There are a wide range of neuropsychiatric conditions associated with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). These mental disorders may be unrecognised yet their presence can significantly affect outcome.
Aim
This study aimed to determine psychiatric comorbidity associated with HIV and AIDS.
Setting
The HIV clinic of a tertiary hospital in North-Eastern Nigeria.
Methods
A cross-sectional descriptive study consecutively recruiting 328 adult persons living with HIV. The Mini International Neuropsychiatric Interview and a sociodemographic questionnaire were administered to the participants.
Results
Two-thirds of the respondents were females. The mean age (±s.d.) was 42 years (±11.24). Majority of the participants had World Health Organization stage 1 HIV disease. The prevalence of psychiatry comorbidity among our respondents was 82.9%. Social phobia was the leading disorder (69.8%). Others were mixed depression anxiety disorder (49.4%) and post-traumatic stress disorder (36.6%). Current psychosis was 27.7%, while major depressive disorder was 12.2%. Psychiatric comorbidity was significantly associated with male gender, religion, ethnicity, marital status and being unemployed with p < 0.01. Human immunodeficiency virus stage was related to panic disorder with p < 0.01, while viral load was significantly associated with depressive disorder with p = 0.001.
Conclusion
Majority of our HIV patients attending the clinic have undetected psychiatric morbidity. Clinicians need to be aware of the features of major psychiatric disorders and refer appropriately for improved overall outcome.
Contribution
This study contributes to the body of work on unrecognised psychiatric comorbidity in people living with HIV and AIDS, especially in North-Eastern Nigeria, identifying issues which are relevant to clinical practice and buttressing the need for integration of mental healthcare services into HIV treatment and prevention services.
People living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) (PLWHA) are more likely to have a higher population with undiagnosed mental illness than the general population.1,2 Psychiatric disorders in this group of persons often go undetected as they are not the focus of treatment. However, it leads to substantially increased morbidity1 and even mortality.3
A systematic review of HIV positive adults in Africa showed that about one-half of HIV positive adults have some form of psychiatric disorder.4 A study from East Africa showed that despite a prevalence of psychiatric comorbidity of 46.5% in the respondents, only 3.6% had a previously diagnosed mental illness.5 Nigerian studies show that the prevalence of both of anxiety and depression can be as high as 48% in PLWHA,6 with another Nigerian study reporting that two-fifths of respondents had various forms of psychiatric comorbidity including substance use, depression and anxiety.7
There is a bidirectional relationship between a positive HIV status and mental health disorders,6,8,9 with neuroinflammatory and certain stress-related factors playing contributory roles.3 On the one hand, having a preexisting mental health disorder might be a contributory factor to contracting the virus, through engaging in risky behaviour such as injection drug use or engaging in risky sexual behaviour in those who have substance use disorders.3 This increased risk of contracting HIV has been reported among individuals with substance use disorder,9 while Wandel et al. showed that the prevalence of substance use disorders was high in HIV positive persons even before the diagnosis of HIV.10 Risky behaviour can also occur in those who are disinhibited in certain affective disorders like mania.11 On the other hand, having a chronic illness, such as HIV, can predispose to mental health disorders both from the development of AIDS and HIV-associated neurocognitive disorder (HAND)10 as well as from various psychological and social processes such as stigma.12 In addition, antiretrovirals,13 viral load1 and decrease in functioning1 can predispose to psychiatric morbidity.
Several mental health conditions are associated with HIV.1 Anxiety disorders are prevalent, with an analysis of global prevalence of anxiety disorders showing a prevalence of 22.85%, almost 5% higher than that in the general population.14 Social phobia has been found in PLWHA, with older quantitative studies reporting up to 14.8% of PLWHA have social phobia15 and a study in North-Central Nigeria reporting a prevalence of 4.0%.16 Qualitative studies among women in Iran report that the root cause of social phobia is stigma.17 Stigma and other psychosocial stressors are linked to the neuroendocrine stress response. They potentiate residual immune dysregulation and alter other biobehavioural processes relevant to health outcomes.9
Suicide ideation is also common among PLWHA and it is very important to do a risk assessment.2 A systematic review and meta-regression analysis by Tsai et al. revealed a pooled prevalence estimate of suicidal ideation, attempted suicide and deaths by suicide of 22.3%, 9.6% and 1.7%, respectively.18 The most common psychiatric conditions predicting suicide are dysthymia, borderline personality and the substance use disorders.19
This study seeks to bridge the gap between research and practice in the zone where this study was carried out to show there is a need for mental health assessments in PLWHA when they come for follow-up, as early identification and management can improve overall outcomes.
