ORIGINAL RESEARCH

published: 07 May 2019

doi: 10.3389/fpsyt.2019.00290

Depression, Anxiety and Their

Correlates Among Patients With HIV
in South Ethiopia: An Institution-
Based Cross-Sectional Study
Bereket Duko 1*, Alemayehu Toma 2, Solomon Asnake 2 and Yacob Abraham 1

Faculty of Health Sciences, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia, 2 Faculty of Medical
1 

Sciences, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia

Background: Depressive and anxious symptoms are more regularly seen in HIV-
infected people than in the general population. This investigation planned to evaluate the
magnitude and factors related to depressive and anxiety symptoms among HIV patients
in South Ethiopia, 2018.
Edited by: Methods: This was an institution-based cross-sectional study directed among 363 HIV-
Yuan-Pang Wang,
University of São Paulo, infected individuals who had a customary visit at Hawassa University Comprehensive
Brazil Specialized Hospital and Yirgalem Hospital, Ethiopia, who were incorporated into the
Reviewed by: study through systematic sampling techniques. The hospital anxiety and depression
Asres Bedaso Tilahune,
scale (HADS) was utilized to take a look at anxious and depressive symptoms.
Hawassa University,
Ethiopia Results: The mean age of the respondents was 37.66 years (SD ±10.03). The prevalence
Minale Tareke,
Bahir Dar University, of depression and anxiety were 32.0% and 34.4%, respectively. Patients who were living
Ethiopia alone [AOR = 1.94, (95% CI: 1.06, 3.56)], had poor social support [AOR = 5.57, (95%
*Correspondence: CI: 1.20, 10.84)] or had HIV-related perceived stigma [AOR = 2.35, (95% CI: 1.44, 3.84)]
Bereket Duko
were more likely to have depression as compared to their counterparts. Those with a
berkole.dad@gmail.com
orcid.org/0000-0002-4419-0016 previous history of mental illness [AOR = 3.36, (95% CI: 1.31, 8.61)] and poor social
support [AOR = 6.67, (95% CI: 1.47, 10.33)] were more likely to have anxiety symptoms.
Specialty section:
This article was submitted to Conclusion: The prevalence of anxiety and depression in the current study was high.
Mood and Anxiety Disorders, Concerned health departments of the country should create guidelines to screen and
a section of the journal
treat depression and anxiety among HIV patients. Further research on hazard factors of
Frontiers in Psychiatry
depression and anxiety ought to be examined to strengthen and expand these findings.
Received: 12 March 2019
Accepted: 15 April 2019
Keywords: depressive symptom, anxiety symptom, perceived stigma, social support, HIV, Ethiopia
Published: 07 May 2019

Citation:
Duko B, Toma A, Asnake S and
BACKGROUND
Abraham Y (2019) Depression,
Anxiety and Their Correlates
Human immunodeficiency virus (HIV) remains a noteworthy social issue worldwide in general
Among Patients With HIV in
South Ethiopia: An Institution-
and, in low- and middle-income nations specifically, where a considerable number of individuals
Based Cross-Sectional Study. living with HIV/AIDS (PLWHA) can be found. The WHO in 2017 reported that an estimated
Front. Psychiatry 10:290. 36.7 million individuals were living with HIV infection and AIDS, with 2.1 million new cases and
doi: 10.3389/fpsyt.2019.00290 1.1 million deaths as a result of HIV-associated causes (1).

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Duko et al. Depression and Anxiety Among HIV Patients

