, Hubei, 430023, China
| | - Hongxin Zhao
- Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, China
| | - Hongxia Wei
- Department of Infectious Diseases, the Second Hospital of Nanjing Affiliated to Southeast University Medical College, Nanjing, Jiangsu, 210003, China
| | - Yanfen Liu
- Department of Infectious Diseases, the Fourth People's Hospital of Nanning, Nanning, Guangxi, 530023, China
| | - Jianhua Yu
- Department of Infectious Diseases, the Sixth People's Hospital of Hangzhou, Hangzhou, Jiangsu, 310023, China
| | - Hongzhou Lu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center Affiliated to Fudan University, Shanghai, 200083, China
| | - Min Wang
- Department of Infectious Diseases, the First People's Hospital of Changsha, Changsha, Hunan, 410005, China
| | - Tong Zhang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, 100069, China.
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, 100069, China.
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Brandt CP, Paulus DJ, Jardin C, Heggeness L, Lemaire C, Zvolensky MJ. Examining anxiety sensitivity as an explanatory construct underlying HIV-related stigma: Relations to anxious arousal, social anxiety, and HIV symptoms among persons living with HIV. J Anxiety Disord 2017; 48:95-101. [PMID: 27527687 PMCID: PMC5293677 DOI: 10.1016/j.janxdis.2016.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/04/2016] [Accepted: 08/05/2016] [Indexed: 12/01/2022]
Abstract
Persons living with HIV (PLHIV) are a health disparity subgroup of the overall population for mental and physical health problems. HIV-related stigma has been shown to increase anxiety symptoms and HIV symptoms among PLHIV. However, little is known about factors that may impact the relations between HIV-related stigma and anxiety symptoms and HIV symptoms among PLHIV. To address this gap in the literature, the current study examined anxiety sensitivity (i.e., the extent to which individuals believe anxiety and anxiety-related sensations) in the relation between HIV-related stigma, social anxiety, anxious arousal, and HIV symptoms among a sample of 87 PLHIV (60.9% cis gender male, 52.9% Black, non-Hispanic). Results indicated that anxiety sensitivity mediated the relations between HIV-related stigma and the dependent variables, with effect sizes indicating moderate to large effects of anxiety sensitivity on these relations. Findings suggest that anxiety sensitivity be a mechanistic factor in the relations between HIV-related stigma and social anxiety, anxious arousal, and HIV symptoms, and therefore, be important element in efforts to reduce mental/physical health disparity among this population.
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Affiliation(s)
- Charles P. Brandt
- University of Houston, Department of Psychology. 3695 Cullen Blvd. Room 126, Houston, Texas 77204,Baylor College of Medicine. 1 Baylor Plaza, Houston, Texas 77030,Corresponding author may be reached at
| | - Daniel J. Paulus
- University of Houston, Department of Psychology. 3695 Cullen Blvd. Room 126, Houston, Texas 77204
| | - Charles Jardin
- University of Houston, Department of Psychology. 3695 Cullen Blvd. Room 126, Houston, Texas 77204
| | - Luke Heggeness
- Kent State University, Department of Psychology. 144 Kent Hall, Kent, Ohio 44242
| | - Chad Lemaire
- Legacy Community Health. 1415 California St, Houston, Texas 77006
| | - Michael J. Zvolensky
- University of Houston, Department of Psychology. 3695 Cullen Blvd. Room 126, Houston, Texas 77204,The University of Texas MD Anderson Cancer Center, Department of Behavioral Science. 1515 Holcombe Blvd, Houston, Texas 77030
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21
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Relationship of Stigma and Depression Among Newly HIV-Diagnosed Chinese Men Who Have Sex with Men. AIDS Behav 2017; 21:292-299. [PMID: 27376900 DOI: 10.1007/s10461-016-1477-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Little is known about the relationship between HIV stigma and depression among newly diagnosed HIV-infected men who have sex with men (MSM). We measured HIV-related stigma and current depression using standard scales among 367 Chinese MSM who had been diagnosed very recently with HIV infection, analyzing key associations with multivariable ordinal logistic regression. Current depression prevalence was 36 %. Median scores for felt, vicarious, and internalized stigma were 17, 2, and 5, respectively, each on a 0-30 scale. A one-point increase in the total stigma score was associated with a 4 % increase in the odds of current depression [adjusted odds ratio (aOR) = 1.04, 95 % confidence interval (CI) 1.03-1.05]. Internalized stigma had the strongest association with depression (aOR = 1.09, 95 % CI 1.07-1.12). Effective interventions to address coping with HIV-related stigma immediately following HIV-diagnosis might help reduce depression, improve long-term mental health, and improve engagement in their care.
