Depressive Symptoms among People Living with HIV Attending ART Centers of Lumbini Province, Nepal: A Cross-Sectional Study

Background Depression is a common mental disorder and is a leading cause of disability globally. Depressive symptoms among people living with HIV can be a significant barrier to ART initiation and thus lead to poor ART adherence. Global studies have found the prevalence of depressive symptoms among people living with HIV ranges from 12 to 63%. The real scenario of Nepal still needs to be explored. Thus, this study aimed to identify the prevalence and predictors of depression in individuals with HIV. Methods An institutional-based cross-sectional study was carried out from August to December 2020 among 406 people living with HIV attending ART centers in Lumbini province. Participants were selected using a systematic random sampling technique and surveyed with a structured questionnaire consisting of sociodemographic variables, HIV AIDS-related variables, and 21 items Beck Depression Inventory tool. The odds ratio was used as the ultimate measure of association, with a 95% confidence interval computed to establish statistical significance. A multivariate regression analysis was carried out to identify the final predictors of depressive symptoms. Results The study found that 26.8% of the respondents had depressive symptoms. Those who were literate (AOR = 0.24, 95% CI: 0.10–0.61), in the poorest wealth quintile (AOR = 7.28, 95% CI: 2.22-23.87), initiated ART within 12 months (AOR = 1.88, 95% CI: 1.03–3.42), had CD4 cell counts below 200 (AOR = 2.50, 95% CI: 1.54–4.06), and had a time difference of 3 months or less between HIV diagnosis and ART initiation (AOR = 0.50, 95% CI: 0.29–0.86) were independently associated with depressive symptoms. Conclusion Routine screening for depressive symptoms should be integrated into national HIV prevention and control programs for people living with HIV. An enabling environment should be created to facilitate the rapid enrollment of individuals newly diagnosed with HIV in ART services, thereby reducing the time gap between HIV diagnosis and ART initiation.


Background
Te World Health Organization (WHO) defnes mental health as a state of wellbeing in which individuals recognize their potential, cope with the normal stresses of life, work productively, and contribute to their community [1].Globally, the two most prevalent mental disorders are depression and anxiety, which ranked among the top 25 leading causes of burden worldwide in 2019 [2,3].
Depression is a common mental disorder characterized by persistent sadness and a loss of interest in previously enjoyable activities [4].Te symptoms of depression can impact how a person feels, thinks, and handles their daily activities [5].Depression is the leading cause of disability worldwide and a signifcant contributor to the overall global burden of disease [4].Te global prevalence of depression is estimated to be 3.4%, with variation across countries ranging from 2.9% in the Solomon Islands to 6.3% in Ukraine [6].
Te Joint United Nation Program on HIV/AIDS (UNAIDS) 2021 report states that 38.4 million people are currently living with the human immunodefciency virus (HIV) and 28.7 million are receiving antiretroviral therapy (ART), a signifcant increase from 7.8 million in 2010 [7].
Tere are currently 22375 people on ART service in Nepal, of which 4325 (19.32%) belong to Lumbini province, the second highest [8].Although Nepal has made substantial progress in its HIV prevention program by reducing the HIV incidence per 1000 population from 0.08% in 2010 to 0.02 in 2021 and increasing the number of ART sites from 2 in 2004 to 84 in 2022 [8], the mental health dimension of people living with HIV (PLHIV) often goes unnoticed and unaddressed.Te global prevalence of depression among PLHIV ranges from 6.73% to 89.9% [9,10].A recent metaanalysis study revealed the pooled prevalence of depression in PLHIV to be 31%, with the highest prevalence of 40% in the Southeast Asia region [11].Studies in Nepal show it ranges from 25.5% to 43%, with occupational and marital status and ART duration as contributing factors [12,13].However, further exploration is needed to understand the scenario of depression and its associated factors among PLHIV in Nepal.Depression is a signifcant barrier to ART initiation and adherence among PLHIV in low-income countries [14][15][16].Terefore, this study aims to determine the prevalence of depressive symptoms and associated factors among PLHIV.To our knowledge, this is the third study in Nepal and the frst global study to assess the relationship between wealth quintile, time gap from HIV diagnosis to ART initiation, and depressive symptoms.
Tis study also aims to provide research evidence to other researchers, health care service providers, and policymakers for designing efective interventional programs to reduce depression prevalence, improve ART adherence, retention, achieve universal health coverage, and sustainable development goal (SDG) 3 where all the individuals will have good health and wellbeing.

