Psychiatry Journal
Volume 2020 (2020), Article ID 5414072, 9 pages
https://doi.org/10.1155/2020/5414072

Research Article

Prevalence and Factors Associated with Depression among HIV/AIDS-Infected Patients Attending ART Clinic at Jimma University Medical Center, Jimma, Southwest Ethiopia

Beyene Dorsisa, Gutema Ahimed, Susan Anand, and Tariku Bekela

School of Nursing and Midwifery, Jimma University, Ethiopia

Correspondence should be addressed to Beyene Dorsisa; beyenedo@gmail.com

Received 17 February 2020; Accepted 24 June 2020; Published 6 August 2020

Academic Editor: Lenin Pavón

Copyright © 2020 Beyene Dorsisa et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. HIV is a chronic life-threatening illness and, like other similar chronic and stigmatizing illnesses, can be stressful to manage. Depression is a common mental health problem that deteriorates the quality of life of people with HIV/AIDS and found to be a strong predictor for noncompliance to antiretroviral therapy treatment. Therefore, epidemiological evidence on the factors associated with depression among patients with HIV/AIDS can contribute towards effective and efficient preventive health care strategies for this population. Objectives. To assess the prevalence and factors associated with depression among HIV/AIDS-infected patients attending ART clinic at Jimma University Medical Center, Jimma, Southwest Ethiopia, in 2018. Methods. This study followed an institution-based cross-sectional quantitative study design. A simple random sampling method yielded 303 participants who were interviewed from April to May 2018, using a pretested questionnaire, followed by their card review. The SPSS version 23 was used for bivariate analysis which was used to find out the significance of association. Variables that showed association in bivariate analysis at value < 0.25 were entered to multivariable logistic regressions to control for confounders, and the significance of association was determined by 95% confidence interval and value < 0.05. Results. The point prevalence of depression was 94 (31%). Variables like sex ( ()), marital status ( ()), opportunistic infection ( ()), and medication adherence ( ()) were significantly associated with depression. Conclusion and Recommendation. From the findings of this study, it is possible to conclude that depression was highly prevalent among people living with HIV/ADS. Sex, marital status, opportunistic infection, and medication adherence were found to be associated with depression and need attention from the health professional working in the ART clinic.

1. Introduction

Depression is one of the major mental health problems categorized under mood disorders and characterized by persistent experience of a depressed mood and loss of interest [1] and accompanied by symptoms like change in appetite, disrupted sleep patterns, increased or diminished activity level, impaired attention and concentration, and markedly decreased feelings of self-worth.

In severe forms, death wish or attempts to take one’s life are present. Early diagnosis is essential, as in addition to the mental suffering, it causes significant social and occupational impairment [2]. HIV/AIDS is one of the global burden diseases, recognized as a serious public health problem and has spread throughout the world affecting all population [3].

It is a chronic and life-threatening illness and overwhelming to the individual [4]. Its life-threatening nature may induce fear of impending mortality. The medical squeal of HIV infection its associated opportunistic infections and side effects of antiretroviral treatment can mimic symptoms of depression (fatigue, concentration problems, somatic symptoms, decreased appetite, and weight loss [5]). When patients with HIV/AIDS develop depression, it accentuates the disease burden and is associated with poor health outcomes. It is also linked with poor antiretroviral therapy (ART) adherence resulting in loss of therapeutic effect, besides having a negative impact on the quality of life of people with HIV/AIDS. Unfortunately, depression is not diagnosed in majority of patients, and therefore, the condition goes untreated [6].

Reasons for high prevalence of depression among people living with HIV/AIDS (PLWHA) could be many [7]. Studies have revealed that depression is associated with different sociodemographic and health-related factors. It is persistently highly prevalent among the poor [8, 9]. Studies in Botswana and Uganda, for example, revealed that depression was associated with food insecurity and the sex of the persons infected with HIV/AIDS [8–10]. The study carried out in Tigray, North Ethiopia, revealed that it was associated with the place of residence, economic status, and occupational status [11]. Depression tends to weaken a person’s capacity for judgment, thereby predisposing for risky behaviors [12]. Recent data on the topic is lacking in Jimma; therefore, this study is aimed at determining the prevalence of depression and associated factors among PLWHA who are in ART follow-up at JUMC, Jimma.

Research evidence on the magnitude of depression among PLWHA is important to design more effective treatment programs for the management and prevention of its consequences and to improve their quality of life.