Aim
This study aimed to determine if there is psychiatric comorbidity and its relationship with clinical correlates and sociodemographic variables among HIV and AIDS clinic attendees of a tertiary health facility. The specific objectives are:
To determine the prevalence of psychiatric comorbidity among HIV clinic attendees.
To determine the association between sociodemographic variables, clinical correlates and psychiatric comorbidity in PLWHA.
Significance of the study
While there are a lot of studies on HIV and AIDS and also on psychiatric morbidity in Nigeria, there are fewer studies on HIV-associated psychiatric comorbidity and fewer still published studies in the immediate locale where this study took place. It is thus hoped that this study will not only help to bridge a data gap in research into HIV and AIDS, but also highlight their plight vis-à-vis mental health access and ensure that mental health is also prioritised for those living with this condition.
Research methods and design
This was a cross-sectional descriptive study design.
Setting
The study was carried out in North-Eastern Nigeria, in Gombe State, a multi-ethnic state with 3 million residents, who are predominantly of Fulani ethnicity.20 The community is strongly religious and all government-owned secondary healthcare centres in each local government have their own HIV units.
The tertiary hospital is a 300-bed specialist tertiary healthcare facility owned by the federal government of Nigeria running specialty clinics and consultations in various fields of medicine. It renders specialist care to the inhabitants of the state and neighbouring states. The HIV unit runs clinics daily, with a usual attendance of about 100 patients. Stable patients are generally seen every 3–6 months.
SamplingInclusion criteria
Patients who were 18 years and older with confirmatory HIV test results and who consented to take part in the study were included.
Exclusion criteria
Patients who did not understand English or Hausa language or those with severe physical or mental conditions who would be unable to fill the questionnaire were excluded from the study.
Sample size calculation
Sample size was estimated by:
n=z2pq/d2
where z = standard deviation set at 1.96 (this corresponds to 95% confidence interval), p = the proportion in the target population estimated to have the desired characteristic and was set at 71.4% (i.e. 0.714),1q = 1.0 – p and d = level of precision (0.05) since degree of precision desired is 95%. Therefore, n = (1.962)2*0.714*0.286/(0.052) n = 314. (However, the data were eventually collected from 328 respondents.)
Instruments and data collection procedure
To facilitate data collection, structured and semi-structured instruments were used. The Mini International Neuropsychiatric Interview (MINI) Plus which can screen and diagnose a wide range of psychiatric disorders was used to assess psychiatric comorbidity. This instrument can also make a ‘current’ (in the last 1 month) diagnosis as well as a ‘lifetime’ (anytime in the past) diagnosis and has been used extensively in similar studies,1,5 as well as a sociodemographic questionnaire.
Ten booked clinic attendees were recruited per day through a random selection method, provided they fulfilled the inclusion criteria and they gave consent. The nature of the study was explained to the selected patients to obtain their consent for the study. Respondents were then administered the MINI Plus instrument as well as a sociodemographic questionnaire. Information needed was asked directly from patients and medical diagnosis and comorbidity was obtained from the case file. The managing physicians filled the clinical characteristics for each patient.
Ethical considerations
Ethical approval to carry out the study was obtained from the Health Research Ethics committee of the hospital: approval code NHREC/25/10/2013. Consent was read out to them from the consent form, and oral permission was obtained from each patient before inclusion in the study. The decision to participate in the study was voluntary and they were free to withdraw consent. Consent and confidentiality of participants was ensured as they filled the questionnaires. Participants were assured of anonymity and confidentiality even during dissemination of findings. However, participants identified with mental or behavioural disorders were referred for formal psychiatric evaluation and management.
