Globally, every year around 800,000 to a million people die due to suicide [
An institution based cross-sectional study was conducted at Zewditu Memorial Hospital. Zewditu Memorial Hospital is one of the five Federal Hospitals located in Cherkos Kifle Ketema at the center of Addis Ababa, capital city of Ethiopia. It is the first hospital where ART was stated for the first time in Ethiopia since 2005. There were 14,347 HIV-positive patients having HIV care follow-up in the hospital in 2014. Participants were eligible to participate in the survey if they were aged 18 years or above and had a follow-up visit at Zewditu hospital during the study period.
The sample size was determined by using single population proportion. The calculated sample size was 423. A systematic random sampling technique was used to select study participants. Every twelve clients were interviewed during the period from May to June 2014. Interviewer-administered questionnaire was used to collect data. Participants’ chart was also reviewed to record their date of HIV diagnosis, WHO clinical stage, and CD4 count of the patient.
Composite International Diagnostic Interview (CIDI) adopted by World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) which was evaluated in Ethiopia in 2002 was used to assess suicidal ideation and attempt among HIV-positive patients. Suicidal ideation was recorded if the respondents respond with "yes" to the following question: have you ever seriously thought about committing suicide? And suicidal attempt was recorded if the respondents respond with "yes" to the following question: have you ever attempted suicide? Patient Health Questionnaire (PHQ-9) was used to assess depression in study participants. PHQ-9 is a toll which contains 9 questions. Each question has values from 0 to 4: 0 means not at all, 1 means several days, 2 means more than half the days, and 4 means nearly every day. The scores in each of the columns were added together. The scores of each column in the PHQ-9 Questionnaire were added together and those who scored 5 to 27 were considered to have depression. Perceived stigma was screened with HIV-related stigma scale. WHO clinical stages were defined as WHO clinical stage I = asymptomatic (no significant immune suppression), WHO clinical stage II = mild clinical symptoms (mild immune suppression), WHO clinical stage III = advanced immune suppression, and WHO clinical stage IV = severe immune suppression with severe clinical symptoms. Primarily the questionnaire was translated from English to Amharic and then back to English by another language instructor to maintain its consistency. Finally, Amharic version of the questionnaire was used to interview patients.
The filled questionnaires were checked manually for completeness, coded and entered into EPI Info version 7 statistical software, and exported to SPSS version 20 for further analysis. Descriptive statistics were computed to explain the study population with respect to the relevant variables. Variables having a
Ethical clearance was obtained from an institutional review board of University of Gondar and Amanuel Specialized Mental Health Hospital. Official letter was written to Zewditu Memorial Hospital. Privacy and confidentiality of the study participants were maintained. Participants were fully informed about the aims of the study before the start of the interview and verbal informed consent was obtained from them.
A total of 417 participants were involved in the study with a response rate of 98.6%. The mean age of respondents was found to be 40.5 (SD: ±8.86) years. Two hundred forty-three (58.3%) of the respondents were female. Two hundred three (48.7%) of the participants were unemployed. Three hundred forty-two (82.0%) of the participants knew their HIV status for at least 36 months prior to the interview. Three hundred twelve (74.8%) of respondents had a CD4 count greater than or equal to 350, and 181 (43.4%) of them were of WHO clinical stage I. Three hundred seventy-nine (90.9%) patients were on HAART.