This study will provide research evidence for stakeholders on the magnitude of depression among PLWHA, in order to implement clinical and community-based intervention programs for the management and prevention of depression among PLWHA, aimed at improving their quality of life.

2. Methods and Materials

2.1. Study Area and Period

Jimma University Medical Center is found in Oromia region, southwest of Ethiopia in Jimma town, which is located 346 km to the southwest of Addis Ababa and provides health services for population in the town and the surrounding districts. In the town, there are different health facilities: four health centers, one general hospital and one specialized hospital currently, and one health center, and the two hospitals are giving ART service for people living with HIV/AIDS. In Jimma University Medical Center Hospital, there is a separate ART clinic at which care and follow-up are given for 3075 PLWHA. The study was conducted from April 3 till May 2018.

2.2. Study Design

Institutional-based cross-sectional study design was used.

2.3. Source Population

The source population were all PLWHA attending ART Clinic at Jimma University Medical Center.

2.4. Study Population

The study population were all PLWHA attending ART clinic at JUMC and who were included in to the sample

2.5. Eligibility Criteria

2.5.1. Inclusion Criteria

(i)Participants aged older than or equal to 18years(ii)Participants who are on routine appointment receiving ART treatment

2.5.2. Exclusion Criteria

(i)Bereavement within 3 months(ii)Female patient in postpartum period(iii)Those who have not done their CD4 count in six months preceding data collection

2.6. Sample Size Determination

The sample size was determined by using single population proportion formula. The following assumptions were made: marginal error () that was tolerated in either sides of the true proportion to be 5%, using 95% confidence level,, and the proportion of depression in HIV/AIDS patient taken from a research done in Fitche Zonal Hospital in 2017. Those on steroid treatment [8]

where is the required sample size/minimum sample size required for the study.

is the standard normal distribution () with confidence interval of 95%, and .

is the prevalence/population proportion ().

is the desired absolute precision, a tolerable margin of error () formula with 10% nonresponse rate which is 28. Therefore, the final sample size is 303.

2.7. Sampling Technique and Sampling Procedures

Simple random sampling technique was used to select the study subjects.

First, the list of patients was obtained from the database and registration logbook. Then, the lottery method was used to select each study subject.

2.8. Data Collection Instrument and Procedure

Data was collected using pretested interviewer-administered questionnaire, patient card review. Generally, questionnaire for this study contains 57 items and takes 30-45 minutes.

Part I. Socioeconomic characteristics were developed based on reviewed literature [8]. This contains 10 items with both open-ended and close-ended questions.

Part II. Behavioral factors are questions pertaining to substance use and sexual practices developed based on revied literature [41]. This contains 05 items with close-ended questions.

Part III. Clinical factors are from some of the questionnaires adapted from another literature [36]. This contains 10 items with both open- and close-ended questions and Morisky Medication Adherence Scale. Eight questionnaires were standard which contains 08 items with close-ended questions; adherence was defined as adherent (high) with a Morisky Medication Adherence Scale score of 0 and nonadherent (medium, low) with a score of 1 [44, 45]. The reliability of the instrument calculated using Cornbrash’s alpha coefficient was 0.725.

Part IV. Patient Health Questionnaire (PHQ-9) depressive symptom scale contains 09 items. It was a Likert scale with the following response options:Pateint health questionnaire (PHQ-9) depressive symptom scale have 09 items. 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day. Classification of depression was measured by verbal responses of participants to PHQ-9 scale and expressed in scores. PHQ-9 was categorized as follows: severe depression: respondent with a score between 20 and 27; moderately severe depression: respondent with a score between 15 and 19; moderate depression: respondent with a score between 10 and 14; mild depression: respondent with a score between 5 and 9; minimal depression: respondent with a score between 1 and 4; and nondepressed respondent with score 0 [46, 47]. The internal consistency of this instrument using Cornbrash’s alpha was 0.883.

Part V. Psychosocial factors: Oslo Social Support Scale contains 03 items by using close-ended questions. It was standard measured by verbal responses of participants to Oslo Social Support Scale and expressed in scores. Social support is categorized as follows: strong social support: respondent with a score between 12 and 14; moderate social support: respondent with a score between 9 and 11; and poor social support: respondent with a score between 3 and 8 [48]. The instrument showed reliability value 0.721, by Cornbrash’s alpha.

Perceived HIV related stigma contains 12-item standard Likert scale with the following response options: 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree. It contains personalized stigma, disclosure, public attitudes, and negative self-image. Perceived HIV-related stigma is assessed with a Likert scale[48]. The Cornbrash’s alpha coefficient value was 0.648.