Study Population.
Participants in the study were HIVpositive individuals aged 18-60 years and enrolled in a selected ART center in Lumbini province.Patients who were grieving within six months, had not undergone a CD4 count in the six months prior to data collection, had known mental illness, and were female participants who were pregnant or in postpartum during the data collection period were excluded from the study.

Sample Size and Sampling
Techniques.Te lumbini province of Nepal consists of twelve districts, of which six are terai districts.Tere are eight ART centers in the Terai districts of Lumbini province, Nepal.ART centers in terai districts of Nepal were divided into three levels: provincial, district, and community.One center was selected from each level using the lottery method.Te study identifed eligible participants through the ART register and used a systematic random sampling method to select participants from each ART site.Participants were surveyed with a structured questionnaire containing socio-demographic variables, HIV-related variables, and the 21-item Beck depression inventory (BDI) tool.Te required sample size was computed using the Stat Calc function of Epi-Info software.
where Z � standard variate, E � error term, p � prevalence of Depressive symptoms, and E is the allowable error.A prevalence of 50% has been taken in this study to ensure a maximum sample size.From the above formula, taking p � 0.5, q � 1 − p � 0.5, and an allowable error of 5%, the sample size was n � 385.Considering a 5% nonresponse rate, the total sample was 406.

Data Collection Tool and Measurement.
Data was collected using a structured questionnaire comprising sociodemographic variables, HIV-related variables, and a 21-item Beck Depression Inventory (BDI) tool.Te study examined the sociodemographic characteristics of participants, including age, gender, marital status, educational status, employment status, and personal habits such as alcohol consumption and tobacco use.HIV-related variables included WHO clinical stage, duration of ART initiation, period since diagnosis, CD4 count, and time duration between HIV diagnosis and ART initiation.Te WHO clinical stage of HIV has been classifed into four stages.In clinical stage I, patients are asymptomatic or have persistent generalized lymphadenopathy for longer than 6 months, clinical stage II refers to a mildly asymptomatic stage characterized by unexplained weight loss of less than 10 percent body weight, recurrent respiratory infections, as well as the range of dermatological conditions [17].Clinical stage III refers to a moderately symptomatic stage characterized by weight loss of more than 10 percent body weight, prolonged (more than one month) unexplained diarrhea, pulmonary tuberculosis, and severe bacterial infections [17].Similarly, clinical stage IV refers to the severe symptomatic stage and includes all AIDS-defning illnesses [17].Clinical variables of HIVpositive participants were collected from their ART register records.Beck depression inventory (BDI) scale was used to assess depressive symptoms.Te BDI scale is composed of 21 items, each with a four-point scale ranging from 0 to 3. Terefore, the value of the BDI scale ranges from 0 (lowest) to 63 (highest).Te Beck Depression Inventory (BDI) was used to assess depression severity, with scores ranging from normal (0-13), mild (14)(15)(16)(17)(18)(19), moderate (20)(21)(22)(23)(24)(25)(26)(27)(28), and severely 2 AIDS Research and Treatment depressed .Te tool has been validated in Nepal with a sensitivity of 0.92 and a specifcity of 0.82 [18].Also, the Cronbach alpha computed in our study was 0.948 which shows strong internal consistency and concurrent validity of the tool.ART counselors received a one-day orientation on data collection, and the collected data were regularly reviewed for errors by the principal investigator.
2.5.Data Processing and Analysis.Data were entered and analyzed in Statistical Package for Social Science (SPSS) software version 25.Te mean and standard deviation were calculated to describe the characteristics of the sample.Te bivariate logistic regression analysis assessed the association between dependent and independent variables.Te ultimate measure of association was the odds ratio, and a 95% confdence interval was computed to determine statistical signifcance.Variables associated with bivariate analysis were entered into a multivariate logistic regression model to identify the fnal predictors of depressive symptoms among people living with HIV.

Ethical Consideration. Ethical approval was obtained from the Universal College of Medical Science and Teaching
Hospital Institutional Review Committee (UCMS/IRC/014/ 20).Permission was obtained from the Medical Superintendent and Chief of the ART center of selected sites to access participants' clinical records.Participants were informed of the study, and written informed consent with a sign or thumbprint was obtained for data collection.