Thirty-six (8.6%) and 5 (1.2%) of the participants had family history of suicidal attempt and suicidal commitment in the past, respectively. One hundred ninety-seven (47.2%) of the respondents had depression and 234 (56.1%) had perceived stigma due to their HIV status. Sixty-eight (16.3%) of the respondents had a history of substance use at least once in their lifetime. Fifty-two (12.5%) of the respondents were chewing khat and 27 (6.5%) of them had a history of alcohol. Only seven (1.7%) participants were current users of substances for a nonmedical purpose (Table
Sociodemographic characteristics of HIV-positive people at Zewditu Memorial Hospital, Addis Ababa, Ethiopia, June 2014
Variables | Categories | Frequency (%) |
---|---|---|
Age in years | 18–27 | 22 (5.3) |
28–37 | 139 (33.3) | |
38–47 | 160 (38.4) | |
48–57 | 75 (18.0) | |
≥58 | 21 (5.0) | |
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Sex | Male | 174 (41.7) |
Female | 243 (58.3) | |
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Ethnicity | Amhara | 231 (55.4) |
Oromo | 63 (15.1) | |
Tigre | 75 (18.0) | |
Gurage | 37 (8.9) | |
Other |
11 (2.6) | |
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Marital status | Married | 188 (45.1) |
Single | 116 (27.8) | |
Divorced | 57 (13.7) | |
Widowed | 56 (13.4) | |
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Religion | Orthodox | 333 (79.8) |
Muslim | 32 (7.7) | |
Protestant | 42 (10.1) | |
Catholic | 10 (2.4) | |
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Educational status | No formal education | 9 (2.2) |
Primary | 106 (25.4) | |
Secondary | 152 (36.5) | |
Tertiary | 150 (35.9) | |
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Occupation | Unemployed | 203 (48.7) |
Employed | 214 (51.3) | |
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Monthly income | <749 | 93 (22.3) |
750–1199 | 52 (12.5) | |
≥1200 | 272 (65.2) | |
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With whom you are living | Alone | 138 (33.1) |
Partner | 183 (43.9) | |
Family | 96 (23.0) | |
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Social support | Good | 205 (49.2) |
Poor | 212 (50.8) | |
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Depression | Presence | 197 (47.2) |
Absence | 220 (52.8) | |
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Perceived stigma | Yes | 234 (56.1) |
No | 183 (43.9) | |
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Ever substance use | Yes | 68 (16.3) |
No | 349 (83.7) | |
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Current substance use | Yes | 7 (1.7) |
No | 410 (98.3) |
Other
Ninety-four (22.5%) and 58 (13.9%) of the study participants had suicidal ideation and suicidal attempt, respectively. Twenty-two (23.4%) of the respondents having suicidal ideation reported that they had it within 3 months after they knew their serostatus. Among the respondents who had suicidal ideation, 66 (70.2%) of them were female. Meanwhile, 13 (22.4%) respondents attempted suicide within 3 months after they knew their positive HIV test result. Among the respondents who attempted suicide, 30 (51.7%) of them had a plan to commit suicide. Among those who attempted suicide, 45 (77.6%) were female (Figure
Gender proportion of suicidal ideation and attempt among HIV-positive patients at Zewditu Memorial Hospital, Addis Ababa, Ethiopia, June 2014.
This study showed that the more the progression of the HIV infection the higher the suicidal ideation and attempt. Those HIV-positive patients with WHO clinical stage IV condition were 6.5 times more likely to have suicidal ideation as compared to those patients who were asymptomatic (WHO clinical stage I) (AOR = 6.55, 95% CI: 2.35–18.20). Furthermore, those patients with WHO clinical stage III condition were 4 times more likely to have suicidal ideation as compared to those who were asymptomatic (WHO clinical stage I) (AOR = 4.12, 95% CI: 2.07–8.16). HIV-positive patients who were not on HAART were 2.5 times more likely to have suicidal ideation as compared to those who were on HAART (AOR = 2.49, 95% CI: 1.07–5.70). HIV-positive patients who had past family history of suicidal attempt were about 2.3 times more likely to have suicidal ideation as compared to those who had no past family history of suicidal attempt (AOR = 2.25, 95% CI: 1.01–5.03). Patients having comorbid depression were 2.5 times more likely to have suicidal ideation as compared to patients with no depression (AOR = 2.45, 95% CI: 1.45–4.12). Moreover, patients who had perceived stigma were 1.8 times more likely to have suicidal ideation as compared to patients who did not have perceived stigma (AOR = 1.76, 95% CI: 1.02–3.03) (Table
Logistic regression analysis of factors associated with suicidal ideation among HIV-positive people at Zewditu Memorial Hospital, Addis Ababa, Ethiopia, June 2014.