2.9. Data Processing and Analyses

The data were analyzed by SPSS version 23, using simple descriptive statistics.

The presence of crude association between the dependent variable with each independent variable was determined by bivariate logistic regression analysis. Variables that showed statistically significant association by bivariate analysis () were further subjected to multivariable logistic regression analysis to control the confounding variables. The significance of association was determined at 95% confidence interval and value < 0.05.

2.10. Data Quality Management

Two days of training were given to data collectors (four BSc nurses) and supervisors (two BSc nurses) on the objectives, clarity of tools, and overall data collection procedures to standardize interview procedures and reduce interviewers’ bias. The final version of the questionnaire was translated into the Afan Oromo and Amharic language and once again retranslated in English language by bilingual experts, to check for language consistency of the tool.

The questionnaires were pretested on 5% of the sample at Shenen Gibe Hospital to determine clarity of the tool and feasibility of the study. At the end of each day, during data collection period, the collected data were checked for consistence and completeness.

2.11. Ethical Consideration

The study was conducted after the investigator gets an approval letter from the Institutional Review Board of Jimma University. Permission letter was provided to the hospital administrator before data collection. The purpose and procedure of data collection were clearly stated for the participants, and confidentiality and privacy were ensured. The right to refuse or withdraw from the study was respected. There were no risks or hazards to the participants, and there was no incentive for the participants. Those participants found to have suicide attempt and severe depression were referred to the psychotic clinics for early treatment.

3. Results

3.1. Socioeconomic Characteristics of the Participants

All the 303 patients who were selected for the study voluntarily responded to the interview, giving 100% response rate. More than half of the respondents, 159 (52.5%), were females. Maximum representation was by patients who were in the productive age group 25-44 yrs, 202 (66.7%) with mean age 39.36 ( years); they were married (125 (41.3%)) and lived with their families (217 (71.6%)). Most had primary education (127 (41.9%)) and were employed (100 (33%)). Urban residents constituted the majority (269 (88.8%)), and 203 (67%) were earning less than 1380 ETB per month. They were of Oromo ethnicity (145 (47.9%)), Orthodox Christians (121 (39.9%)) with moderate social support (143 (47.2%)) (Table 1).

Table 1: Distribution of study participants by their socioeconomic characteristics, Jimma University Medical Center, April to May 2018 ().

Characteristics

%

Sex

    Male
144
47.5

    Female
159
52.5

    Total
303
100

Age

    18-24
13
4.3

    25-44
202
66.7

    45-64
80
26.4

    >65
8
2.6

    Total
303
100

Marital status

    Married
125
41.3

    Single
42
13.9

    Divorced
74
24.4

    Separated
6
2.0

    Widowed
56
18.5

    Total
303
100

Living status

    With family
217
71.6

    Alone
53
17.5

    With relatives
33
10.9

    Total
303
100

Educational status

    No education
63
20.8

    Primary school
127
41.9

    Secondary school
42
13.8

    Above secondary
71
23.4

    Total
303
100

Occupation

    Farmer
18
5.9

    Government employee
100
33.0

    Student
12
4.0

    Daily laborer
91
30.0

    Housewife
68
22.4

    Unemployed
14
4.6

    Total
303
100

Residence

    Rural
34
11.2

    Urban
269
88.8

    Total
303
100

Monthly income

    <1380
203
67.0

    1381-2872
45
14.9

    >2872
55
18.2

    Total
303
100

Ethnicity

    Oromo
145
47.9

    Amhara
82
27.1

    Tigre
19
6.3

    Gurage
26
8.6

    Dawuro
31
10.2

    Total
303
100

Religion

    Muslim
105
34.7

    Orthodox
121
39.9

    Protestant
63
20.8

    Catholic
14
4.6

    Total
303
100

Social support

    Poor support
117
38.6

    Moderate support
143
47.2

    Good support
43
14.2

    Total
303
100

3.2. Prevalence of Depression

Nearly one-third (94 (31%)) of the participants were found to have depression, while 72 (24%) had mild depression, 19 (6%) had moderate depression, and 3 (1%) were found to be with moderately severe depression (Figure 1).

Figure 1: Prevalence of depression among study participants, Jimma University Medical Center, April to May 2018 ().

3.3. Substance Use and Risky Behavior

Interview on the behavioral characteristics revealed that few numbers of the respondents (53 (17.5%)) used alcohol, 7 (2.3%) of the participants smoked tobacco, and 78 (25.7%) of the participants chewed khat. Information on the sexual practices showed that 25 (67.6%) reported inconsistent use of condom whereas 12 (32.4%) never used a condom (Table 2).

