|Year : 2021 | Volume
| Issue : 1 | Page : 27-34
Assessment of depression in HIV-positive patients attending antiretroviral treatment center of a tertiary care institute in Eastern India: A hospital-based cross-sectional study
Sudipta Kumar Sinha, Mithilesh Kumar, Surendra Singh, Vivek Kashyap
Department of Community Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
|Date of Submission||29-Apr-2020|
|Date of Decision||27-Aug-2020|
|Date of Acceptance||23-Sep-2020|
|Date of Web Publication||27-Jan-2021|
Department of Community Medicine, Rajendra Institute of Medical Sciences, Ranchi - 834 009, Jharkhand
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Neurological ailments have complex relation with HIV/AIDS. Depression in seropositive patients directly affects treatment outcome. Aims: This study aims to determine the prevalence of depression/depressive symptoms in HIV/AIDS patients attending antiretroviral treatment center and ascertain the underlying factors that have bearing on depression. Settings and Design: This was a cross-sectional study conducted among HIV seropositive patients attending ART center of the largest public health hospital in Jharkhand. Subjects and Methods: Between April 2018 and March 2019, 250 adult subjects were consecutively recruited and interviewed. Depressive symptoms were assessed with the 9-item Patient Health Questionnaire (PHQ-9), with a positive depression screen defined as PHQ-9 score ≥10. Statistical Analysis Used: Chi-square was used to assess association. Factors found significant underwent multivariable logistic regression analysis. Results: The overall prevalence of depressive symptoms was 18.8% (95% Confidence Interval (CI) [95% CI]: 14.2, 24.2). Multivariable logistic regression analysis identified history of weight loss (Adjusted odds ratio [aOR] 6.17, 95% CI: 2.0, 19.08; P = 0.002), presently suffering from tuberculosis (aOR 5.65, 95% CI: 1.47, 21.74; P = 0.012), bad relationship with family members (aOR 6.85, 95% CI: 1.49, 31.53, P = 0.013) as correlates of depressive symptoms. Conclusions: The present study found depressive symptoms among adults with seropositive status, attending the ART center. HIV seropositive patients with known comorbidities, for example, with a history of weight loss, presently suffering from tuberculosis and with stressed relation within the family were prone to depressive symptoms.
Keywords: Acquired immune deficiency syndrome, depression, outcome, PHQ-9, prevalence
|How to cite this article:|
Sinha SK, Kumar M, Singh S, Kashyap V. Assessment of depression in HIV-positive patients attending antiretroviral treatment center of a tertiary care institute in Eastern India: A hospital-based cross-sectional study. J Nat Sc Biol Med 2021;12:27-34
|How to cite this URL:|
Sinha SK, Kumar M, Singh S, Kashyap V. Assessment of depression in HIV-positive patients attending antiretroviral treatment center of a tertiary care institute in Eastern India: A hospital-based cross-sectional study. J Nat Sc Biol Med [serial online] 2021 [cited 2021 Mar 8];12:27-34. Available from: http://www.jnsbm.org/text.asp?2021/12/1/27/307862
| Introduction|| |
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is a modern pandemic. There was approximately 37 million people worldwide living with HIV/AIDS at the end of 2017 with India accounting for 2.1 million or the third largest HIV population in the world. In 2017, HIV prevalence in India was estimated to be 0.22%.
Mental and neurological disorders have an intertwined relationship with HIV, with cognitive disorders, substance abuse, and disorders of personality influencing behavior in ways that lead to greater risk of HIV infection. On the other hand, HIV/AIDS itself causes a number of psychological conditions due to the crisis encompassing the disease, and psychiatric conditions resulting from HIV-related neurological changes. These disorders adversely influence the progression of the disease, lead to noncompliance with treatment, and increase the likelihood that people living with HIV/AIDS (PLWHA) will act in high-risk ways.
