Depression in people living with HIV in sub‐Saharan Africa: time to act

Sub-Saharan Africa remains the centre of the HIV and AIDS epidemic. As life expectancy increases for people living with HIV in the region, more attention is being paid to the impact of comorbid non-communicable disorders (NCDs) (WHO 2013). Much has been written about the importance of certain NCDs in people living with HIV – including cardiovascular disease, renal disease and certain cancers (Adebamowo et al. 2014; Bloomfield et al. 2014; Kalyesubula et al. 2014) – but too little attention has been given to the significant mental health burden. We argue that depression screening and treatment should be among the most important priorities for HIV care services in sub-Saharan Africa (SSA). We support this by presenting evidence of the high prevalence of depression in people living with HIV in SSA, the nature and severity of disabilities associated with depression, the negative impact of depression on HIV progression and the cost-effectiveness of 'best buy' treatment options for depression (World Federation for Mental Health 2011). Depression is an important but neglected public health problem in sub-Saharan Africa. By depression, we are referring here to major depression or clinical depression, which is characterised by changes in mood, thinking, concentration, sleep, appetite, energy and in a person's normal capacity to gain pleasure and motivation from life and the world around them. Diagnosis depends on a number of these symptoms being present consistently for at least a 2-week period, causing impairment in day-to-day activities and/or noticeable problems in relationships with others (APA 2013). The average prevalence of depression in SSA is roughly 5. 5% (Ferrari et al. 2013), but it is higher in people living with HIV (Owe-Larsson et al. 2009; Breuer et al. 2011). Studies using good sample sizes and internationally accepted diagnostic criteria for major depression report a prevalence of around 8% among people living with HIV in SSA (Kinyanda et al. 2011; Gaynes et al. 2012). Even higher figures are reported in particular settings and population groups, for example post-natal mothers (Stranix-Chibanda et al. 2005; Adewuya et al. 2007; Chibanda et al. 2010; Nakimuli-Mpungu et al. 2011). Some of the excess depression prevalence found in people living with HIV can be explained by the challenges of coping with diagnosis, disease symptoms, bereavement, relationship crises, social rejection, co-existing poverty and the side effects of certain antiretrovirals (Gibbie et al. 2006). Inflammatory processes triggered by chronic stress, HIV infection itself or other HIV comorbidities also contribute (Castelo et al. 2006; Lawson et al. 2011; Berk et al. 2013; Slavich Mast et al. 2004; Nakimuli-Mpungu et al. 2011). Disability reflects the interaction between a person's health impairments and the environment and society in which they live (WHO 2002). Disability is intrinsic to depression and its diagnosis. To be diagnosed with depression, an individual should be experiencing symptoms that disrupt their normal functioning, such as persistent low mood or poor concentration. These symptoms can result in impaired economic productivity, reduced ability to perform work and social roles, loss of relationships, poor child health, physical decline, increased accidents and deficits in problem-solving (Kennedy et al. 1990; Bruce et al. 1994; Ormel et al. 1994; Penninx et al. 1998; Prince et al. 2007). This inherent disability is frequently exacerbated by stigma and discrimination (Lasalvia et al. 2013). The projected economic toll of neuropsychiatric disorders is staggering, with one model estimating a total cost to low- and middle-income countries of US 7. 3 trillion between 2011 and 2030 (Bloom et al. 2012). This compares to US 7. 1 trillion for cardiovascular diseases and US 3. 2 trillion for chronic respiratory diseases during the same period (Bloom et al. 2012). Depression in the general population accounts for around one third of all disability-adjusted life years (DALYs) caused by neuropsychiatric disorders (WHO 2008). Depression is a predictor of worse HIV treatment outcomes. It is associated with treatment failure and the emergence of drug-resistant HIV strains (Hartzell et al. 2008; Horberg et al. 2008), in part due to depression causing poor adherence to antiretroviral therapy (ART) (Gonzalez et al. 2011; Nakimuli-Mpungu et al. 2011; Mayston et al. 2012). Two studies conducted in Ethiopia found a significant association between depression and non-adherence to ART, with small to medium effect sizes of 0. 