Table 2: Distribution of study participants by their behavioral characteristics, Jimma University Medical Center, April-May 2018 ().

Characteristics

Male
Female
Total
Percent

Alcohol use

    Yes
28
25
53
17.5

    No
116
134
250
82.5

Tobacco use

    Yes
5
2
7
2.3

    No
139
157
296
97.7

Khat use

    Yes
44
34
78
25.7

    No
100
125
225
74.3

Unsafe sex practice

    Yes
22
15
37
12.2

    No
122
114
266
87.8

Condom utilization

    Inconsistent condom use
15
10
25
67.6

    Never use a condom
1
3
4
32.7

3.4. Clinical Characteristics of the Participants

Most of the participants (290 (95.7%)) were at HIV stage T1, 125 (41.3%) had been diagnosed as HIV infected for the past 6-10 years, and 128 (42.2%) had been on treatment since the last 6-10 yrs.

While most participants (226 (74.6%)) had never been screened for depression prior to initiation of ART, 155 (51.2%) received treatment with 1e/Tdf-3tc-Nvp. Majority of the participants (264 (87.1%)) did not experience side effect from ART and 218 (71.9%) did not have opportunistic infection, 147 (48.5%) had recent CD4 cell count which was between 200 and 499 cells/mm³, and 228 (75.2%) of the participants had never received food supplement from ARV treatment programmer. But more than half of the respondents (164 (54.1%)) reported good adherence to ART (Table 3).

Table 3: Distribution of study participants by their clinical characteristics, Jimma University Medical Center, April-May 2018 ().

Characteristics
()
%

Side effects of ART

    None
264
87.1

    Sometimes
29
9.6

    Always
10
3.3

Diagnosed with OIs in the past 6 months

    None
218
71.9

    Once and twice or more
85
28.1

Recent CD4 level

    <200
7
2.3

    200-499
147
48.5

    >500
149
49.2

Chronic disease

    Yes
80
26.4

    No
223
73.6

Screened for depression prior to ART

    Yes
77
25.4

    No
226
74.6

Stage of HIV/ADS

    T1
290
95.7

    T2
13
4.3

Type of ART regimen

    1c
81
26.7

    1d
30
9.9

    1e
155
51.2

    1f
28
9.2

    2h
9
3.0

Duration on HAART treatment (in months)

    4-40
41
13.5

    41-80
104
34.3

    81-120
128
42.2

    >120
30
9.9

Duration from diagnosis HIV infection (in months)

    4-40
37
12.2

    41-80
103
34.0

    81-120
125
41.3

    >120
38
12.5

Receive food supplement from ARV treatment programmer

    Never
228
75.2

    Previously
66
21.8

    Currently
9
3.0

Medication adherence

    Good adherence
164
54.1

    Poor adherence
139
45.9

3.5. Aspects of Stigma

The HIV/AIDS-related stigma scale showed personal stigma mean score , disclosure mean score , public attitude mean score , and self-image mean score (Table 4).

Table 4: Distributions of study participants by their stigma characteristics, Jimma University Medical Center, April-May 2018 ().

Characteristics
Mean
Standard deviation
Item

Personal stigma
6.23
1.572
3

Disclosure
7.49
1.819
3

Public attitude
5.78
1.060
3

Self-image
5.88
1.386
3

3.6. Factors Associated with Depression among People Living with HIV/AIDS

Among all the explanatory variables subjected to bivariate binary logistic regression analysis, sex of participant, marital status, occupation, social support, medication adherence, alcohol drinking, khat chewing, opportunistic infection, and CD4 count had value < 0.25 and were further entered into multivariable analysis to control for confounding.

In multivariable logistic regression, four independent predictor variables (sex, marital status, opportunistic infection, and medication adherence) were found to be significantly associated with depression at value less than 0.05.

Susceptibility for depression was more among HIV-infected females (AOR: 0.510, 95% CI: 0.264-0.986), widowed persons (AOR: 3.610, 95% CI: 1.649-7.901), contracting opportunistic infections (AOR: 3.122, 95% CI: 2.719-61.923), and poor medication adherence (AOR: 0.470, 95% CI: 0.266-0.831) (Table 5).

Table 5: Bivariate binary logistic regression analysis and multivariable logistic regression analysis of the respondents in JUMC, April to May 2018.