Variable | Categories | Suicidal ideation | COR (CI: 95%) | AOR (CI: 95%) | |
---|---|---|---|---|---|
Yes | No | ||||
Sex | Male | 28 | 146 | 1.00 | 1.00 |
Female | 66 | 177 | 1.94 (1.18–3.18) |
1.67 (0.96–2.88) | |
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Occupation | Unemployed | 56 | 147 | 1.76 (1.10–2.81) | 1.59 (0.94–2.68) |
Employed | 38 | 176 | 1.00 | 1.00 | |
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Living with | Alone | 38 | 100 | 1.90 (0.98–3.65) | 1.53 (0.74–3.14) |
Partner | 40 | 143 | 1.39 (0.73–2.65) | 2.01 (0.98–4.08) | |
Family | 16 | 80 | 1.00 | 1.00 | |
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Social support | Good | 36 | 169 | 1.00 | 1.00 |
Poor | 58 | 154 | 1.77 (1.10–2.82) |
1.07 (0.56–2.01) | |
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WHO clinical stages | I | 26 | 155 | 1.00 | 1.00 |
II | 29 | 112 | 1.54 (0.86–2.76) | 1.47 (0.77–2.79) | |
III | 28 | 45 | 3.71 (1.97–6.95) |
4.12 (2.07–8.16) |
|
IV | 11 | 11 | 5.96 (2.34–15.15) |
6.55 (2.35–18.2) |
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Being on ART | Yes | 82 | 297 | 1.00 | 1.00 |
No | 12 | 26 | 1.67 (0.80–3.45) | 2.49 (1.07–5.70) |
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Family history of suicidal attempt | Yes | 15 | 21 | 2.73 (1.34–5.53) |
2.25 (1.01–5.03) |
No | 79 | 302 | 1.00 | 1.00 | |
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Depression | Presence | 62 | 135 | 2.69 (1.66–4.36) |
2.45 (1.45–4.12) |
Absence | 32 | 188 | 1.00 | 1.00 | |
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Social stigma | Yes | 67 | 167 | 2.32 (1.41–3.81) |
1.76 (1.02–3.03) |
No | 27 | 156 | 1.00 | 1.00 |
Model: Chi-square = 9.94, df = 8, and Sig. = 0.269.
In a multivariable analysis, HIV-positive patients with WHO clinical stage IV condition were 11 times more likely to have suicidal attempt as compared to those who were asymptomatic (WHO clinical stage I) (AOR = 10.98, 95% CI: 3.56–33.79). This study also found that patients who had WHO clinical stage III condition were 4.5 times more likely to attempt suicide as compared to those who were asymptomatic (WHO clinical stage I) (AOR = 4.46, 95% CI: 1.93–10.29). HIV-positive females were 4.5 times more likely to attempt suicide (AOR = 4.48, 95% CI: 1.85–10.81). Patients who were not on HAART were 3.4 times more likely to attempt suicide (AOR = 3.44, 95% CI: 1.33–8.89). Participants who used substance at least once in their life were 3.39 times more likely to attempt suicide as compared to those who never used any substance in their lifetime (AOR = 3.39, 95% CI: 1.32–8.73). Patients having comorbid depression were 2 times more likely to attempt suicide as compared to patients who had no depression (AOR = 2.04, 95% CI: 1.07–3.87) (Table
Logistic regression analysis of factors associated with suicidal attempt among HIV-positive people at Zewditu Memorial Hospital, Addis Ababa, Ethiopia, June 2014.
