Prevalence of Depression and Anxiety Disorders in People Living with HIV/AIDS in a Tertiary Hospital in South Western Nigeria

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Prevalence of Depression and Anxiety Disorders in People Living with
HIV/AIDS in a Tertiary Hospital in South Western Nigeria
Adekunle Olatayo Adeoti1*, Mobolaji Usman Dada2 and Joseph Olusesan Fadare1
1Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria
2Department of Psychiatry, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria
*Corresponding author: Adekunle Olatayo Adeoti, Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria, Tel:
+2348035017228; E-mail: Kadeoti2002@yahoo.com
Received Date: Jan 04, 2018; Accepted Date: Feb 10, 2018; Published Date: Feb 20, 2018
Copyright: © 2017 Adeoti AO, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Background: In sub-Saharan Africa, HIV/AIDS constitutes a major burden with its attendant mental health
related challenges. The aim of this study was to determine the prevalence of depression and anxiety disorder
among HIV patients attending a tertiary institution in south western Nigeria.
Method: A cross-sectional study conducted among HIV patients attending HIV/AIDS clinic of the Ekiti State
University Teaching Hospital, Ado-Ekiti, Nigeria. A semi-structured questionnaire was administered to collect socio-
demographic characteristics with the incorporation of Hospital anxiety depression questionnaire to assess the
prevalence of depression and anxiety in the study and control groups.
Results: A total of 424 HIV positive study participants were recruited. A corresponding age and sex matched 429
control subjects were also enrolled. The mean age of HIV positive patients and controls are 42.2 ± 9.5 years and
43.4 ± 12.4 years respectively. There was a female prepondence among both study populations. The prevalence of
depression among PLHIV was 39.6% whereas depression was lower in the (22.0%) control group. Likewise anxiety
was reported in PLHIV and control group as 32.6% and 28.7% respectively. Female gender, illiteracy, being
divorced/widowed, unemployed and low income and low CD4 count were associated with depression while factors
associated with anxiety disorder included lower age, female gender, low income, and low CD4 count.
Conclusion: The prevalence of depression and anxiety are high in the HIV patients, hence proper integration of
mental health care into the HIV programme is inevitable to give patients holistic care.
Keywords: Prevalence; Depression; Anxiety; HIV/AIDS;
Antiretroviral treatment; PLHIV
Introduction
HIV/AIDS is a disease of major global concern with signicant
burden in sub-Saharan Africa. It is globally estimated that 36.7 million
people are living with HIV (PLHIV) in 2016, of which 1 million people
died of AIDS and 1.8 million new infections in the same year [1].
PLHIV oen suer from depression and anxiety as they adjust to the
impact of the diagnosis and face the diculties of living with a chronic
life-threatening illness, of which cure is yet to be discovered [2].
Depression is the commonest psychiatric syndrome reported in
PLHIV, however, the majority of the patients with depressive
symptoms also had prominent anxiety symptoms and fullled the
ICD-10 criteria for generalized anxiety disorder [3]. Adjustment
disorder is the most common psychiatric disorder that manifests as
anxiety, and is common aer receiving an HIV diagnosis. Anxiety
disorders are a serious concern for PLHIV with poor coping strategies
and social support network, such as family, friends, or a faith
community [4]. e prevalence of depressive illness among PLHIV on
antiretroviral therapy in sub-Saharan Africa is estimated to range from
29 to 63.1% [5-9].
e prevalence of anxiety disorders among PLHIV as reported in
another study in Nigeria was 21.7% while mixed anxiety and
depression was 5.3% [10]. However, the overall prevalence of
psychiatric disorders was reported to be as high as 59.1% among
PLHIV [11].
Various risk factors for developing these psychiatric disorders
among these patients have being reported in Africa and these include
low income, perceived stigma of the infection, poor level of social
support, stage of the disease, unemployment, being unmarried,
females, low level of formal education and comorbid opportunistic
infections [8-11]. ese comorbid states have dual relationships with
HIV/AIDS which could aect patients’ adherence to antiretroviral
drugs, quality of life and life expectancy [11,12].
ere is however paucity of data on the burden of mental health
problems among PLHIV in Nigeria and no studies investigating this
key aspect in the management of PLHIV in Ekiti State. Most of the
available studies focused only on depressive illness, others had no
control group and relatively small sample size [10,11]. Hence, this
study aimed at determining the prevalence of depression and anxiety
among PLHIV comparing the ndings with age and sex matched
control who are HIV sero-negative patients.