Since 1990, HIV infection-associated death has reduced required sample size using a 95% confidence interval and a
due to the introduction of active antiretroviral therapy (ART). 5% margin of error using the prevalence of depression and
Thus, people who are living with HIV/AIDS have begun to live anxiety: (larger proportion) proportion = 38.94% (17). Study
longer. Nevertheless, people with HIV/AIDS are prone to mental participants were allocated to their respective study setting
illness, especially depression and anxiety, because of sexual-related through a proportional allocation method. The study population
problems, social and perceived stigma, the undesirable effects was incorporated through a systematic sampling technique,
of antiretroviral treatment and neurophysiological changes K = 4. A total of 363 individuals with HIV who had follow-up
(2, 3). Investigations indicated that as compared to HIV-negative for treatment were recruited for the study. The study participants
individuals or the general population, depression occurs at rates two who had hearing problems, patients who had known severe
to four times higher in HIV-positive individuals (4–9). It has been psychiatric illness or those who needed intensive care therapy
observed to be related with higher HIV viral loads and lower CD4 were not interviewed.
number, even in the wake of controlling for the impacts of adherence, Data collection: Experienced and trained psychiatry
which predict illness advancement and mortality (6, 10–12). nurses gathered the data using interviewer-administered
Among psychiatric problems when compared with the general questioner. The data collection instrument incorporated
population, anxiety and depression are commonly found in HIV- socio-economic as well as demographic characteristics and
affected people (6–10). Depression is a conceivably hazardous clinically-related factors depicting questions. HIV-associated
condition that can impact not just personal satisfaction, stigma was assessed through the 11-item HIV stigma scale.
connections, work and adherence to therapeutic consideration, This scale comprised of four-point Likert questions concerning
as well as possibly survival. The effect of mental health problems apparent isolation, shame, blame or guilt and disclosure of
on HIV patients is frequently underestimated and is more critical HIV status. The item scores of this scale questions summed
in resource-constrained settings, which is due to an absence of to build a sole stigma variable. Study participants were
training for health care providers, lack of awareness among HIV classified as having or not having seen stigma utilizing the
patients and lack of guidelines to manage psychiatric disorders in mean of the stigma scale (≥18.38 or ≥5.86) (20, 21). The
HIV clinics (13, 14). Oslo 3-item social support scale was utilized to collect social
People living with HIV/AIDS are increasingly inclined to support related issues. It has a total score scale running from
display anxious and depressive symptoms which, thus, affects the 3 to 14 with three general classifications: “poor support”
stigma associated with the illness, decreases personal satisfaction, 3–8, “moderate support” 9–11 and “strong support” 12–14
increases mortality, lessens medication adherence and impedes (22). Anxious and depressive symptoms were assessed using
their capacity to resist disease (13–16). Having low income, being the Hospital Anxiety and Depression Scale (HADS). This is
widowed, being female, having no job, substance abuse including a 14-item questionnaire used to screen for manifestations of
alcohol, non-adherence to medication, low educational status depression and anxiety symptoms. It was approved for local
and being in stage III and stage IV were factors that contribute use in Ethiopia, and its internal consistency was 0.78 for
to depression and anxiety among HIV patients (17–19). These anxiety, 0.76 for depression subscales and 0.87 for both scales.
show that anxiety and depression greatly affect these patient The scales utilize a cut-off point for anxiety and depression
populations’ treatment outcomes. >8 (23).
Therefore, this study aimed to assess the magnitude and Data Processing and Analyses: The collected data was
correlates of depressive and anxious symptom among HIV patients checked for comprehensiveness, consistency and, at that
in South Ethiopia. point data was coded, cleaned and entered into EPI info
version 7. SPSS version 22 was utilized to examine the data.
The association of every independent variable with the
METHODS dependent variable was assessed by bivariate analysis. In
order to distinguish potential confounders, a multi-variable
Study design and setting: This research was undertaken as an logistic regression model was utilized. A p-value of under 0.05
institution-based cross-sectional study at Hawassa University was considered statistically significant, and adjusted odds
Comprehensive Specialized Hospital (HUCSH) and Yirgalem ratio with 95% CI was determined to decide the association.
General Hospital (YGH), South Ethiopia, from January 22, Finally, the information was displayed by utilizing numbers,
2018 to March 22, 2018. HUCSH is the only comprehensive frequencies, tables, graphs and figures.
specialized university hospital in the region, and it is situated at
Hawassa city, 273km from Addis Ababa, the capital of Ethiopia.
This hospital started delivering service in 2004 and provides both RESULTS
outpatient and inpatient services for more than 18 million people
in its catchment area. The hospital has over 400 beds for inpatient Socio-Demographic Characteristics
service. YGH is in the town of Yirgalem, which is 42km from of the Study Participants
Hawassa City and was established in 1966, delivers both inpatient A total of 363 study participants were selected for the investigation
and outpatient services to about 4.2 million people. with a participation rate of 98.1%. The mean (±SD) age of the
Sample size determination and sampling procedure: A respondents was 37.66 years (±10.03). Among the investigation
single-population proportion formula was used to obtain the participants, 239 (65.8%) were females, 165 (45.5%) had primary

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Duko et al. Depression and Anxiety Among HIV Patients

TABLE 1 | Socio-demographic characteristics of people living with HIV/AIDS at TABLE 2 | Clinical and psychosocial characteristics of people living with HIV/
Hawassa University Comprehensive Specialized Hospital and Yirgalem Hospital, AIDS at Hawassa University Comprehensive Specialized Hospital and Yirgalem
South Ethiopia, 2018. Hospital, South Ethiopia, 2018.