According to some authors, “Major depression (MD) is highly prevalent in HIV-infected patients and offers significant diagnostic challenges because of the biological, psychological, and social components associated with the infection.” The American Psychiatric Association delineates symptoms of true clinical depression in two categories-affective and somatic. The association suggests the affective symptoms to include; depressed mood, loss of interest in normally pleasurable activities, feeling of guilt or worthlessness, hopelessness or suicidal ideation while somatic symptoms include loss of weight, anorexia, sleep disturbance, agitation, fatigue, and loss of concentration. A multitude of factors have been identified which can lead to depression in PLWHA. These include socioeconomic factors as gender,, education,, income,, marriage, and family grouping,, while other factors that have also been widely studied include stress, low social support, negative life events, and CD4 cell count of <500 cells/mm3,,, HIV-positive patients who have not disclosed their seropositive status to their loved ones or are themselves in an advancing stage of illness are also at serious risk of depression. Furthermore, due to new treatments and increasing life expectancies, mental disorders are becoming progressively more relevant for HIV/AIDS management.
The prevalence of depression among HIV-positive patients in India ranges from 10% to 40%.,, HIV/AIDS remains an issue in Jharkhand and although the prevalence of HIV/AIDS at 0.14% is less than the national average, the magnitude of the problem as well as the correlates of mental disorders especially depression are either not studied or are relatively few. The primary aim of this study was to determine the prevalence of depression/depressive symptoms in PLWHA attending the Anti-Retroviral Treatment (ART) center of Rajendra Institute of Medical Sciences, Ranchi, and secondarily to ascertain the underlying factors that have bearing on depression.
| Subjects and Methods|| |
This was a cross-sectional study conducted among PLWHA attending ART center of Rajendra Institute of Medical Sciences, Ranchi, in eastern India, between April 2018 and March 2019. RIMS is one of the foremost tertiary care institutes in the state of Jharkhand and caters to wide distribution of populace, state-wide as well as from other adjoining areas. Adult HIV prevalence of Jharkhand is 0.14%, however, the exact prevalence of depression among adult PLWHAs is not known. The ART center at RIMS provides essential medicines to the patients free of cost as well as counseling and testing services to the clients with more than 6000 patients currently enrolled at this center.
The study participants were patients attending ART center of RIMS, Ranchi. The study participants were adults >18 years, with confirmed HIV-positive status and on combination antiretroviral therapy (cART) for at least more than a year and having consented to participate in our study. Participants who were severely ill were not included in the study and so were eligible participants who could not understand Hindi/English.
Sampling and sample size
The selection of study participants was done through consecutive sampling of eligible patients attending the ART clinic, until the final sample size was achieved. The sample size was determined using single population proportion formula. It was ascertained that taking the prevalence of depression amongst PLWHAs at 20% and with absolute precision of 5%, the study would be sufficiently powered and would be feasible in the settings of our study. Therefore, the estimated sample size was rounded to give a final sample size of 250.
During the data collection period, a single researcher interviewed the participants who gave their consent. A semi-structured questionnaire was used to collect data from the study participants. This questionnaire was administered in a private room within the ART complex, and each session lasted approximately 30 min. An informed consent statement was read in Hindi/English; the two most commonly understandable languages, to the patients at start of interview. The participants were assured of confidentiality of their data and their anonymity.
The 2-item Patient Health Questionnaire (PHQ-2) and 9-item PHQ-9 were administered as a measure of depression. This instrument has been validated to measure depression in various clinical settings,, as well as to measure depression in HIV/AIDS patients,, and has been found to have good internal consistency as measured by Cronbach's alpha. The PHQ-9 items are rated based on a Likert scale of “0” (not at all) to “3” (nearly every day), with the individual scores summed to derive a total score ranging from 0 to 27. Scores of 5–9 points, 10–14 points, 15–19 points, and 20–27 points indicate; mild, moderate, moderately severe, and severe levels of depressive symptoms, respectively. The PHQ-2 (i.e., the first two items of the PHQ-9) is an ultra-brief and accurate screening tool for which a total score of 3 or over is considered a positive depression screening result.