Data analysis
Study data were analysed using Statistical Package for Social Sciences (SPSS) programme, version 21.0. Descriptive statistics were presented using frequency distribution tables reflecting percentages, mean and standard deviation. Medians were preferred as the measure of central tendency for data that were skewed. Between-group differences in categorical variables, such as gender, religion, place of residence, etc., were compared using chi-square statistics, while differences in continuous variables, such as age, were compared using independent students t-test. The confidence interval set at 95% and p-value less than 0.05 (p < 0.05) were taken to be significant. The following disorders were used to model ‘psychiatric comorbidity’: (1) current depressive disorder, (2) current hypomania or mania, (3) current psychotic symptoms, (4) social anxiety disorder, (5) obsessive compulsive disorder, (6) generalised anxiety disorder, (7) somatisation, (8) hypochondriasis, (9) adjustment disorder, (10) mixed depression anxiety disorder, (11) panic disorder and (12) post-traumatic stress disorder (PTSD).
Results
The mean age (± s.d.) of participants was 41.89 years (± 11.24) and it ranged between 18 and 71 years (Table 1).
Sociodemographic variables (N = 328).
Sociodemographic characteristics of respondents
Total
%
Gender
Male
108
32.9
Female
220
67.1
Total
328
100.0
Age groups (years)
Young
133
40.5
Middle aged
174
53.0
Elderly
21
6.4
Total
328
100.0
Ethnicity
Hausa
201
61.3
Fulani
61
18.6
Other tribes
66
20.1
Total
328
100.0
Religion
Christian
153
46.6
Muslim
175
53.4
Total
328
100.0
Place of abode
State capital
244
74.4
Within the state
60
18.3
Outside the state
24
7.3
Total
328
100.0
Marital status
Single
55
16.8
Married
205
62.5
Separated
29
8.8
Widowed
39
11.9
Total
328
100.0
Living circumstance
Alone
25
7.6
With nuclear
271
82.6
Other family
29
8.8
Non-family
3
0.9
Total
328
100.0
Employment status
Employed
133
40.5
Unemployed
176
53.7
Retired
19
5.8
Total
328
100.0
Psychiatric comorbidity and its association with sociodemographic variables
Psychiatric comorbidity was found in 272 (82.9%) participants as assessed by the MINI (Table 2) with significant associations between psychiatric comorbidity and gender, ethnicity, religion, marital status and employment status.
Relationship between sociodemographic features and psychiatric comorbidity.
Sociodemographic characteristics of respondents
Psychiatric comorbidity
χ2
P
Absent (N = 56)
Present (N = 272)
Total (N = 328)
n
%
n
%
n
%
Gender
13.03
< 0.01
Male
30
27.8
78
72.2
108
32.9
-
-
Female
26
11.8
194
88.2
220
67.1
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Age groups (years)
5.63†
0.05
Young
17
12.8
116
87.2
133
40.5
-
-
Middle aged
32
18.4
142
81.6
174
53.0
-
-
Elderly
7
33.3
14
66.7
21
6.4
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Ethnicity
26.00
< 0.01**
Hausa people
26
12.9
175
87.1
201
61.3
-
-
Fulani people
5
8.2
56
91.8
61
18.6
-
-
Other tribes
25
37.9
41
62.1
66
20.1
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Religion
10.24
< 0.01**
Christian
37
24.2
116
75.8
153
46.6
-
-
Muslim
19
10.9
156
89.1
175
53.4
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Place of abode
6.24
0.06
State capital
47
19.3
197
80.7
244
74.4
-
-
Within the state
4
6.7
56
93.3
60
18.3
-
-
Outside the state
5
20.8
19
79.2
24
7.3
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Marital status
17.76†
< 0.01**
Single
12
21.8
43
78.2
55
16.8
-
-
Married
43
21.0
162
79.0
205
62.5
-
-
Separated
0
0.0
29
100.0
29
8.8
-
-
Widowed
1
2.6
38
97.4
39
11.9
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Living circumstance
Alone
4
16.0
21
84.0
25
7.6
-
-
With nuclear
47
17.3
224
82.7
271
82.6
-
-
Other family
5
17.2
24
82.8
29
8.8
-
-
Non-family
0
0.0
3
100.0
3
0.9
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Employment status
18.79†
< 0.01**
Employed
33
24.8
100
75.2
133
40.5
-
-
Unemployed
16
9.1
160
90.9
176
53.7
-
-
Retired
7
36.8
12
63.2
19
5.8
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Expected cell count < 5 Fisher’s exact test used.
, p < 0.05;
, p < 0.01.
Prevalence of individual psychopathology or psychiatric diagnosis
Table 3 shows the most common disorder was social phobia 229 (69.8%). Mixed depression anxiety disorder 162 (49.4%) followed by Post traumatic stress disorder 120 (36.6%). Sixty respondents had suicide ideation.