Characteristics
Depression
COR (95% CI) value
AOR (95% CI) value

None
Depressed

Sex

    Male
107
37
0.619 (0.377-1.015)
0.510 (0.264-0.986)

    Female
102
57
1
1

Marital status

    Married
97
28
1
1

    Single
32
10
0.310 (0.158-0.607)
0.889 (0.318-2.486)

    Divorced
46
28
0.336 (0.139-0.811)
1.638 (0.752-3.568)

    Separated
97
28
0.654 (0.323-1.322)
0.778 (0.079-7.635)

    Widowed
32
10
0.215 (0.024-1.958)
3.610 (1.649-7.901)

Occupation

    Farmer
12
6
1
1

    G. employee
74
26
1.833 (0.367-9.166)
2.680 (0.443-16.220)

    Student
9
3
1.288 (0.333-4.982)
2.418 (0.517-11.303)

    Daily laborer
53
38
1.222 (0.197-7.594)
1.395 (0.147-13.226)

    H. wife
50
18
2.629 (0.686-10.069)
3.757 (0.800-17.642)

    Unemployed
11
3
1.320 (0.330-5.276)
1.232 (0.246-6.178)

Alcohol use

    Yes
31
22
1.754 (0.952-3.233)
1.590 (0.715-3.537)

    No
178
72
1
1

Khat use

    Yes
49
29
1.457 (0.847-2.505)
1.482 (0.717-3.063)

    No
160
65
1
1

Diagnosed with OIs

    None
166
52
1
1

    Once and twice or more
43
42
0.321 (0.189-0.543)
3.122 (1.700-5.733)

CD4 level

    <200
5
2
1
1

    200-499
93
54
1.168 (0.218-6.274)
0.860 (0.119-6.192)

    >500
111
38
1.696 (1.031-2.791)
1.096 (0.602-1.997)

Medication adherence

    Good adherence
105
59
2.343 (1.475-3.723)
0.470 (0.266-0.831)

    Poor adherence
60
79
1
1

Social support

    Poor support
66
51
1
1

    Moderate support
110
33
2.550 (1.150-5.654)
1.956 (0.785-4.871)

    Good support
33
10
0.990 (0.442-2.220)
1.074 (0.428-2.697)

NB: , , 1 = reference.

4. Discussion

This study was conducted to investigate the prevalence of depression among PLWHA enrolled in ART and its association with sociodemographic, behavioral, clinical, and social support factor.

4.1. The Prevalence of Depression

This study revealed that the prevalence of depression among the study participants was 94 (31%) and was lower than that of the studies conducted in Ethiopia at Debre Birhan (38.94%) and in northern Showa (76.7%) [41, 8]. Studies done in India showed that the prevalence of depression was 58.75% and 67.3% at different periods [7, 32] similarly in Brazil, Denmark, and north central Nigeria (42.3%, 61%, and 56.7%, respectively) [29, 30, 33], but higher than the prevalence among patients at Hawassa, Ethiopia (24.5%) [49].

The variations could be attributed to differences in sample size, instruments used to determine depression, and different geographical locations. Moreover, it is likely that responding by a face-to-face interview may have prompted the participants to give socially desirable answers. However, this very significant finding in the current study highlights the need for early diagnosis of depression in this vulnerable population.

4.2. Factors Associated with Depression

Research shows gender is closely associated with depression with women being more prone to depression. This study confirmed that HIV-infected males were 49% less likely to develop depression when compared to females. Similar findings were shown in studies from northern Showa, north central Nigeria, Tehran, and Hawassa [8, 33, 37, 49]. Women in male-dominated societies are at the receiving end for all the misfortunes such as poverty, violence, discrimination, and single parenthood. Being diagnosed with HIV adds to this burden and makes them more vulnerable to depression than males. The findings are negated by the study at Harar region of Ethiopia [36].

This study found that the marital status of the HIV-infected person is a significant factor for comorbidity with depression. Widowhood predisposed a person nearly 4 times to develop depression when compared to those who had a stable marital life. The findings are in line with studies conducted in Harar and Hawassa (Ethiopia) [36, 37] and Tehran in Iran [49]. Unstable marital relationships and loss of partner predispose for depression, but presence of good social support can be a buffer against stress and depression.

Another major finding of this study was the risk for depression increased threefold when the person contracts opportunistic infections, which is in line with a study at Fiche, Ethiopia [8]. Opportunistic infections have synergistic effects on the disease progression and AIDS-related mortalities. Depression has an effect on immunosuppression, and immunosuppression inversely predisposes depression.