Various data related to age, sex, ethnicity, marital status, education level, employment status, and residence were asked from the respondents. Socioeconomic status was assessed by B. G. Prasad classification updated for January 2018.
Participants self-reported history of weight loss, sleep disturbances, and present sexual drive were asked. They were also queried about the history of smoking, alcohol intake or presence of comorbidity with TB and any opportunistic infection or STIs.
Record-based data were obtained from the respondents for the duration of HIV diagnosis, most recent cART regimen, CD4 cell count.
The data were analyzed using Statistical Package of Social Science (SPSS Version 20), IBM, USA. Frequencies (with percentages) and means (with standard deviations [SDs]) were used to describe sample variables. The prevalence was presented as percentages. Univariate analysis using Chi-square was used to assess the crude association between sample characteristics and positive depression screen (PHQ-9 cut off score ≥10) while t-test was used to measure difference between outcomes of continuous variables based on positive depression screen. Multivariable logistic regression analysis was lastly used to investigate factors associated with a positive depression screen. All significant variables from univariate analysis were included in multivariable analysis. Hosmer–Lemeshow goodness of fit statistic with a P > 0.05 was taken as a well-fitting logistic regression model. For analysis P < 0.05 was considered statistically significant for all tests of hypothesis.
The ethical approval for the study was obtained from Institutional Ethics Committee of RIMS, Ranchi (Vide memo no. 31, Dated: 20/02/2018). Interview of study subjects were conducted after taking written informed consents in Hindi language and they were assured of confidential nature of data provided.
| Results|| |
A total of 250 patients were enrolled in the study. The overall mean age of the participants was 41.5 (SD = 9.5) years. An independent sample t-test revealed that the mean age of study participants was significantly higher among the not depressed participants than the depressed, when measured on a binary PHQ-9 scale (cut off score ≥10) [Table 1].
|Table 1: Age distribution of depression amongst human immunodeficiency virus patients (n=250)|
Click here to view
Other demographic, health related, and clinical characteristics of the subjects are shown in [Table 2]. More than half of the study participants were male (57.2%) and most were married (74.8%). Majority had at least completed secondary education (85.6%) while over half belonged to the lower middle class (56.4%). When enquired about their personal habits, majority reported that they had never smoked (85.6%) and over half had never taken alcohol (57.2%). Only some of the respondents reported any history of weight loss (26.8%) and lower sex drive (22.4%), with approximately half reporting sleep disturbances (46%) though almost all of the respondents reported that they had good relations with family members (88.8%).
|Table 2: Explanatory variables characteristic in not depressed versus depressed human immunodeficiency virus patients (n=250)|
Click here to view
From a clinical viewpoint, majority suffered from HIV/AIDS for <10 years (72.4%) and almost all were currently on first line of ART (90.4%). Few respondents reported that they were currently suffering from tuberculosis (10.4%) while some participants gave a history of suffering from sexually transmitted diseases (28.8%).
Prevalence of depression and severity
Using a binary PHQ-9 cut off score ≥10, which has been shown to maximize for sensitivity and specificity in screening of depression; the overall prevalence of depression was 18.8%. However, PHQ-2 with cut off score ≥3, reported a prevalence of 42.8%. In terms of severity of depression in the respondents, 26% had mild, 8% had moderate, 9.2% had moderately severe, and 1.6% had severe symptoms [Table 3].
|Table 3: Prevalence of depression based on 2-item Patient Health Questionnaire and 9-item Patient Health Questionnaire (n=250)|
Click here to view
Factors associated with depression
[Table 2] and [Table 4] present the results following univariate analysis by Chi-square and multivariate logistic regression analyses of factors associated with positive depression screen among respondents attending ART center of RIMS.