Prevalence of individual psychiatric comorbidity (N = 328).
Clinical condition or psychopathology
Absent
Present
n
%
n
%
Lifetime psychosis
207
63.1
121
36.9
Current psychosis
237
72.3
91
27.7
Depressive disorder lifetime
272
82.9
56
17.1
Depressive disorder (current)
288
87.8
40
12.2
Suicide ideation
268
81.7
60
18.3
Hypomania or mania
273
83.2
55
16.8
Mixed depression anxiety
166
50.6
162
49.4
Social phobia
99
30.2
229
69.8
Obsessive compulsive disorder
284
86.6
44
13.4
Generalised anxiety disorder
254
77.4
74
22.6
Somatisation disorder
304
92.7
24
7.3
Unspecified anxiety disorders
297
90.5
31
9.5
Hypochondriasis
278
84.8
50
15.2
Adjustment disorder
289
88.1
39
11.9
Panic disorders
321
97.9
7
2.1
Post-traumatic stress disorder
208
63.4
120
36.6
Alcohol use disorders
299
91.2
29
8.8
Substance use disorders
321
97.9
7
2.1
Alcohol and drug use
Lifetime alcohol use was significantly related to developing psychiatric comorbidity. Current cigarette smoking or current use of psychoactive substances was unrelated to psychiatric comorbidity (Table 4).
Alcohol and drug use.
Psychoactive substance
Psychiatric comorbidity
χ2
P
Absent
Present
Total (N = 328)
n
%
n
%
n
%
Lifetime use of alcohol
4.40
0.04*
No
39
14.9
223
85.1
262
79.9
-
-
Yes
17
25.8
49
74.2
66
20.1
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Current use of alcohol
2.37
0.12
No
47
16.0
247
84.0
294
89.6
-
-
Yes
9
26.5
25
73.5
34
10.4
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Lifetime cigarette smoking
2.48
0.12
No
48
16.1
251
83.9
299
91.2
-
-
Yes
8
27.6
21
72.4
29
8.8
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Current cigarette smoking
1.02
0.31
No
52
16.6
261
83.4
313
95.4
-
-
Yes
4
26.7
11
73.3
15
4.6
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Current use of illicit drugs
0.06
0.80
No
54
17.0
264
83.0
318
97.0
-
-
Yes
2
20.0
8
80.0
10
3.0
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Clinical parameters
All respondents had commenced antiretroviral (ARV) medication, 14 (4.1%) of respondents had commenced antiretroviral medication in the last year and 14 (4.1%) were not currently using cotrimoxazole. The most common medication was combination of tenofovir, lamivudine and dolutegravir (TLD) at 89%. Nine-tenths of them were on first-line medication.
Body mass index (BMI) ranged from 10.6 to 46.9 with a mean of 23.7 (±5.37). Nineteen (5.6%) of them were hypertensive, 8 (2.35%) had a current febrile illness and 1 person had confirmed tuberculosis.
Only BMI was significantly related to psychiatric comorbidity (Table 5), and when multivariate analysis was performed, the likelihood ratio test value was 0.048 with goodness-of-fit giving a Pearson of 0.49, showing that BMI was related to psychiatric morbidity. In Table 6, depression was related duration on ARV medication and the viral load.
Relationship between clinical characteristics and psychiatric comorbidity.