14 (Tadios Nolen-Hoeksema et al. 2008). A study conducted among HIV+ women without access to ART in Tanzania found that those with depression were at increased risk of HIV disease progression (Antelman et al. 2007). This was still the case after controlling for socio-demographic variables, psychosocial support and clinical condition at enrolment. Depression is also associated with mortality even when viral suppression is achieved, as shown by a longitudinal study in Uganda. Depression in this cohort predicted increased mortality regardless of whether or not people living with HIV achieved immune suppression. Mechanisms for this association may include the immunological effects of depression and stress (Slavich Rahman et al. 2008; Patel et al. 2010). Three studies from SSA provide preliminary evidence of the effectiveness of psychological interventions for depression, including in people living with HIV (Chibanda et al. 2011; Kaaya et al. 2013; Nakimuli-Mpungu et al. 2014). The common element of all three was the use of simple, structured approaches based on problem-solving therapy and other forms of cognitive behavioural therapy in routine clinical settings. Effective psychological therapies share common elements including social support, ritual and being delivered by someone with the status of a healer (Frank 2006). In addition to these ingredients, problem-solving therapy empowers individuals by enhancing coping skills and reducing avoidance, rather than through actually solving problems (Nezu 2004). Critical work conducted by the WHO used evidence globally on the costs and benefits of treating depression in general health-care settings (WHO 2013). This showed that depression treatment using simple psychological therapy and/or antidepressants can be endorsed as a 'best buy' intervention providing good value for money (World Federation for Mental Health 2011). It is very cost-effective (cost per healthy life year gained < average income), quite affordable (implementation cost < US 1 per person) and feasible for delivery through primary care (World Federation for Mental Health 2011). Mathematical modelling found that the most cost-effective package of care for depression comprised generically produced newer antidepressants and brief psychological treatment (Chisholm Tsai 2014). Translation should be carried out by a multidisciplinary team, including professionals familiar with the local presentation of mental symptoms, to ensure that translated items capture important local meaning. For instance, making slight modifications to the Patient Health Questionnaire resulted in it performing with excellent validity and reliability in Ghana (Weobong et al. 2009). Health staff should be trained to use a screening tool and to provide depression care. While mhGAP (WHO 2010) can be used to train on depression care and on assessing and managing suicide risk, this needs to be supplemented. Training and supervision are necessary for health staff to learn how to talk to clients with low mood; how to listen and offer confidential, sensitive support that takes account of local norms; and how to provide simple, structured, problem-solving therapy (Babatunde for example, 4-6 sessions of supportive talking and listening from an HIV clinic adherence counsellor or nurse, with an emphasis on encouraging clients to list their problems, prioritise those to work on, and suggest and select their own solutions (Cuijpers et al. 2007; IMPACT 2012). An antidepressant, ideally an SSRI, should be offered as a monitored treatment for those with major depression who do not respond to problem-solving therapy (WHO 2010). Research is needed to develop and validate short screening scales for depression, ideally with binary yes/no answers as these seem preferable in HIV settings. We also need to pilot treatments and models of service delivery in HIV mental health. Curricula for HIV teaching in medical schools in Africa should include depression diagnosis and treatment (Chibanda et al. 2014; Mangezi et al. 2014). Programmes are needed to build capacity within SSA to conduct health services and operational research on HIV and depression (Abas et al. 2014). We have drawn on existing evidence to demonstrate the profound disability associated with depression in people living with HIV. In addition to impacting on physical, economic and social outcomes, depression presents additional threats to people living with HIV through its negative impact on ART adherence, disease progression and mortality. There is a need for wider public health approaches to prevent depression in people living with HIV. Treatment of major depression is cost-effective and should be prioritised in HIV services in sub-Saharan Africa.