Sociodemographic Characteristics of Study Participants.
Table 1
Te observed diference in prevalence rate might be due to diferent study populations, cultural settings, study time, sample size, and the use of diferent diagnostic tools to assess depressive symptoms.
Te educational status of study participants was signifcantly associated with depressive symptoms.Literate study participants had a protective efect against depressive symptoms, as literate study participants were 76% less likely to have depressive symptoms than their illiterate counterparts, which aligns with studies conducted in India [25] and Sudan [26].Te social causation perspective suggests that higher education can lead to better socioeconomic conditions, reduced stress, improved coping strategies, and a decreased risk of depressive symptoms [35].In addition, higher education levels have a long-term efect on depressive symptoms and can help reduce the risk of depression later in life [36].However, previous studies conducted in Nepal [12], Pakistan [37], and Bhutan [22] did not fnd any association between education and depressive symptoms.
PLHIV in the poorest wealth quintile were more likely to have depressive symptoms than in the wealthiest quintile.Te fndings of this study are supported by a study conducted in India [38], Vietnam [19], and Cameroon [39], where PLHIV with low socioeconomic status were found to have more depressive symptoms compared to PLHIV with high socioeconomic status.Socioeconomic status can impact the development of mental illness through adverse, economically stressful conditions among lower-income groups [40].Also, having fnancial resources can prevent the stressors that drive depression and reduce the blow of disruptions in daily living [40].
PLHIV with a period of ART initiation ≤12 months were more likely to have depressive symptoms than those with a period of ART initiation >12 months, supported by a study conducted in Nepal [13] and Vietnam [19].PLHIV with a shorter duration of ART initiation might feel burdened with taking medicine, maintaining an ART adherence rate, and having less confdence regarding the positive efects of ART drugs which might trigger stress levels and develop depressive symptoms.With longer ART initiation duration and experiencing the benefts of ART drugs, HIV patients may feel more normal regarding their disease status, have lower stress levels, and have decreased depressive symptoms.However, previous studies conducted in China, Bhutan, Ethiopia, and Cameroon [9,22,32,39] did not show any association.Tis could be because of the diferent cutof points used for the duration of ART initiation.
Te CD4 count of PLHIV was signifcantly associated with depressive symptoms.PLHIV with a CD4 count <200 cells/mm 3 was 2.61 times more likely to have depressive symptoms than those with HIV with a CD4 count ≥200 cells/mm 3 .Tis study's fndings are in alignment with the other studies conducted in Pakistan [24], Vietnam [33], Ethiopia [41], Cameroon [21,39,42], and Nigeria [43].A lower CD4 count often results in an AIDS-defning illness and increased mortality [44].HIV patients with low CD4 cell counts might have an increased fear of dying, leading to depressive symptoms.Also, the inability to maintain a normal CD4 cells count despite being on ART medication might discourage HIV patients and help with the progression of depressive symptoms [21].
To the best of our knowledge, this is the frst global study to assess the association between the time gap between HIV diagnosis and ART initiation and depressive symptoms among PLHIV.Our fndings suggest that those diagnosed with HIV and who began ART within three months were 50% less likely to experience depressive symptoms than

AIDS Research and Treatment
those who waited longer.People who have been newly diagnosed with HIV can be considered to have stressful life events [45] and have increased concern about their longterm health, social stigma, and medication [46], all of which may result in stress, psychological burden, and depressive symptoms.Reducing the time gap between HIV diagnosis by the timely initiation of ART medication and counseling services may help newly diagnosed individuals build confdence, develop coping strategies, and reduce stress levels, burden, and depressive symptoms associated with HIV infection.Tough Nepal has made good progress in its HIV prevention and control program, policies addressing the mental health needs of PLHIV are still lacking.Regardless of the signifcant predictors found in this study, there is a need to develop HIV care guidelines regarding the management of depressive symptoms in PLHIV.Interventions, including cognitive-behavioral group plans and community-based interpersonal psychotherapy can be benefcial in reducing depressive symptoms in PLHIV, especially in developing countries like Nepal [47,48].Having family, friends, and special someone can act as constant support physically, mentally, and emotionally in particular matters related to taking care of the health needs of PLHIV, thus improving overall well-being and quality of life among PLHIV [49].ART centers act as focal points for providing treatment, care, and support for PLHIV; hence, staf working in ART centers need to be trained regarding the assessment of determinants of mental health, social needs, and clinical issues of PLHIV.Family members and friends need to be involved from the beginning in providing care and support to PLHIV through proper counseling services and peer support groups.Te role of the private and developmental sectors can be explored in addressing the mental health needs of PLHIV.