Clinical parameters
Psychiatric comorbidity
χ2
P
Absent (N = 56)
Present (N = 272)
Total (N = 328)
n
%
n
%
n
%
BMI
8.64
0.03*
< 18.5
5
12.2
36
87.8
41
12.5
-
-
18.5–24.9
22
12.9
148
87.1
170
51.8
-
-
25–30
21
27.3
56
72.7
77
23.5
-
-
> 30
8
20.0
32
80.0
40
12.2
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Adherence
0.672
0.41
No
20
19.6
82
80.4
102
31.1
-
-
Yes
36
15.9
190
84.1
226
68.9
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Frequency hospital visits
3.12†
0.19
1–2 per year
45
16.2
233
83.8
278
84.8
-
-
3–4 per year
9
28.1
23
71.9
32
9.8
-
-
5–6 per year
2
11.1
16
88.9
18
5.5
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Regimen
3.14
0.08
First line
54
18.3
241
81.7
295
89.9
-
-
Second line
2
6.1
31
93.9
33
10.1
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Duration of treatment
6.08
0.11
≤ 5 years
7
11.3
55
88.7
62
18.9
-
-
6–10 years
9
11.3
71
88.8
80
24.4
-
-
11–15 years
30
21.0
113
79.0
143
43.6
-
-
≥ 16 years
10
23.3
33
76.7
43
13.1
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
Viral load (copies/mL)
1.69†
0.43
Undetectable
25
19.7
102
80.3
127
38.7
-
-
≤ 1000
31
16.2
160
83.8
191
58.2
-
-
> 1000 to < 5000
0
0.0
3
100.0
3
0.9
-
-
≥ 5000
0
0.0
7
100.0
7
2.1
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
WHO HIV stage
0.72†
0.89
One
53
17.3
254
82.7
307
93.6
-
-
Two
3
16.7
15
83.3
18
5.5
-
-
Three
0
0.0
2
100.0
2
0.6
-
-
Four
0
0.0
1
100.0
1
0.3
-
-
Total
56
17.1
272
82.9
328
100.0
-
-
BMI, body mass index; HIV, human immunodeficiency virus; WHO, World Health Organization.
Fisher’s exact test used when cell counts < 5.
, significant p < 0.05.
Relationship between clinical parameters and psychiatric morbidity.
Clinical parameters
Depression
Suicide
Mania
Psychosis
Social phobia
PTSD
Duration on antiretrovirals
Pearson chi-square
8.63
2.34
6.67
1.32
4.07
1.10
df
3
3
3
3
3
3
P
0.03*
0.51
0.08
0.72
0.25
0.78
Current line of management
Pearson chi-square
2.77
0.87
0.05
1.67
0.17
0.001
df
1
1
1
1
1
1
P
0.09
0.35
0.82
0.20
0.68
0.98
Adherence
Pearson chi-square
0.32
0.262
0.98
4.89
1.83
1.73
df
1
1
1
1
1
1
P
0.57
0.61
0.32
0.03*
0.18
0.19
Viral load suppression achieved
Pearson chi-square
1.16
1.03
0.971
1.32
0.53
0.25
df
1
1
1
1
1
1
P
0.28
0.31
0.32
0.25
0.47
0.06
WHO HIV and AIDS stage
Pearson chi-square
4.68
10.38
3.46
0.88
1.95
1.37
df
3
3
3
3
3
3
P
0.20
0.02*
0.33
0.83
0.58
0.71
Frequency of hospital visits per year
Pearson chi-square
5.16
0.21
4.76
0.97
3.29
0.17
df
2
2
2
2
2
2
P
0.08
0.09
0.09
0.61
0.19
0.92
Viral load
Pearson chi-square
15.84
2.69
1.26
1.18
1.74
3.03
df
3
3
3
3
3
3
P
0.001**
0.44
0.73
0.76
0.63
0.39
PTSD, post-traumatic stress disorder; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; WHO, World Health Organization.
, p < 0.05;
, p < 0.01.
Discussion
Human immunodeficiency virus is associated with significant unrecognised psychiatric comorbidity. This may be because the distress associated with a major mental disorder is subsumed under the distress associated with the HIV infection itself. In other cases, physicians do not assess for the psychological disorders, thus missing opportunities to help the patient. The prevalence of psychiatric comorbidity is higher in this study (82.9%) and differs from the prevalence in other African studies 71.4% and 45% respectively in this study (82.9%), differing from other African studies with 71.4% and 45%, respectively,1,5 and Nigerian studies 48%.6 Different factors may account for this, including the fact that different instruments were used. The Nigerian study assessed mainly for depression and anxiety. Respondents in those studies also came from different socioeconomic backgrounds. In addition, there is a long running insurgency in surrounding states with almost two-thirds of residents of some states witnessing severe ethnoreligious violence and 46.1% of respondents in some areas developing PTSD,21 while in internally displaced camps, more than three quarters of respondents (78.0%) may have PTSD.22 When these factors are coupled with the current socioeconomic status of many respondents, it may account for the higher prevalence. However, this higher prevalence might also be due to various neurocognitive factors, which were not assessed for, such as central nervous system (CNS) toxicity of ARVs23 and viral escape.24
Psychiatric comorbidity was higher in females. Studies have corroborated the higher incidence of psychiatric comorbidity in women with HIV,1,25 usually from depression and anxiety disorders. This might have been due to the fact that there were more females in these studies. However, it could also be due to treatment seeking behaviour among women,26 who access HIV testing services more than men26 and tend to seek for healthcare earlier. Women are introduced to formal healthcare more readily during pregnancy, labour, immunisations and childcare and so have a better chance of psychiatric comorbidity being recognised while men may present later. In addition, being female is associated with higher odds of having detectable viral load,27 which is associated with depression in this study.