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ISSN: 2572-5130
Medical Reports and Case Studies
Adeoti, et al., Med Rep Case Stud 2018, 3:1
DOI: 10.4172/2572-5130.1000150
Research Article Open Access
Med Rep Case Stud, an open access journal
ISSN: 2572-5130
Volume 3 • Issue 1 • 1000150

Materials and Methods
Study design
A Hospital based cross-sectional study which was conducted among
patients accessing care for HIV infection in Ekiti State University
Teaching Hospital (EKSUTH). e hospital is located in Ado-Ekiti,
Ekiti state situated in the south western region of Nigeria. Ekiti state is
located within 7° 40I N 5° 15I E with an estimated population of
2,384,212 as at 2006 population census [13].
Study population
Adult HIV patients on follow up who were diagnosed of this
infection and have been on treatment for at least 6 months were
recruited for the study. e HIV patients receive treatment at the
Medical Outpatient Department where specialists in HIV medicine
regularly attend to them like other medical cases. Critically ill patients
and non-consenting individuals were excluded from the study.
Another group of HIV negative who consented to HIV screening,
attending the General Outpatient Department (GOPD) served as
control were age and sex matched [14].
Sampling size calculation
e sample size was calculated using the online statistical soware
from Raoso Incorporated. e estimated sample size was 327 from a
population of 2150 HIV patients in our facility, using 50% as response
distribution. Twenty percent of the calculated sample size was added to
account for incompletely lled questionnaires thereby making a total of
392. We further increased this number to 424 to increase the power of
the study.
Survey instrument
A pretested semi-structured questionnaire was administered by two
research assistants who obtained information on socio-demographic
prole, stigmatization, suicidal ideation, medication use, HIV
screening results. In addition, the Hospital Anxiety Depression scale
was used to assess the prevalence of this condition. e same
instrument was administered to an unexposed age and sex matched
group, who were HIV negative, who presented at the general
outpatient department for treatment. e HADS consists of 14 items;
the anxiety (HADS-A) and depression (HADS-D) subscales each
include 7 items. It has been validated for use as a screening tool for
depression and anxiety disorders in general medical outpatient clinics
and widely used in clinical practice and research [15,16].
Statistical analysis
Obtained data were analysed using SPSS statistical soware version
20 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were initially
used to explore the data and to present results of prevalence and socio-
demographic data. Categorical variables were expressed in proportions
while continuous variables in mean (standard deviation). A
comparison of categorical variables was done using Pearson’s Chi-
square test while student’s t-test was used for comparing continuous
variables. A p-value of less than 0.05 was considered statistically
signicant.
Ethical considerations
Ethical approval to conduct the study was obtained from the
institution’s ethics and research committee. Informed verbal and
written consent was obtained from every participant and they were
ensured of the anonymity and condentiality by assigning numerical
codes to each questionnaire. HIV/AIDS patients found to have
depression and anxiety were referred to the psychiatrist’s clinic for
further evaluation.
Results
Sociodemographic characteristics
A total of 424 HIV positive patients were recruited with a
corresponding age and sex matched control group of 429 HIV negative
patients. e mean age of the HIV positive patients was 42.2 ± 9.5
years while the control group was 43.4 ± 12.4 years. ere was a female
preponderance in both the exposed and control groups as the male to
female ratios were 1 to 2.8 and 1 to 1.8 respectively. A major
percentage (76.2%) of HIV positive patients were married and likewise
(68.1%) in the control group. More than half of the respondents in
both the HIV positive and control were self-employed (61.1% and
50.1% respectively).
Almost two thirds (63.4%) of the HIV positive patients had a
monthly income less than 140 dollars while just about half (52.4%) of
the control group had a monthly income less than 140 dollars. Only
16.9% and 14.2% of the HIV positive patients and control group
respectively had no formal education as shown in Table 1.
Variable HIV n (%) Control n (%) Test/chi2p-value
Age (mean ± SD) 42.16+9.537 43.37+12.380 t=-1.598 0.11
Sex
Male 111 (26.2) 154 (35.9)
chi2=0.347 0.556
Female 313 (73.8) 275 (64.1)
Marital status
Single 45 (10.6) 90 (21)
chi2=22.352
< 0.0001
Married 323 (76.2) 292 (68.1)
Divorce 28 (5.9) 11 (2.6)
Citation: Adeoti AO, Dada MU, Fadare JO (2018) Prevalence of Depression and Anxiety Disorders in People Living with HIV/AIDS in a Tertiary
Hospital in South Western Nigeria. Med Rep Case Stud 3: 150. doi:10.4172/2572-5130.1000150
Page 2 of 5
Med Rep Case Stud, an open access journal
ISSN: 2572-5130
Volume 3 • Issue 1 • 1000150

Widow (er) 31 (7.3) 36 (8.4)
Occupation
Civil servant 131 (30.9) 129 (30.1)
chi2=30.859
<0.0001
Retired 7 (1.7) 38 (8.9)
unemployed 27 (6.4) 47 (11.0)
Self employed 259 (61.1) 215 (50.1)
Education
Primary 68 (16.0) 60 (14.0)
chi2=15.116
0.002
Secondary 144 (34.0) 105 (24.5)
Tertiary 197 (46.5) 252 (58.7)
None 4 (0.9) 1 (0.2)
Average monthly income
<140 dollars 269 (63.4) 225 (52.4)
chi2=8.887
0.012
140-280 dollars 86 (20.3) 77 (17.9)
>280 dollars 12 (2.8) 28 (6.5)
Exchange rate at 357 naira to 1 dollar
Table 1: e socidemographic characteristics of the study and control groups.