Good medication adherence can lower the risk for depression by more than half as revealed through this study and supported by similar studies in Addis Ababa, Ethiopia [42]. HIV-infected people often default on medication due to difficulty in accessing the health center, being forgetful and due to unpleasant side effects of antiretroviral therapy. This significant finding reemphasizes the need for creating awareness on medication compliance among HIV-infected people and providing supportive services for individuals on treatment.

It is perplexing that this study did not find a significant association between depression and social support, perceived stigma, substance use, and CD4 count among the respondents, contrary to available literature. The recent CD4 cell count of most participants in this study was between 200 and 499 cells/mm³. Moreover, the tendency to give socially desirable responses in an interview may be a reason for this contradiction.

Individual’s sex, marital status, opportunistic infections, and medication adherence were factors associated with risk of developing depression among people living with HIV/AIDS.

Abbreviations

AIDS: | Acquired immune deficiency syndrome
AOR: | Adjusted odds ratio
ART: | Antiretroviral therapy
BDI: | Beck Depression Inventory
BMI: | Body mass index
CI: | Confidence interval
COR: | Crude odds ratio
ETB: | Ethiopian birr
JUMC: | Jimma University Medical Center
MMAS: | Morisky Medication Adherence Scale
OIs: | Opportunistic infections
OR: | Odds ratio
PHQ: | Patient Health Questionnaires
PLWHA: | People living with HIV/AIDS
SPSS: | Statistical Package Software for Social Sciences
WHO: | World Health Organization.

Data Availability

The data used to support the findings of this study are included within the article.

Conflicts of Interest

BD is a staff in the School of Nursing in the Institute of Health Jimma University, GA (BSc, MSc) is a lecturer of psychiatry in the Institute of Health Jimma University, SA is a professor (BSc, MSc, M. Phil, PhD) in Jimma University, and TB is a lecturer of the Midwifery Department at Jimma University. All authors are currently staff members in their respective departments in Jimma University. The authors declare that they have no competing interests.

Authors’ Contributions

BD was involved in designing the study, data collection, data analysis, drafting, and critically reviewing the manuscript. Likewise, GA and SA were involved in designing the study, analysis of the data, and critically reviewing the manuscript. TB was involved in data collection, data analysis, and commenting on the manuscript. All authors read and approved the final manuscript. GA, SA, and TB are equal contributors.

Acknowledgments

We would like to acknowledge Jimma University for giving us the opportunity to do this research. We also acknowledge the data collectors and Jimma University Medical Center ART clinic. This study was funded by Jimma University in partial fulfillment of the requirement for Master of Science degree in adult health nursing.

References

K. K. Lee, “Major depressive disorder and bipolar mood disorders,” Encyclopedia of Social Work, pp. 1–30, 2016.

M. Slot, M. Sodemann, C. Gabel, J. Holmskov, T. Laursen, and L. Rodkjaer, “Factors associated with risk of depression and relevant predictors of screening for depression in clinical practice: a cross-sectional study among HIV-infected individuals in Denmark,” HIV Medicine, vol. 16, no. 7, pp. 393–402, 2015.

Depression overview, https://www.nimh.nih.gov/health/topics/depression/index.shtml.

D. Goldberg, “The detection and treatment of depression in the physically ill,” World Psychiatry, vol. 9, no. 1, pp. 16–20, 2010.

S. A. Safren, J. S. Gonzalez, D. J. Wexler et al., “A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes,” Diabetes Care, vol. 37, no. 3, pp. 625–633, 2014.

P. B. Kodali, “Mental health needs of people living with HIV/AIDS : a thematic overview,” MOJ Public Health, vol. 7, no. 1, pp. 1–6, 2018.

M. S. Bhatia and S. Munjal, “Prevalence of depression in people living with HIV/AIDS undergoing ART and factors associated with it,” Journal of Clinical and Diagnostic Research, vol. 8, no. 10, pp. 1–4, 2014.

T. Yeneabat, A. Bedaso, and T. Amare, “Factors associated with depressive symptoms in people living with HIV attending antiretroviral clinic at Fitche Zonal Hospital, Central Ethiopia: cross-sectional study conducted in 2012,” Neuropsychiatric Disease and Treatment, vol. Volume 13, pp. 2125–2131, 2017.

E. Kinyanda, P. Woodburn, J. Tugumisirize, J. Kagugube, S. Ndyanabangi, and V. Patel, “Poverty, life events and the risk for depression in Uganda,” Social Psychiatry and Psychiatric Epidemiology, vol. 46, no. 1, pp. 35–44, 2011.