|Table 4: Multivariable logistic regression analysis for correlates of depressive symptoms in patients with human immunodeficiency virus|
Click here to view
In the univariate analysis, it was found that depression was more prevalent among females (25.2%) than males (14%) and this difference was statistically significant (χ2 = 5.07, P = 0.024). The prevalence of depression in the married (12.8%), unmarried (61.5%), and divorced/widow/widower (30%) population was statistically significant (χ2 = 24.02, P ≤ 0.001); however, on conducting a post hoc test, the statistical difference was mainly between the married and unmarried groups. Similarly, a post hoc test reported significant difference between prevalence of depression and present smokers (χ2 = 8.39, P = 0.015). On evaluation of the clinical and health-related statistics in relation to presence of depression, history of weight loss (χ2 = 100.30, P ≤ 0.001), sleep disturbance (χ2 = 67.94, P ≤ 0.001), lower sex drive (χ2 = 27.35, P ≤ 0.001), currently suffering from tuberculosis (χ2 = 72.99, P ≤ 0.001), lower CD4 count (χ2 = 17.63, P ≤ 0.001), and being on second line of ART (χ2 = 6.08, P = 0.024) were significantly associated with the prevalence of depression. Results also revealed significant association between prevalence of depression and bad relationship with family members (χ2 = 20.10, P ≤ 0.001), infection of their child with HIV/AIDS (χ2 = 4.18, P = 0.041) and the belief that their life would not be prolonged even after taking ART (χ2 = 4.44, P = 0.035). All these significant variables were added to the multivariate logistic regression.
In the final multivariable analysis, factors that were significantly associated with positive depression screen included: having a history of weight loss (P = 0.002), currently suffering from tuberculosis (P = 0.012), and bad relationship with family members (P = 0.013).
| Discussion|| |
The prevalence of depression found among HIV/AIDS patients in our study was 18.8 (95% confidence interval: 14.2, 24.2). Other studies from India have similarly reported the prevalence of depression among HIV-positive patients ranging from 10% to 40%.,, However, this reported prevalence was less in comparison to a study done in Delhi which reported the prevalence of depression at 58.75%. These differences in the prevalence may be due to different instruments used to measure depression in different studies. Other studies done in sub-Saharan Africa also differ in prevalence of depression and one study reported that these findings could be due to differences in sample size, study population (selection bias), or tools used across studies.
PHQ-9 is a validated tool that was used to measure depressive symptoms in this study. Various studies from across globe have consistently found good internal consistency when used among PLWHAs. In our study, we reported a Cronbach's alpha of 0.94 meaning high internal consistency. However, this high internal consistency can also be partly assumed due to lesser amount of skewness in our data. Overall, it is challenging to definitively ascertain whether depression increases HIV-infected patients' risk for disease progression, or whether HIV disease progression is associated with increased risk of depression.
In our study, we found that people suffering from depression were relatively younger 36.87 ± 8.126 years (Mean ± SD) than people who were not 42.64 ± 9.491 years (Mean ± SD) and this difference was statistically significant. Similar results were found in a multicountry longitudinal group-randomized HIV prevention trial which also found that younger age was associated with greater levels of depression. Another study conducted in Uganda among HIV-positive patients also reported similar findings. These findings may be due to the stigma associated with HIV/AIDS and thus increased scrutiny of this group of population by the society; as still now HIV/AIDS in India is mostly thought of as a disease common in young people due to their risky behavior and thus contracted through unprotected sex with commercial sex workers. However, other studies have found contrasting evidence and report that depression was more prevalent in older age group while a meta-analysis done in China reported no significant association between age and the pooled prevalence of depression.
The prevalence of depression found in our study was higher in females than the males but this difference was not statistically significant. Other studies have reported contrasting evidence; some studies report that female gender was more prone to depression,, while some studies have either found no association or shown gender to be protective for depression. We think that these inconsistencies need to be addressed by further research. Further, in India, a study has suggested that the association between common mental disorder and female gender may due to gender disadvantage experienced by women. On multivariate regression analysis, no other socio-demographic correlates were found to be statistically related to depression.