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22
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Hidru TH, Wang F, Lolokote S, Jia Y, Chen M, Tong W, Li XF. Associated factors of self-reported psychopathology and health related quality of life among men who have sex with men (MSM) with HIV/AIDS in Dalian, China: a pilot study. Infect Dis Poverty 2016; 5:108. [PMID: 27903303 PMCID: PMC5131411 DOI: 10.1186/s40249-016-0204-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 10/24/2016] [Indexed: 01/25/2023] Open
Abstract
Background Despite the availability of Anti-Retroviral Therapy (ART), the health-related quality of life (HRQoL) among HIV-positive men who have sex with men (HIVMSM) in China remains poor. This study aimed to explore the relationship between self-reported psychopathology and HRQoL among HIVMSM in Dalian, China. Methods A cross-sectional study was conducted in 112 HIVMSM. Symptom check list 90 (SCL 90): a measure of psychopathology and World Health Organization quality of life in HIV infection (WHOQOL-HIV-Bref): a measure of HRQoL were used. Correlation and multiple regression analysis were employed to explore the association between self-reported psychopathology and HRQoL in HIVMSM. Results Out of the total 112 HIVMSM cases, 9 (8 %) cases were homosexuals and 103 (92 %) ones were bisexuals. The participants who had low family income (P = 0.001), perceived discrimination (P = 0.001) and lack of regular attendance in medical follow-ups (P = 0.014) reported poorer HRQoL than their counterparts. Somatization, obsession, depression, phobia and overall SCL 90 scores in self-reported psycholpathology had a negative impact on the domains of HRQoL among HIVMSM. Conclusions Total quality of life was predicted by family income, perceived discrimination, and medical follow-up attendance. Self-reported psychopathology was negatively correlated with HRQoL in HIVMSM. The Strategies that target MSM focusing on linking and engaging HIV-positive patients in medical care is the key step to improve their HRQoL. More emphasis is needed on the newly diagnosed HIVMSM in Dalian in order to develop a more targeted intervention to prevent perceived discrimination and lack of proper medical follow-up services. Trial registration The trial registration number does not require for this manuscript. The study is cross-sectional design that do not involve intervention at all, it is not a clinical trial. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0204-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tesfaldet Habtemariam Hidru
- Department of Epidemiology and Biostatistics, Dalian Medical University, Dalian, Liaoning, 116044, People's Republic of China
| | - Feng Wang
- Department of Epidemiology and Biostatistics, Dalian Medical University, Dalian, Liaoning, 116044, People's Republic of China
| | - Sainyugu Lolokote
- Department of Epidemiology and Biostatistics, Dalian Medical University, Dalian, Liaoning, 116044, People's Republic of China
| | - Yong Jia
- School of Public Health, Dalian Medical University, Dalian, Liaoning, 116044, People's Republic of China
| | - Min Chen
- School of Public Health, Dalian Medical University, Dalian, Liaoning, 116044, People's Republic of China
| | - Wei Tong
- Department of HIV/AIDS, Dalian Center for Disease Control and Prevention, Dalian, 116023, Liaoning, People's Republic of China
| | - Xiao-Feng Li
- Department of Epidemiology and Biostatistics, Dalian Medical University, Dalian, Liaoning, 116044, People's Republic of China.
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