Depression, Alcohol Use and Adherence to Antiretroviral Therapy in Sub-Saharan Africa: A Systematic Review
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624N. Broadway, Hampton House, Baltimore, MD, 21205, USA, . AIDS and Behavior
(Impact Factor: 3.49).
11/2011; 16(8):2101-18. DOI: 10.1007/s10461-011-0087-8
This study evaluated estimates of depression symptoms, major depression, alcohol use or disorders and their association with ART adherence in sub-Saharan Africa. Studies published between January 1, 2006 and July 31, 2011 that documented rates of these mental health problems were identified through electronic databases. A pooled analysis of 23 studies reporting rates of depression symptoms and six studies reporting rates of major depression indicated a pooled estimate of 31.2% (95% CI 25.5-38.2%, Tau(2) = 0.23) and 18% (95% CI 12.3-25.8%, Tau(2) = 0.19) respectively. Few studies reported rates of alcohol use or disorders, and so we did not pool their estimates. Likelihood of achieving good adherence was 55% lower among those with depression symptoms compared to those without (pooled OR = 0.45 (95% CI 0.31-0.66, Tau(2) = 0.20, P value = 0.000). Interventions to improve mental health of HIV-positive individuals and to support adherence are desperately needed in sub-Saharan Africa.
Available from: Simon G Agolory
- "Similarly, in our univariate analysis, participants who reported feeling sad, down, or depressed were about 50% more likely to report incomplete adherence. This finding supports the screening for depression among patients with HIV.However the region's health system capacity to detect and treat depression is limited.Dietary protein supplementation has been suggested as a specific strategy to further reduce depression in patients on ART, in settings with food insecurity.Only "
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To identify the reasons patients miss taking their antiretroviral therapy (ART) and the proportion who miss their ART because of symptoms; and to explore the association between symptoms and incomplete adherence.
Secondary analysis of data collected during a cross-sectional study that examined ART adherence among adults from 18 purposefully selected sites in Tanzania, Uganda, and Zambia. We interviewed 250 systematically selected patients per facility (≥18 years) on reasons for missing ART and symptoms they had experienced (using the HIV Symptom Index). We abstracted clinical data from the patients' medical, pharmacy, and laboratory records. Incomplete adherence was defined as having missed ART for at least 48 consecutive hours during the past 3 months.
Twenty-nine percent of participants reported at least one reason for having ever missed ART (1278/4425). The most frequent reason was simply forgetting (681/1278 or 53%), followed by ART-related hunger or not having enough food (30%), and symptoms (12%). The median number of symptoms reported by participants was 4 (IQR: 2-7). Every additional symptom increased the odds of incomplete adherence by 12% (OR: 1.1, 95% CI: 1.1-1.2). Female participants and participants initiated on a regimen containing stavudine were more likely to report greater numbers of symptoms.
Symptoms were a common reason for missing ART, together with simply forgetting and food insecurity. A combination of ART regimens with fewer side effects, use of mobile phone text message reminders, and integration of food supplementation and livelihood programmes into HIV programmes, have the potential to decrease missed ART and hence to improve adherence and the outcomes of ART programmes.
Available from: Victoria Ngo
- "However, depression has emerged as a major threat to the success and benefits of ART, as it impedes ART adherence [9-11] and condom use [12-14], and has been associated with a greater likelihood of mortality [15-17] and worse immunologic and virologic response to treatment [18-21]. Clinical depression, as diagnosed by structured clinical interviews, generally ranges from 10 to 20% among PLWHIV in SSA [22-24], while an additional 20 to 30% have elevated depressive symptoms [23-27]. A wide range of interventions are effective in treating depression in PLWHIV , including antidepressants [29,30], and depression treatment improves ART use, adherence and outcomes [31-34]. "
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Despite 10 to% of persons living with HIV in sub-Saharan Africa having clinical depression, and the consequences of depression for key public health outcomes (HIV treatment adherence and condom use), depression treatment is rarely integrated into HIV care programs. Task-shifting, protocolized approaches to depression care have been used to overcome severe shortages of mental health specialists in developing countries, but not in sub-Saharan Africa and not with HIV clients. The aims of this trial are to evaluate the implementation outcomes and cost-effectiveness of a task-shifting, protocolized model of antidepressant care for HIV clinics in Uganda.
INDEPTH-Uganda is a cluster randomized controlled trial that compares two task-shifting models of depression care - a protocolized model versus a model that relies on the clinical acumen of trained providers to provide depression care in ten public health HIV clinics in Uganda. In addition to data abstracted from routine data collection mechanisms and supervision logs, survey data will be collected from patient and provider longitudinal cohorts; at each site, a random sample of 150 medically stable patients who are depressed according to the PHQ-2 screening will be followed for 12 months, and providers involved in depression care implementation will be followed over 24 months. These data will be used to assess whether the two models differ on implementation outcomes (proportion screened, diagnosed, treated; provider fidelity to model of care), provider adoption of treatment care knowledge and practices, and depression alleviation. A cost-effectiveness analysis will be conducted to compare the relative use of resources by each model.
If effective and resource-efficient, the task-shifting, protocolized model will provide an approach to building the capacity for sustainable integration of depression treatment in HIV care settings across sub-Saharan Africa and improving key public health outcomes.
INDEPTH-Uganda has been registered with the National Institutes of Health sponsored clinical trials registry (3 February 2013) and has been assigned the identifier NCT02056106.
Available from: Isabell Schierenbeck
- "The prevalence rate of HIV/AIDS in South Africa is as high as 17.8% among adults aged 15–49 (UNAIDS, 2012) and untreated depression among such people may be a risk for low adherence to antiretroviral treatment (ART) (Nel and Kagee, 2011). A recent review study from Sub- Sahara Africa found that the likelihood of good adherence to ART was 55% lower among persons with depressive symptoms compared to persons with no sign of depression (Nakimuli-Mpungu et al., 2012). In the Eastern Cape Province in South Africa, the HIV prevalence in the general population was approximately 10% in 2011 (SANAC, 2011) and among pregnant mothers aged 15–49 years, 28.1% in 2009 (Department of Health, 2010). "
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