Other discerning variables implicated in depression that were found in our study were prior history of weight loss, decreased sleep, and lower sex drive. Prior history of weight loss was also significant in the final regression model. A study done in Cameroon reported insomnia, weight changes (nearly always weight loss) and decreased appetite to be frequent among PLWHAs. The study further stressed that having a greater number of HIV symptoms increased the odds of having MD disorder within the past year. These findings can be accounted when factored in for somatic symptoms experienced by the HIV+ve patient and which generally indicate progression or failure of treatment. In contrast in the presence of depression these symptoms may aggravate or arise de novo. Similarly, studies have shown an association between depression and lower sexual drive,, which was consistent with our findings. Studies implicate erectile dysfunction, delayed ejaculation, and other factors for lower sexual drive and thus depression.,
Various studies have reported family relations to be significantly associated with depressive symptoms for PLWHAs.,,, In our study, the odds of depression was seven times more in respondents who had bad relations with family members. This finding stresses the importance of caregivers in the management of depression in PLWHAs. If the family unit is able to successfully overcome the challenges of HIV, the quality of life of not only the patient but all family members can be maintained.
With the advent of cART for the treatment of HIV/AIDS, the lives of patients have been prolonged, leading to chronicity in disease progression. This makes the patients susceptible to various opportune infections. Tuberculosis is one such common disease. Studies show increased prevalence of depression in HIV+ve patients who are simultaneously infected with TB., Our study found that HIV+ve patients suffering from tuberculosis were six times more susceptible for depression. This may be attributed to long and potentially toxic treatment that may make the patient stressed de-motivated and debilitated. Our study also reported association between prevalence of depression with second line of cART and lower CD4 counts in bivariate analysis. These findings are corroborated by findings in other studies.,, However, the final regression model did not find the association significant.
Limitation and strengths of the study
First, the cross-sectional nature of this study prohibits the interpretation of predictive associations between risk factors and outcomes and does not demonstrate causality. Second, the findings may not be externally valid to the larger HIV population as the respondents were a convenience sample from a single public hospital in Jharkhand. Third, we did not evaluate clinical depression but the depressive symptoms. However, sample size with adequate power, the use of validated tool to research depression and distinctive study setting, as it is first in eastern India as per our knowledge, are strengths of this study.
| Conclusions|| |
The current study reveals the presence of depressive symptoms in seropositive subjects attending the ART clinic; but with paucity of studies done in this subgroup in Jharkhand, further studies are needed to correctly conclude the prevalence of depressive symptoms. The present study also found that subjects with a history of weight loss or presently suffering from tuberculosis or having bad relationship with family members were significantly correlated with depressive symptoms. To conclude HIV seropositive patients with known comorbidities and with stressed relation within the family are prone to depressive symptoms.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. World Health Organization/Data and Statistics. Switzerland: Geneva: World Health Organization; 2020.
Joint United Nations Programme on HIV/AIDS. India/Joint United Nations Programme on HIV/AIDS. Switzerland: Geneva: Joint United Nations Programme on HIV/AIDS; 2020.
Ministry of Health and Family Welfare, Government of India. HIV Facts & Figures. New Delhi, India: National AIDS Control Organization.; 2018.
Baingana F, Thomas R, Comblain C. HIV/AIDS and Mental Health, Washington, D. C.: The International Bank for Reconstruction and Development/The World Bank. Health, Nutrition and Population (HNP) Discussion Paper; January 2005.
Arseniou S, Arvaniti A and Samakouri M. HIV infection and depression. Psychiatry Clin Neurosci 2014;68:96-109.
Bhatia MS, Munjal S. Prevalence of Depression in People Living with HIV/AIDS Undergoing ART and Factors Associated with it. J Clin Diagn Res 2014;8:WC01-4.
Nogueira Campos L, De Fátima Bonolo P, Crosland Guimarães MD. Anxiety and depression assessment prior to initiating antiretroviral treatment in Brazil. AIDS Care 2006;18:529-36.
Hutton HE, Lyketsos CG, Zenilman JM, Thompson RE, Erbelding EJ. Depression and HIV risk behaviors among patients in a sexually transmitted disease clinic. Am J Psychiatry 2004;161:912-4.