Clinical characteristics
Most (70.3%) of the HIV positive patients are currently on
antiretroviral (TDF+3TC+EFV) medication combination. More than
half of the HIV seropositive patients had been on the antiretroviral
medications for a period of 6 to 10 years. However, very few of the
respondents were on antiretroviral medications for 5 years and below
as shown in Figure 1.
Figure 1: Pie chart of duration on antiretroviral medication.
e median CD4 count of the patients at diagnosis was 224.0
cells/ul with interquartile range (IQR) of 110.5 to 400 cells/ul. A
remarkable increase in median current CD4 count to 405.0 cells/ul
(IQR 266.0 to 575 cells/ul) was observed and with a median viral load
of 42.0 (IQR 20.0 to 555.0).
About a third of the exposed group was unaware of their spouses’
HIV status and among those that knew, 79.8% of them had HIV
negative partners. Serodiscordant couples constituted a major percent
(79.8%) of the married respondents while seroconcordant couples were
20.2%.
Psychiatric morbidity
e prevalence of depression among the HIV positive patients and
control group was 39.6% and 22.0% respectively (p<0.001). However,
the prevalence of anxiety disorder was 32.6% and 28.7% among the
exposed and control groups respectively (p> 0.219). e co-existence
of both anxiety and depression in HIV positive patients and control
was 21.9% and 14.5% respectively as shown in Table 2.
More of cases of depression were reported in females (42.5% of
females compared to 31.5% of males) (CI=0.009-0.132). Married HIV
positive patients had the least proportion (37.2%) of depression
whereas the highest proportion of depression was found among
widows (58.1%) followed by divorced patients (48.0%). ese
dierences were found to be signicant with p value of 0.03.
Citation: Adeoti AO, Dada MU, Fadare JO (2018) Prevalence of Depression and Anxiety Disorders in People Living with HIV/AIDS in a Tertiary
Hospital in South Western Nigeria. Med Rep Case Stud 3: 150. doi:10.4172/2572-5130.1000150
Page 3 of 5
Med Rep Case Stud, an open access journal
ISSN: 2572-5130
Volume 3 • Issue 1 • 1000150

Variable Depression Test p value Anxiety Test p value
Age T test=-0.769 0.442 T test=1.972 0.049*
Sex Chi2=4.115 0.043* Chi2=6.986 0.008*
Marital status Chi2=5.986 0.03* Chi2=1.001 0.801
Educational level Chi2=13.710 0.003* Chi2=1.150 0.765
Occupation Chi2=13.768 0.003* Chi2=2.663 0.446
Income Chi2=8.101 0.017* Chi2=6.205 0.045*
Known HIV of partner Chi2=13.981 0.001* Chi2=0.283 0.595
HIV status of partner Chi2=2.168 0.338 Chi2=5.180 0.075
Comorbidity Chi2=9.000 0.061 Chi2=9.000 0.061
Viral load Corr coef=0.004 0.955 Corr coef=-0.065 0.372
CD4 COUNT at diagnosis Corr coef=0.044 0.383 Corr coef=-0.55 0.275
Current CD4 count Corr coef=-0.166 0.001* Corr coef=-0.102 0.043*
Table 2: Factors associated with depression and anxiety disorder.
Almost all the retired HIV positive patients (71.4%) had depression
as opposed to those who were still gainfully employed (p value=0.003).
Similarly, HIV infected patients without formal education and only
primary education had high rates of depression (100.0% and 51.5%
respectively) (p value=0.003).
Depression was also associated with lower socioeconomic class (less
than $140/month) as assessed with monthly income with p
value=0.017, insomnia (p<0.0001), low current CD4 count (p
value=0.001), unaware of spouses’ HIV status (P<0.001) and having
thoughts of suicide (p<0.0001).