Characteristics Category Frequency Percent (%) Variables Category Frequency Percent %

Sex Male 124 34.2 CD4 cell count <200 29 8.0

Female 239 65.8 200–1000 308 84.8
Age 18–29 71 19.6 ≥1000 26 7.2
30–39 147 40.5 On ART Yes 309 85.1
40–49 99 27.3 No 54 14.9
≥50 46 12.7 Perceived stigma No 187 51.5
Residence Hawassa 213 58.7 Yes 176 48.5
Yirgalem 150 41.3 Current substance Yes 45 12.4
Religion Muslim 54 14.9 No 318 87.6
Orthodox 155 42.7 Social support Poor social 154 42.4
Protestant 122 33.6 support
Catholic 32 8.8 Moderate social 179 49.3
Educational level Unable to write and read 49 13.5 support
Primary school 165 45.5 Strong social 30 8.3
High school 100 27.5 support
Tertiary education 49 13.5 Family history of mental Yes 43 11.8
Marital status Single 67 18.5 illness No 320 88.2
Married 188 51.8 Previous history of mental Yes 23 6.3
Divorced 55 15.2 illness No 340 93.7
Widowed/widower 53 14.6 Partner HIV status Sero-positive 201 55.4
Occupation Housewives 65 17.9 Sero-negative 58 16.0
status Civil servants 81 22.3 Does not have 104 28.7
Privet employee/NGO 30 8.3 partner
Day laborer 27 7.4 Have child/children Yes 220 60.6
Merchants 128 35.3 No 143 39.4
Unemployed 32 8.8 Duration of illness <5 years 11 30.6
Monthly income <2500 ETB per month 266 73.3 5–10 years 183 50.4
2500–5000 ETB 78 21.5 ≥10 years 69 19.0
per month Living status With Family/ 284 78.2
>5000 ETB per month 19 5.2 relatives
Alone 79 21.8
Co-morbid medical Illness TB 38 10.5
Diabetes 19 5.2
school as their maximum level of education, 188 (51.8%) were Heart Diseases 16 4.4
married, 128 (35.3%) were merchants and 128 (35.3%) received Renal diseases 14 3.9
less than 2500 Ethiopian birr per month (Table 1). No co-morbid 276 76.0
illness

Clinical and Psychosocial Characteristics

of the Study Participants DISCUSSION
A total of 309 (85.1%) of the study participants were on ART,
The prevalence of depression in the current study was in line
154 (42.4%) had poor social support, 308 (84.8%) had CD4 cell
with finding from South Africa (24). However, the current
count ranges between 200 and 1000, 220 (60.6%) had a child or
study finding was higher than other studies in Ghana, Nigeria,
children and 45 (12.4%) were currently using substances (alcohol
South Africa and Brazil (18, 25–29). On the other hand, it
and tobacco products) (Table 2).
is lower than other studies in Ethiopia (17, 26, 30), in Delhi
(India) (19), North Central Nigeria (31), in Cameroon 63%
Prevalence of Depressive and Anxiety (32), USA, Denmark (33, 34, China, India and Cameron
Symptoms and Their Correlates (35–37). The prevalence of anxiety symptoms in the current
The magnitude of co-occurring depression and anxiety in study was 34.4%, which is similar with studies conducted
this study was 33.5%, while the prevalence of depression and in Ethiopia (25), USA, South Africa, Canada and Western
anxiety was 32.0% and 34.4%, respectively. Multivariable Europe (17, 37–39). However, the finding was lower than
binary logistic regression analysis revealed that HIV patients studies conducted in Albania and China (19, 27, 32) but
who had no children, were living alone, had perceived HIV higher than studies conducted in Ethiopia, Ghana, Thailand,
related stigma and those who had poor social support were Brazil and Asia (26, 38, 40–42). This study used the hospital
associated with depressive symptoms (Table 3). On the other anxiety and depression scale (HADS) for assessing anxiety and
hand, patients who had a previous history of psychiatric depressive symptoms among HIV patients while others used
illness and poor social support were associated with anxiety the Hamilton depression scale (HDS), Beck’s depression scale
symptoms (Table 4). (BDS), Beck’s anxiety scale (BAS), the State trait anxiety scale

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Duko et al. Depression and Anxiety Among HIV Patients

TABLE 3 | Factors associated with depression among people living with HIV/AIDS at Hawassa University Comprehensive Specialized Hospital and Yirgalem Hospital,
South Ethiopia, 2018.