The family was still the bastion of care with more than 90% of respondents living within the family circle. However, four-fifths of those who lived alone were females. In such a strongly patriarchal society, marriage is usually the major reason why women move away from parent’s homes. A high proportion of females living alone could thus be due to the presence of discrimination and stigma, the experience of which could be contributory to the presence of psychiatric comorbidity.
Psychiatric comorbidity was unrelated to drugs of abuse both licit and illicit, even though the prevalence of use of these substances was high, consistent with Nigerian studies in PLWHA.6 This may be due to the widespread availability of these substances and the use of these substances as a maladaptive coping mechanism for the stress related to living with a chronic illness or a means to ameliorate symptoms of psychological distress.
About a quarter of respondents had experienced psychotic symptoms in the last month. Nigerian studies have shown that almost two-thirds of non-clinical members of the general population exhibit psychotic-like events with up to 13% of them having clinically significant psychotic-like events.28 This discrepancy between clinical and non-clinical samples highlights the gap between those who need evaluation and those who present for treatment. In addition, people may experience psychotic symptoms without significant distress and it may go unrecognised. Also, because of cultural factors, people may hold a general belief that people are trying to harm them especially if they have a serious medical disorder (since it is believed that these disorders have ‘spiritual causation’), which is why patients often visit native healers or ‘spiritual healers’ before coming to the hospital. However, these beliefs even though strongly held are not considered abnormal as other members of the socioethnic group also hold on to the same belief.
The prevalence of depressive disorder among PLWHA in studies is quite variable. In the United States, it can be up to 30% – 40%,29 in African studies up to 32.2%1 and in Nigerian studies 39.6%.25 Depressive disorders have been shown to exist with chronic medical conditions and may be the primary cause of previously unrecognised psychiatric comorbidity.1 People living with HIV and AIDS may become depressed as a reaction to the illness and go through the stages of grief.2 The depressed mood in HIV may be linked to neuroinflammation and stress-induced neuroendocrine changes among other causes.3
While having thoughts of suicide is not a disorder, suicide ideation often occurs in depressive disorders and is linked to suicide acts.25 However, suicide ideation can occur without the presence of depression.30
Human immunodeficiency virus and acquired immunodeficiency syndrome is highly stigmatised despite the many social media campaigns against it. This may account for why social phobia and the fear of being identified or being the focus of attention was observed in more than two-thirds of respondents, as they may be experiencing internalised stigma.
The prevalence for manic or hypomanic symptoms was higher than other studies.31 However, this study did not differentiate between the two states. In assessing for mania, irritability is one of the major symptoms. Studies on ‘psychological reactance’ in women with HIV have shown increased irritability due to stigma and discrimination.32 The limitations PLWHA place on themselves but which they are unhappy about can manifest through ego defence mechanisms as irritability. In addition, irritability is a common symptom, especially in older PLWHA, which may herald neurologic dysfunction especially in older adults.33 At first glance, a subset of patients exhibiting depressive and manic or hypomanic symptoms simultaneously might seem odd. However, bipolar disorders are disorders of dimensions of mood and can present at any point between the dimensions.
Respondents who were not adherent to HIV medication were more likely to have psychotic features. Patients who are not adherent with HIV medication are also unlikely to be adherent to antipsychotics and are thus likely to be more symptomatic especially when they lack ‘insight’.
Adherence was unrelated to social phobia and coming for follow-up. This could be a result of the effectiveness of the campaigns against stigmatising PLWHA and counselling they receive at follow-up. In addition, patients may have seen the improvements in quality of life since they started medication with a sort of positive feedback mechanism, coupled with the fact that PLWHA groups now exist where there is little fear of not being accepted.