Chandra P, Ravi V, Desai A, Subbakrishna DK. Anxiety and depression among HIV-infected heterosexuals – A report from India. J Psychosom Res 1998;45:401-09.
Serovich JM, Kimberly JA, Mosack KE, Lewis TL. The role of family and friend social support in reducing emotional distress among HIV-positive women. AIDS Care 2001;13:335-41.
Narayan KM, Miotti PG, Anand NP, Kline LM, Harmston C, Gulakowski R 3rd
, et al
. HIV and noncommunicable disease comorbidities in the era of antiretroviral therapy: A vital agenda for research in low-and middle-income country settings. J Acquir Immune Defic Syndr 2014;67 Suppl 1:S2-7.
Ngum PA, Fon PN, Ngu RC, Verla VS, Luma HN. Depression among HIV/AIDS patients on highly active antiretroviral therapy in the southwest regional hospitals of Cameroon: A cross-sectional study. Neurol Ther 2017;6:103-14.
Krishna VA, Chandra PS. Concerns and psychiatric morbidity among people living with HIV/AIDS. NIMHANS J. 1998; 17: 253-60.
Chandra PS, Ravi V, Desai A, Subbakrishna DK. Anxiety and depression among HIV-infected heterosexuals - A report from India. J Psychosom Res 1998;45:401-9.
Algoodkar S, Kidangazhiathmana A, Rejani PP, Shaji KS. Prevalence and factors associated with depression among clinically stable people living with HIV/AIDS on antiretroviral therapy. Indian J Psychol Med 2017;39:789-93.
] [Full text]
Hinz A, Mehnert A, Kocalevent RD, Brähler E, Forkmann T, Singer S, et al
. Assessment of depression severity with the PHQ-9 in cancer patients and in the general population. BMC Psychiatry 2016;16:22.
Muñoz-Navarro R, Cano-Vindel A, Medrano LA, Schmitz F, Ruiz-Rodríguez P, Abellán-Maeso C, et al
. Utility of the PHQ-9 to identify major depressive disorder in adult patients in Spanish primary care centres. BMC Psychiatry 2017;17:291.
Urtasun M, Daray FM, Teti GL, Coppolillo F, Herlax G, Saba G, et al
. Validation and calibration of the patient health questionnaire (PHQ-9) in Argentina. BMC Psychiatry 2019;19:291.
Monahan PO, Shacham E, Reece M, Kroenke K, Ong'or WO, Omollo O, et al
. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya. J Gen Intern Med 2009;24:189-97.
Nolan CP, O'Donnell PJM, Desderius BM, Mzombwe M, McNairy ML, Peck RN, et al
. Depression screening in HIV-positive Tanzanian adults: Comparing the PHQ-2, PHQ-9 and WHO-5 questionnaires. Glob Ment Health (Camb) 2018;5:e38.
Nyongesa MK, Mwangi P, Wanjala SW, Mutua AM, Newton CR, Abubakar A. Prevalence and correlates of depressive symptoms among adults living with HIV in rural Kilifi, Kenya. BMC Psychiatry 2019;19:333.
Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284-92.
Akena D, Joska J, Obuku EA, Stein DJ. Sensitivity and specificity of clinician administered screening instruments in detecting depression among HIV-positive individuals in Uganda. AIDS Care 2013;25:1245-52.
Kingori C, Haile ZT, Ngatia P. Depression symptoms, social support and overall health among HIV-positive individuals in Kenya. Int J STD AIDS 2015;26:165-72.
Seth P, Kidder D, Pals S, Parent J, Mbatia R, Chesang K, et al
. Psychosocial functioning and depressive symptoms among HIV-positive persons receiving care and treatment in Kenya, Namibia, and Tanzania. Prev Sci 2014;15:318-28.
Akena D, Musisi S, Joska J, Stein DJ. The association between aids related stigma and major depressive disorder among HIV-positive individuals in Uganda. PLoS One 2012;7:e48671.