Characteristics Depression COR (95% CI) AOR (95% CI)

Yes No

Sex Male 90 34 1 1
Female 157 82 1.38, (0.86, 2.23)
Age 18–29 46 25 2.58, (1.04, 6.38)
30–39 91 56 2.92, (1.27, 6.72)
40–49 72 27 1.78, (0.74, 4.30)
≥50 38 8 1 1
Educational level Unable to read & write 30 19 1.95, (0.82, 4.66)
Primary education 115 50 1.34, (0.64, 2.78)
Secondary education 65 35 1.66, (0.77, 3.59)
College and above 37 12 1 1
Marital status Single 38 29 1 1
Married 150 38 0.33, (0.18, 0.61)
Divorced 32 23 0.46, (0.46, 1.94)
Widowed/widower 27 26 1.26, (0.61, 2.60)
Children Have children 164 56 0.47, (0.30, 0.95) 0.53,(0.32, 1.16)
Have no children 82 59 1 1
Living status With family or relatives 210 74 1 1
Alone 37 42 3.22, (1.92, 5.39) 1.94, (1.06, 3.56)**
Perceived stigma Yes 144 43 2.37, (1.51, 3.74) 2.35, (1.44, 3.84)*
No 103 73 1 1
Social support Poor 89 65 10.23, (2.35, 14.46) 5.57, (1.20, 10.84)**
Moderate 130 49 5.28, (1.21, 9.89) 3.75, (0.82,10.24)
Strong 28 2 1 1

*Significant association (p-value < 0.05), **significant association (p-value < 0.01).

TABLE 4 | Factors associated with anxiety among people living with HIV/AIDS at Hawassa University Comprehensive Specialized Hospital and Yirgalem Hospital, South
Ethiopia, 2018.

Characteristics Anxiety COR (95% CI) AOR (95% CI)

Yes No

CD4 count <200 20 9 0.64, (0.15, 2.84)

200–1000 198 110 0.79, (0.22, 2.88)
≥1000 20 6 1 1
Duration of illness <5 years 76 35 1 1
5–10 years 120 63 1.14, (0.68, 1.88)
≥10 years 42 27 1.39, (0.74, 2.62)
Partner HIV status Sero-positive 142 59 0.43, (0.26, 0.71)
Sero-negative 43 15 0.36, (0.18, 0.73)
Don’t have partner 53 51 1 1
Perceived stigma No 124 63 1 1
Yes 114 62 1.07, (0.69,1.65)
Previous history of psychiatric Yes 8 15 3.92,(1.61, 9.53) 3.36, (1.31,8.61)*
illness No 230 110 1 1
Family history of mental illness Yes 30 13 0.81, (0.40, 1.61) 0.65, (0.44, 1.24)
No 208 112 1 1
Social support Poor 83 71 11.98, (2.76, 22.04) 6.67, (1.47, 10.33)*
Moderate 127 52 5.73, (1.32, 14.94) 3.83, (0.85, 8.23)
Strong 28 2 1 1

*Significant association (p-value < 0.05).

(STAS) or Patient health questionnaire item 9 (PHQ9). Socio- Ethiopia (17, 26, 30, 34). HIV is associated with a large
demographic and economic variation could play a vital role amount of stigma and, along these lines, HIV patients might
for the difference in the magnitude of depression and anxiety think it is less demanding to be separated from everyone
between studies from Ethiopia and other studies from other else in order to maintain a strategic distance from stigma or
parts of the world. segregation, or they might not have the vitality to be socially
Study participants who had HIV-related self-felt stigma connected (30–34). Stigma by itself might build dimensions
had more depression when contrasted to their counterparts. of exhaustion and diminishing consideration or feelings
This is in line with other findings in Botswana (43) and in of uselessness.

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Duko et al. Depression and Anxiety Among HIV Patients