Variable | Categories | Suicidal attempt | COR (CI: 95%) | AOR (CI: 95%) | |
---|---|---|---|---|---|
Yes | No | ||||
Sex | Male |
13 | 161 | 1.00 | 1.00 |
Female | 45 | 198 | 2.82 (1.46–5.39) |
4.48 (1.85–10.81) |
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Occupation | Unemployed | 37 | 166 | 2.04 (1.15–3.63) |
1.91 (1.001–3.65) |
Employed | 21 | 193 | 1.00 | 1.00 | |
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Monthly income (Ethiopian Birr) | <750 | 20 |
73 | 2.21 (1.18–4.12) |
1.58 (0.72–3.44) |
750–1200 | 8 | 44 | 1.47 (0.63–3.40) |
1.06 (0.38–2.92) | |
≥1200 | 30 | 242 | 1.00 | 1.00 | |
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Social support | Good | 20 |
185 | 1.00 | 1.00 |
Poor | 38 | 174 | 2.02 (1.13–3.60) |
1.63 (0.84–3.13) | |
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WHO clinical stages | I |
14 | 167 | 1.00 | 1.00 |
II |
16 | 125 | 1.53 (0.71–3.24) | 1.47 (0.64–3.33) | |
III | 18 | 55 | 3.90 (1.82–8.36) |
4.46 (1.93–10.29) |
|
IV | 10 | 12 | 9.94 (3.65–27.04) |
10.98 (3.56–33.79) |
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Started HAART | Yes | 49 | 330 | 1.00 | 1.00 |
No | 9 | 29 | 2.09 (0.09–4.67) |
3.44 (1.33–8.89) |
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Family history of suicidal attempt | Yes | 10 | 26 | 2.67 (1.21–5.87) |
2.26 (0.88–5.75) |
No | 48 | 333 | 1.00 | ||
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Depression |
Presence | 38 | 159 | 2.39 (1.33–4.26) |
2.04 (1.07–3.87) |
Absence | 20 | 200 | 1.00 | 1.00 | |
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Perceived stigma | Yes | 42 | 192 | 2.28 (1.23–4.21) |
1.34 (0.60–3.01) |
No | 16 | 167 | 1.00 | 1.00 | |
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Ever use of substance | Yes | 13 | 55 | 1.59 (0.80–3.15) | 3.39 (1.32–8.73) |
No | 45 | 304 | 1.00 | 1.00 |
Model: Chi-square = 11.11, df = 8, and Sig. = 0.19.
In this study, the prevalence of suicidal ideation among HIV-positive individuals was found to be 22.5%. It was higher than that in a community-based study conducted in Addis Ababa among the adult general population (2.7%) in 1994 [
The prevalence of suicidal ideation at Zewditu Memorial Hospital was lower than that in a study conducted in Nigeria, 34.7% [
This finding was almost in line with the studies conducted in South Africa among HIV-positive patients at HIV counseling and testing clinic, 17.1% [
Fifty-eight (13.9%) of the respondents had suicidal attempt. This is almost similar to the study done in South Korea, 11% [
The study also revealed that suicidal attempt among HIV-positive patients was in line with other studies done in Nigeria, 9.3% [
WHO clinical stage of HIV was significantly associated with suicidal ideation. Those who had WHO clinical stage IV condition were 6.5 times more likely to have suicidal ideation as compared to those who were asymptomatic (WHO clinical stage I) (AOR = 6.55, 95% CI: 2.35–18.20) and those who had WHO clinical stage III condition were 4 times more likely to have suicidal ideation as compared to those who were asymptomatic (WHO clinical stage I) (AOR = 4.12, 95% CI: 2.07–8.16). This may be due to the fact that clinical stages are classified based on the presence and absence of opportunistic infections. HIV-positive patients who are on advanced clinical disease may have decreased quality of life which may lead them to think of death. This is supported by other similar studies conducted in Benin City, Nigeria. This finding is also in line with the study conducted in New York among HIV-positive women and those who were not on HAART [
Not being on HAART was significantly associated with suicidal ideation. HIV-positive patients who were not on HAART were 2.5 times more likely to have suicidal ideation as compared to those who were on HAART (AOR = 2.49, 95% CI: 1.07–5.70). That is to say, patients may assume the future burden of HAART in terms of long-term side effects and pill burden. So they may have suicidal ideation. Another possible reason may be that those who are not on HAART may have a thought of burden of lifelong treatment in addition to HIV infection itself. Those HIV-positive patients with comorbid depression were 2.5 times more likely to have suicidal ideation as compared to those with no depression and this is supported by the study conducted in four US cities [
This study also showed that those who had a family history of suicidal attempt were two times more likely to have suicidal ideation as compared to those with no family history of suicidal attempt (AOR = 2.25, 95% CI: 1.01–5.03). This may be due to the fact that genetic predisposing increases the risk for suicidal ideation, which is supported by international scholars [
Comorbid depression was found to be significantly associated with suicidal ideation. HIV-positive patients who had depression were about 2.5 times more likely to have suicidal ideation as compared to those who had no depression (AOR = 2.45, 95% CI: 1.45–4.12). This is supported by other studies done in New York and Virginia University [
HIV-positive patients who perceived stigma were two times more likely to have suicidal ideation as compared to those who did not (AOR = 1.76, 95% CI: 1.02–3.03), which is in line with studies conducted in Sub-Saharan Africa, Virginia University, and South Africa [
Being female, WHO clinical stage, not being on HAART, depression, and ever uses of substance were significantly associated with suicidal attempt among HIV-positive patients.