In contrast, female sex (P value<0.008), lower age of respondents (P
value<0.049), presence of insomnia (P value<0.0001), low income (P
value <0.045), and low current CD4 count (P value<0.043) were
signicantly associated with anxiety disorder among HIV positive
patients in this study.
Discussion
is study found a higher prevalence of depression and anxiety
disorders among HIV patients compared to the controls as well as a
higher prevalence of comorbid occurrence of both conditions in HIV
patients.
Previous studies have reported similar prevalence of 29.0% and
40.0% for depression and 21.7% for anxiety disorders among HIV
patients [6,7,10]. However prevalence as high as 63% and 77.1% has
been reported among HIV patients in other studies [9,16]. is calls
for a proper integration of mental health services in HIV care so as to
address the prevailing psychosocial needs of PLHIV as they adapt to
the challenge of living with a chronic and at the moment uncurable
disease.
Similarly, we found a higher prevalence rate of 21.9% for comorbid
anxiety and depression in this study among HIV positive patients
compared to a rate of 14.5% among the controls. e prevalence rate
among the HIV positive patients was far higher than a prevalence rate
of 5.3% reported in another study in this environment [10]. However,
similar prevalence has been reported in another study [8]. e
dierences in the various prevalent rates may be due to the dierent
diagnostic tools, sample size variations and dierent locations of the
study.
In this study, depression and anxiety were more common among
females. is was also reported by other researchers [8,9,17,18].
Marriage as observed in this study appeared to be protective against
depression but not against anxiety disorder, as fewer proportion of
married HIV positive patients had depression compared to those who
were divorced or widowed. Similar studies have also reported that
being unmarried or divorced were risk factors for psychiatric
morbidity among HIV patients [8,10]. Possible reasons for the high
rate especially among divorced respondents include low self-
condence and possible nancial problems [19]. Furthermore, the loss
of a close condant and possibly poor social support system could be
responsible for the level of depression among the widowed and
divorced. On the contrary, Elbadawi et al. reported high psychiatric
morbidity in married HIV patients [9].
e emotional burden associated with low income could be
responsible for the reported depression and anxiety in our study. Most
of the respondents earned less than two dollar per day and they could
be faced with the challenge of meeting nancial obligations [20].
Illiteracy was another factor found to be associated with depression
but not anxiety disorder. Other studies have also reported similar
ndings [9,21]. Our study found that the unemployed and retired
patients had the highest rate of depression. is was collaborated by
other studies who reported that unemployment was a risk factor for
psychiatric morbidity among HIV patients [10,22].
is study found that lower age of respondents was a possible risk
factor for anxiety disorder but not for depression. Younger age as a risk
factor for psychiatric morbidity was also reported by other researchers
[10,22]. e current CD4 count as opposed to the CD4 count at
diagnosis was inversely correlated with depression and anxiety. Other
Citation: Adeoti AO, Dada MU, Fadare JO (2018) Prevalence of Depression and Anxiety Disorders in People Living with HIV/AIDS in a Tertiary
Hospital in South Western Nigeria. Med Rep Case Stud 3: 150. doi:10.4172/2572-5130.1000150
Page 4 of 5
Med Rep Case Stud, an open access journal
ISSN: 2572-5130
Volume 3 • Issue 1 • 1000150

studies have also reported that low CD4 count was a risk factor
psychiatric morbidity [22-24]. is may be because patients with lower
CD4 count are probably having more symptoms of HIV infection and
consequently more emotional and physical disability. e high rate of
depression among patients who do not know the HIV status of their
spouses may be due to the constant worrying of these patients about
their infection and perceived consequences of informing their partners
about their HIV status [25].
Our study has some limitations as depressive and anxiety disorders
oen change with time, hence a snapshot analysis might not give exact
degree of the condition. However, the advantage of a non-exposed
control group helped assess the extent in the general population.
Conclusion
e prevalence of depression and anxiety is high among PLHIV and
could present in a subtle manner. A routine screening for depressive
and anxiety symptoms is recommended with a proper integration of
mental health services into HIV care to give a comprehensive
management to all HIV patients.
Conicts of Interest
e authors declare no competing interests.
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Citation: Adeoti AO, Dada MU, Fadare JO (2018) Prevalence of Depression and Anxiety Disorders in People Living with HIV/AIDS in a Tertiary
Hospital in South Western Nigeria. Med Rep Case Stud 3: 150. doi:10.4172/2572-5130.1000150
Page 5 of 5
Med Rep Case Stud, an open access journal
ISSN: 2572-5130
Volume 3 • Issue 1 • 1000150