People living HIV/AIDS who were living alone were 1.94 General Hospital, Ethiopia. Study participants were informed
times more prone to have depressive symptoms when contrasted about their rights to interrupt the interview at any time and
to those HIV patients who were living with their family or written informed consent was obtained from each study
relatives. Being forlorn is a solid hazard factor for depressive participant. Confidentiality was maintained at all levels of the
symptoms, well beyond proportions of target social interaction study. HIV-positive subjects who were found to have moderate
(44, 45). to severe depressive and anxiety symptoms were referred to
Patients who had poor social support had a statically psychiatry clinics for further investigations.
significant association with depressive and anxiety symptoms
when contrasted to patients with good social support. This is
comparable with other studies in India (19) and in Nigeria (18, DATA AVAILABILITY STATEMENT
19, 22, 26, 31, 32). This may be because of the way that social
separation diminishes social support, which can negatively All relevant data are within the paper.
affect mental and physical prosperity. Likewise, these patients
preferred to abstain from looking for assistance from others
and from opening up about their wellbeing because of social ETHICS STATEMENT
stigma towards themselves, which builds their seclusion and
loneliness (19, 26). Ethical clearance for this study was obtained from the
Lastly, HIV patients with a past history of mental issues were Research and Ethics Review Committee of the College
3.36 times more prone to experiencing anxiety symptoms. It is of Medicine and Health Sciences, Hawassa University.
not clear whether the existence of HIV affects the seriousness Permission letter was obtained from Research and community
of past psychiatric symptoms of patients or not. This may service directorate of the College of Medicine and Health
be because HIV by itself may cause progressively extreme Sciences, Hawassa University and, submitted to Hawassa
symptoms. Moreover, HIV-affected patients with previous University Comprehensive Specialized Hospital and Yirgalem
psychiatric problems presumably demonstrate a relapse of General Hospital. Study participants were informed about
previous illness. their rights to interrupt the interview at any time and written
informed consent was obtained from each study participants.
Confidentiality was maintained at all levels of the study. HIV
Conclusion positive subjects who were found to have moderate to severe
The magnitudes of depression and anxiety among HIV depressive and anxiety symptoms were referred to psychiatry
patients were high (32% and 34.4%, respectively). Perceived clinics for further investigations.
HIV-related stigma, living alone and poor social support had
a significant association with depressive symptoms. Having
a previous history of psychiatric illness and poor social AUTHOR CONTRIBUTIONS
support had a significant association with anxiety symptoms.
Concerned health departments of the country should create BD conceived the study and was involved in the study design,
principles and standards to screen and treat these conditions reviewed the article, analysis, report writing and drafted the
in this patient population. Further research on the hazards of manuscript. AT, YA and SA were involved in the study design and
anxiety and depression ought to be directed to reinforce and proposal development. All authors read and approved the final
widen these findings manuscript.

Study Limitations FUNDING

We did not use standard tools or scales for substance abuse-related
factors. Some important variables like medication adherence and This study was funded by Hawassa University, Ethiopia. The
opportunistic infections were not included. funding only covers the data collection and write up. No funding
received for open access publications and other publication
processing fee.
Ethical Approval and Consent
to Participate:
Ethical clearance for this study was acquired from the Research ACKNOWLEDGEMENTS
and Ethics Review Committee of College of Medicine and
Health Sciences, Hawassa University, Ethiopia. A letter of The authors recognize Hawassa University, Ethiopia for
permission was acquired from the Research and Community financing the investigation. The authors appreciate the data
Service Directorate of the College of Medicine and Health measurement personnel, their supervisors and the respective
Sciences, Hawassa University and submitted to Hawassa study institution for their assistance and the study participants
University Comprehensive Specialized Hospital and Yirgalem for their participation in giving all vital data.

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Duko et al. Depression and Anxiety Among HIV Patients

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with co-occurring HIV and substance use disorders, but only when mood Conflict of Interest Statement: The authors declare that the research was
disorders are present. J Multidiscip Healthc (2013) 6:229–37. doi: 10.2147/ conducted in the absence of any commercial or financial relationships that could
JMDH.S44204 be construed as a potential conflict of interest.
41. Sun W, Wu M, Qu P, Lu C, Wang L. Psychological well-being of people living The reviewer AT declared a shared affiliation, with no collaboration, with the
with HIV/AIDS under the new epidemic characteristics in China and the authors to the handling editor.
risk factors: a population-based study. Int J Infect Dis (2014) 28:147–52. doi:
10.1016/j.ijid.2014.07.010 Copyright © 2019 Duko, Toma, Asnake and Abraham. This is an open-access
42. Gohain Z, Halliday MAL. Internalized HIV-stigma, mental health, coping article distributed under the terms of the Creative Commons Attribution License
and perceived social support among people living with HIV/AIDS in (CC BY). The use, distribution or reproduction in other forums is permitted,
Aizawl District—a pilot study. Psychology (2014) 5:1794–812. doi: 10.4236/ provided the original author(s) and the copyright owner(s) are credited and
psych.2014.515186 that the original publication in this journal is cited, in accordance with accepted
43. Gupta R, Dandu M, Packel L, Rutherford G, Leiter K, Phaladze N, et al. academic practice. No use, distribution or reproduction is permitted which does
Depression and HIV in Botswana: a population-based study on gender-specific not comply with these terms.

Frontiers in Psychiatry  |  www.frontiersin.org 7 May 2019 | Volume 10 | Article 290