Conclusion
More than one-fourth (26.8%) of the people living with HIV had depressive symptoms.Educational status, wealth quintile, CD4 count, duration of ART initiation, and time diference between HIV diagnosis and ART initiation were found to be signifcant predictors of depressive symptoms among PLHIV.Routine mental health screening for all PLHIV attending ART centers should be done to identify the risk of depressive symptoms.Also, mental health care services need to be integrated into national HIV prevention and control programs.Te PLHIV group should be made aware of the importance of timely treatment initiation and adherence to ART.An enabling environment should be created to facilitate the rapid enrollment of individuals newly diagnosed with HIV for ART services, thereby reducing the time gap between HIV diagnosis and ART initiation.Tere is a need to advocate for making policies that prioritize mental health services within HIV care and allocate resources accordingly to address the mental health needs of PLHIV.More studies regarding mental health issues among PLHIV need to be conducted, which can provide evidence to other researcher's health care service providers and policymakers for designing efective interventional programs to address the issue.Since most of the studies conducted are cross-sectional in nature, there is a need to conduct analytical studies which will help establish causal relationships.
An institutional-based crosssectional study was conducted from August to December 2020 at Lumbini Provincial Hospital, Prithivi Chandra Hospital, and Maharajgunj Primary Health Care Center in Lumbini Province, Nepal.Lumbini Province is in western Nepal and is the third-largest and most populous province.It covers an area of 22,228 sq.km, or 15.11% of the total country area.
Depression and Clinical Characteristics of StudyParticipants.Table3shows the depression and clinical characteristics of study participants at selected ART centers in Lumbini province.Among the study participants, 109 (26.8%) had depressive symptoms.Te majority of the study participants with a period of diagnosis of HIV more than 12 months from the survey date were 344 (84.7%).Sociodemographic Predictors of Depression.Table4shows sociodemographic predictors of depression.Results from the bivariate analysis revealed that educational status and occupation of the respondent, family type, wealth quintile, and occupation of the respondent's partner were associated with depression.Factors signifcant in bivariate analysis were entered into the multivariate regression model for confounding adjustment.Te multivariate regression model results identifed educational status and wealth quintiles as sociodemo-Table5shows the clinical predictors of depression.Factors associated with depression, resulting from the bivariate analysis, were entered into a multivariate model, which identifed the period of ART initiation, the time diference between the period of diagnosis and the period of ART initiation, and CD4 cells count as clinical predictors of depression.Te odds of depression among study participants with a period of ART initiation ≤12 months were 1.88 times higher than study participants with a period of diagnosis >12 months (AOR � 1.88, CI: 1.03-3.42).Similarly, the time diference between the period of diagnosis and ART initiation with ≤3 months was found to have a protective efect against depression (AOR � 0.50, CI: 0.29-0.86).Te odds of depression were 2.50 times higher in study participants with a low CD4 cell count (AOR � 2.50, CI: 1.54-4.06).
tics of the respondent's partner.Te mean age of the respondent's partner was 39.49 years, with a standard deviation of ±7.75 years.Among respondent's partners, 106 (41.1%) were aged between 30−40 years, 179 (69.4%) were illiterate, 90 (34.9%) were involved in the agriculture sector, and 196 (76%) did not consume tobacco or alcohol products in the three months prior to the survey.3.3.graphicpredictors of depression.Literate study participants were found to have a protective efect on depression (AOR � 0.40, CI: 0.17-0.95)compared to illiterate participants.Te odds of depression among the poorest wealth quintile were 7.28 times higher than the richest (AOR � 7.28, CI: 2.22-23.87).3.5.Clinical Predictors of Depression.

Table 2 :
Sociodemographic characteristics of the respondent's partner at selected ART centers in Lumbini province, 2020.

Table 3 :
Depression and clinical characteristics of study participants at selected ART centers in Lumbini province, 2020.

Table 1 :
Sociodemographic characteristics of study participants at selected ART centers in Lumbini province, 2020.

Table 4 :
Sociodemographic predictors of depression at selected ART centers in Lumbini province, 2020.

Table 5 :
Clinical predictors of depression at selected ART centers in Lumbini province, 2020.