A. C. Tsai, D. R. Bangsberg, E. A. Frongillo et al., “Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda,” Social Science & Medicine, vol. 74, no. 12, pp. 2012–2019, 2012.

H. Berhe and A. Bayray, “Prevalence of depression and associated factors among people living with HIV/AIDS in Tigray, North Ethiopia: a cross sectional hospital based study,” International Journal of Pharmaceutical Sciences and Research, vol. 4, no. 2, pp. 761–771, 2013.

D. H. Akena, S. Musisi, and E. Kinyanda, “A comparison of the clinical features of depression in hiv-positive and hiv-negative patients in Uganda,” The African Journal of Psychiatry, vol. 13, pp. 43–51, 2010.

Republic FD, Federal Democratic Republic of Ethiopia Ministry of Health National Mental, 2015.

S. Das and G. S. Leibowitz, “Mental health needs of people living with HIV/AIDS in India: a literature review,” AIDS Care, vol. 23, no. 4, pp. 417–425, 2011.

B. W. Pence, “The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS,” Journal of Antimicrobial Chemotherapy, vol. 63, no. 4, pp. 636–640, 2009.

C. Kamen, C. Vorasarun, T. Canning et al., “The impact of stigma and social support on development of post-traumatic growth among persons living with HIV,” Journal of Clinical Psychology in Medical Settings, vol. 23, no. 2, pp. 126–134, 2016.

E. Martz, “Promoting self-management of chronic health conditions,” Oxford Clinical Psychology, 2017.

WHO, Integrating mental health into primary care: a global perspective, 2010.

Ethiopia FDR of. Country progress report on the HIV, 2014.

M. A. Horberg, M. J. Silverberg, L. B. Hurley et al., “Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients,” JAIDS Journal of Acquired Immune Deficiency Syndromes, vol. 47, no. 3, pp. 384–390, 2008.

C. Castrighini, E. Gir, L. Neves, R. Reis, M. Galvão, and M. Hayashido, “Depression and self-esteem of patients positive for HIV/AIDS in an inland city of Brazil,” Retrovirology, vol. 7, Suppl 1, p. P66, 2010.

E. Gupta, “Unraveling the conundrum of seemingly discordant protein-protein interaction datasets,” in 2010 Annual International Conference of the IEEE Engineering in Medicine and Biology, Buenos Aires, Argentina, September 2010.

S. M. Asch, the HCSUS Consortium, A. M. Kilbourne et al., “Underdiagnosis of depression in HIV who are we missing?” Journal of General Internal Medicine, vol. 18, no. 6, pp. 450–460, 2003.

M. Abas, “Depression in people living with HIV in sub-Saharan Africa: time to act,” Tropical Medicine & International Health, vol. 19, no. 12, pp. 1392–1396, 2014.

Y. Wang et al., NIH Public Access, vol. 385, no. 1, pp. 22–29, 2010.

M. De Hert, C. U. Correll, J. Bobes et al., “Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care,” World Psychiatry, vol. 10, no. 1, pp. 52–77, 2011.

W. H. Day, T. World, and H. Day, mhGAP Intervention Guide - Version 2 . 0 - JUST RELEASED Psychological first aid on World Mental Health Day 2016 Continuing momentum in reforming access to care in West Africa Regional workshop on suicide prevention held in Costa Rica, 2017.

P. W. Ng'ang'a, Prevalence of anxiety and depression among HIV/AIDS patients attending the comprehensive care centre (CCC), Kenyatta National Hospital (KNH), pp. 34–60, 2011.

R. K. Reis, Ribeirão Preto College of Nursing, University of São Paulo, São Paulo, Brazil, E. S. Melo et al., “Prevalence and factors associated with depressive symptoms in individuals living with HIV/AIDS,” Salud mental, vol. 40, no. 2, pp. 57–62, 2017.

M. Slot, M. Sodemann, C. Gabel, J. Holmskov, T. Laursen, and L. Rodkjaer, “Factors associated with risk of depression and relevant predictors of screening for depression in clinical practice : a cross-sectional study among HIV-infected individuals in Denmark,” HIV Medicine, vol. 16, no. 7, pp. 393–402, 2015.

W. Laohasiriwong, M. Thandar, S. Boonyaleepun, and C. T. Khaing, “Prevalence of depression and its associated factors among PLHIVs attending the Public ART centers, Yangon region, Myanmar,” Annals of Tropical Medicine and Public Health, vol. 10, no. 1, pp. 216–221, 2017.