Females were 4.5 times more likely to attempt suicide as compared to males (AOR = 4.48, 95% CI: 1.85–10.81). This disagrees with other studies conducted in South Africa and Sub-Saharan Africa [
WHO clinical stage was significantly associated with a suicidal attempt. Respondents who had WHO clinical stage IV condition and WHO clinical stage III condition were 11 and 4.5 times more likely to attempt suicide as compared to those who were asymptomatic (WHO clinical stage I), respectively. This may be due to the fact that those HIV-positive patients with advanced immunosuppression may suffer from variety of opportunistic infections (OIs) and this suffering may lead to suicidal attempt.
HIV-positive patients who were not on HAART were 3.5 times more likely to have suicidal attempt as compared to those who were on HAART. The possible reason may be the fact that those HIV-positive patients who were not on HAART may think next of being on HAART and the probable outcome of lifelong drug side effect. Another possible reason may be patients thinking about future burden of lifelong treatment.
Participants with depression were two times more likely to have a suicidal attempt as compared to those with no depression. This is in agreement with other similar studies conducted in Uganda, New York, and Virginia University [
The result of the present study revealed that ever use of the substance was another factor for suicidal attempt among HIV-positive participants. Those who ever used substance in their life were 3.4 times more likely to attempt suicide as compared to those who had no history of substance use in their life. This may be due to the fact that use of substance could disturb normal function of the brain, which could contribute to attempting suicide [
In this study, we assessed suicidal ideation; individuals may not disclose their actual thought about suicide through an interview. Those comorbid medical and psychiatric problems that may be a factor for suicidal ideation and attempt were not assessed.
The prevalence of suicidal ideation and suicidal attempt was found to be high among HIV-positive patients. Advanced WHO clinical stage, not being on HAART, family history of the suicidal attempt, depression, and perceived stigma were associated with suicidal ideation and attempt.
Early diagnosis and treatment of opportunistic infections and depression as well as timely provision of ART need to be encouraged in HIV-positive adults. Furthermore, counseling on substance use and its consequences and early identification of HIV-positive people with family history of suicidal ideation have to be considered. Psychiatric evaluation needs to be done for those HIV-positive people using substances.
The authors declare that they have no conflicts of interest.
Etsay Hailu Gebremariam wrote the proposal, participated in data collection, and analyzed the data. Mebratu Mitiku Reta approved the proposal with some revisions, participated in data analysis and revised subsequent drafts of the paper, and was involved in manuscript writing. Zebiba Nasir approved the proposal with some revisions and participated in data analysis. Fisseha Zewdu Amdie participated in commenting on the proposal and was involved in manuscript preparation. All authors read and approved the final manuscript.
The authors acknowledge College of Medicine and Health Sciences, University of Gondar, and Amanuel Specialized Mental Health Hospital for their financial and technical support. Zewditu Memorial Hospital, data collectors, and all the study participants are also highly acknowledged.