Kinyanda E, Woodburn P, Tugumisirize J, Kagugube J, Ndyanabangi S, Patel V. Poverty, life events and the risk for depression in Uganda. Soc Psychiatry Psychiatr Epidemiol 2011;46:35-44.
Wang T, Fu H, Kaminga AC, Li Z, Guo G, Chen L, et al
. 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.
Deshmukh NN, Borkar AM, Deshmukh JS. Depression and its associated factors among people living with HIV/AIDS: Can it affect their quality of life? J Family Med Prim Care 2017;6:549-53.
] [Full text]
Egbe CO, Dakum PS, Ekong E, Kohrt BA, Minto JG, Ticao CJ. Depression, suicidality, and alcohol use disorder among people living with HIV/AIDS in Nigeria. BMC Public Health 2017;17:542.
Patel V, Kirkwood BR, Pednekar S, Weiss H, Mabey D. Risk factors for common mental disorders in women. Population-based longitudinal study. Br J Psychiatry 2006;189:547-55.
Gaynes BN, Pence BW, Atashili J, O'Donnell J, Kats D, Ndumbe PM. Prevalence and predictors of major depression in HIV-infected patients on antiretroviral therapy in Bamenda, a semi-urban center in Cameroon. PLoS One 2012;7:e41699.
Amini Lari M, Faramarzi H, Shams M, Marzban M, Joulaei H. Sexual dysfunction, depression and quality of life in patients with HIV infection. Iran J Psychiatry Behav Sci 2013;7:61-8.
de Ryck I, Van Laeken D, Nostlinger C, Platteau T, Colebunders R. Eurosupport study group. Sexual satisfaction among men living with HIV in Europe. AIDS and Behavior 2012;16:225-30.
Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moreira E, et al
. Sexual problems among women and men aged 40-80 y: Prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res 2005;17:39-57.
Rosen RC, Seidman SN, Menza MA, Shabsigh R, Roose SP, Tseng LJ, et al
. Quality of life, mood, and sexual function: A path analytic model of treatment effects in men with erectile dysfunction and depressive symptoms. Int J Impot Res 2004;16:334-40.
Li L, Liang LJ, Ding YY, Ji G. Facing HIV as a family: Predicting depressive symptoms with correlated responses. J Fam Psychol 2011;25:202-9.
Lee SJ, Detels R, Rotheram-Borus MJ, Duan N, Lord L. The effect of social support on mental and behavioral outcomes among adolescents: Annual review of public health with parents with HIV/AIDS. Am J Public Health 2007;97:1820-6.
Amiya RM, Poudel KC, Poudel-Tandukar K, Pandey BD, Jimba M. Perceived family support, depression, and suicidal ideation among people living with HIV/AIDS: A cross-sectional study in the Kathmandu Valley, Nepal. PLoS One 2014;9:e90959.
Thomas BE, Shanmugam P, Malaisamy M, Ovung S, Suresh C, Subbaraman R, et al
. Psycho-socio-economic issues challenging multidrug resistant tuberculosis patients: A systematic review. PLoS One 2016;11:e0147397.
Das M, Isaakidis P, Van den Bergh R, Kumar AM, Nagaraja SB, Valikayath A, et al
. HIV, multidrug-resistant TB and depressive symptoms: When three conditions collide. Glob Health Action 2014;7:24912.
Isaakidis P, Rangan S, Pradhan A, Ladomirska J, Reid T, Keilman K. 'I cry every day': Experiences of patients co-infected with HIV and multidrug-resistant tuberculosis. Trop Med Int Health 2013;18:1128-33.
Amanor-Boadu S, Hipolito MS, Rai N, McLean CK, Flanagan K, Hamilton FT, et al
. Poor CD4 count is a predictor of untreated depression in human immunodeficiency virus-positive African-Americans. World J Psychiatry 2016;6:128-35.
[Table 1], [Table 2], [Table 3], [Table 4]