P. Rai and B. L. Verma, “A study on depression in people living with HIV/AIDS in South-West part of Uttar Pradesh, India,” South East Asia Journal of Public Health, vol. 5, no. 1, pp. 12–17, 2015.

I. B. A. O. GT, “Prevalence and correlates of depressive disorders among people living with HIV/AIDS, in north central Nigeria,” Journal of AIDS & Clinical Research, vol. 4, no. 1, 2013.

J. N. Sayles, A. Pettifor, M. D. Wong et al., “Factors associated with self-efficacy for condom use and sexual negotiation among South African youth,” Journal of Acquired Immune Deficiency Syndromes, vol. 43, no. 2, pp. 226–233, 2013.

M. J. Rotheram-Borus, J. A. Stein, C. Jiraphongsa, S. Khumtong, S.-J. Lee, and L. Li, “Benefits of family and social relationships for Thai parents living with HIV,” Prevention Science, vol. 11, no. 3, pp. 298–307, 2010.

M. M. B. Mengistie, “Prevalence of depression and associated factors among HIV patients seeking treatments in ART clinics at Harar Town, Eastern Ethiopia,” Journal of AIDS & Clinical Research, vol. 6, no. 6, 2015.

M. Saadat, Z. M. Behboodi, and E. Saadat, “Comparison of depression, anxiety, stress, and related factors among women and men with human immunodeficiency virus infection,” Journal of Human Reproductive Sciences, vol. 8, no. 1, pp. 48–51, 2015.

E. Kinyanda, S. Hoskins, J. Nakku, S. Nawaz, and V. Patel, “Prevalence and risk factors of major depressive disorder in HIV/AIDS as seen in semi-urban Entebbe district, Uganda,” BMC Psychiatry, vol. 11, no. 1, 2011.

T. Bitew, “Prevalence and risk factors of depression in Ethiopia: a review,” Ethiopian Journal of Health Sciences, vol. 24, no. 2, pp. 161–169, 2014.

F. H. Galvan, M. A. Burnam, and E. G. Bing, “Co Occuring psychiatric symptoms and drug dependence, heavy drinking among HIV positive people,” Journal of Psychoactive Drugs, vol. 35, pp. 153–160, 2003.

D. A. Eshetu and S. Meseret, “Prevalence of depression and associated factors among HIV/AIDS patients attending ART clinic at Debrebirhan Referral Hospital, North Showa, Amhara Region, Ethiopia,” Clinical Psychiatry, vol. 1, no. 1, 2015.

G. Tesfaw, G. Ayano, T. Awoke et al., “Prevalence and correlates of depression and anxiety among patients with HIV on-follow up at Alert Hospital, Addis Ababa, Ethiopia,” BMC Psychiatry, vol. 16, no. 1, p. 368, 2016.

U. E. Chikezie, A. N. Otakpor, O. B. Kuteyi, and B. O. James, “Depression among people living with human immunodeficiency virus infection/acquired immunodeficiency syndrome in Benin City, Nigeria: a comparative study,” Nigerian Journal of Clinical Practice, vol. 16, no. 2, pp. 238–242, 2013.

S. Okello, B. Nasasira, A. N. W. Muiru, and A. Muyingo, “Validity and reliability of a self-reported measure of antihypertensive medication adherence in Uganda,” Plos One, vol. 11, no. 7, p. e0158499, 2016.

A. Janežič, I. Locatelli, and M. Kos, “Criterion validity of 8-item Morisky Medication Adherence Scale in patients with asthma,” Plos One, vol. 12, no. 11, p. e0187835, 2017.

T. Inoue, T. Tanaka, S. Nakagawa et al., “Utility and limitations of PHQ-9 in a clinic specializing in psychiatric care,” vol. 12, no. 1, 2012.

Y. K. Woldetensay, T. Belachew, M. Tesfaye et al., “Validation of the Patient Health Questionnaire (PHQ-9) as a screening tool for depression in pregnant women: Afaan Oromo version,” PLoS ONE, vol. 13, no. 2, article e0191782, 2018.

S. A. Stevelink, I. C. Wu, C. G. Voorend, and W. H. van Brakel, “The psychometric assessment of internalized stigma instruments : a systematic review,” Stigma Research and Action, vol. 2, no. 2, pp. 100–118, 2012.

D. Press, “Prevalence of unrecognized depression and associated factors among patients attending medical outpatient department in Adare Hospital,” Neuropsychiatric Disease and Treatment, vol. 12, no. 55, pp. 2723–2729, 2016.