Viral load was related to depression. The explanation for this is probably multifactorial with patients with higher viral loads being relatively ‘sicker’ and having more AIDS defining disorders. The frequency of hospital visits was not related to psychopathology except panic disorder. Generally, patients are given shorter appointments when they require close monitoring. More frequent hospital visits decrease the chance of missing symptoms which may be of clinical importance. However, the patient may perceive frequency to mean the HIV treatment is not working and this may lead to anxiety and panic especially when clinic appointments are imminent while awaiting the result of the latest viral load.
Most patients were on first-line medication, and those on second-line medication were more likely to develop a psychiatric comorbidity. This might lend credence to the antiretroviral toxicity theory.23
Duration on highly active anti retro-viral therapy (HAART) was related to depression and just five (1.5%) of the patients were in stage three or four despite having been on medication for more than 10 years, testament to the effectiveness of antiretrovirals. Human immunodeficiency virus stage was unrelated to psychiatric disorders screened for but was related to having suicide ideation which could be due to the chronicity of the illness.
Strengths of the study
Apart from contributing to the body of literature on psychiatric morbidity, one of the advantages of this study was that it was able to identify patients who had previously unrecognised mental illness, as well as showing that social phobia and its attendant avoidance behaviour is still prevalent. This is in addition to showing the importance of adherence to antiretrovirals in the prevention of psychiatric morbidity. Finally, this study underscores the need for integrating mental healthcare into HIV treatment and prevention services.
Limitations
This was a hospital-based study in a tertiary referral centre with a limited population and as such is likely to overestimate the prevalence of conditions studied and it may be difficult to generalise the results of this study to other settings. This was also a cross-sectional study and attribution is difficult to make. In addition, the model used to determine ‘psychiatric comorbidity’ may overestimate the prevalence of psychiatric comorbidity, as in clinical practice, the best fit diagnosis would be given. Also, ‘false positives’ can be quite high when using instruments. The same patient may meet multiple psychiatric diagnostic criteria, but in clinical practice, the best fit diagnosis would be used as the primary diagnosis to be managed. Finally, neurocognitive symptoms which could be the bridge between HIV infection and the development of psychiatric disorders were not explored.
Recommendation
This study showed a high prevalence of undetected psychiatry disorders among HIV patients. It is, therefore, recommend that these patients are frequently assessed to facilitate early detection and treatment of identified psychiatry comorbidities. This will subsequently impact on the HIV treatment outcome.
Conclusions
People living with HIV and AIDS present with substantial psychiatric comorbidity, which is often unrecognised. The most common disorders are social phobia and mixed depression anxiety disorders. Patients who are non-adherent and those on second-line medication were more likely to have psychiatric morbidity. Thus, patients need to be screened for psychiatric comorbidity and managed appropriately when they present for their medication refills in addition to the counselling on medication adherence.
AcknowledgementsCompeting interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
The authors confirm contribution to the research article as follows: Study conceptualisation and design by A.R.O. and G.O.O. The literature review and instrument design as well as data collection and collation were by A.R.O. and the checking and draft manuscript by A.R.O. and G.O.O. who also reviewed the results and approved the final version of the manuscript.
Funding information
This research received no specific funding grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The data for this study are not publicly available but can be made available upon reasonable request from the corresponding author A.R.O.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.
ReferencesNg’ang’aPW, MathaiM, ObondoA, MutaviT, KumarM. Undetected psychiatric morbidity among HIV/AIDS patients attending Comprehensive Care Clinic (CCC) in Nairobi Kenya: Towards an integrated mental health care. Ann Gen Psychiatry. 2018;17(1):1–7. https://doi.org/10.1186/s12991-018-0179-1JonssonG, DaviesN, FreemanC, et al. Management of mental health disorders in HIV-positive patients. S Afr J HIV Med. 2013;14(4):155–165. https://doi.org/10.4102/sajhivmed.v14i4.50NedelcovychMT, ManningAA, SemenovaS, GamaldoC, HaugheyNJ, SlusherBS. The psychiatric impact of HIV. ACS Chem Neurosci. 2017;8(7):1432–1434. https://doi.org/10.1021/acschemneuro.7b00169BrandtR. The mental health of people living with HIV/AIDS in Africa: A systematic review. Afr J AIDS Res. 2009;8(2):123–133. https://doi.org/10.2989/AJAR.2009.8.2.1.853KwobahE, EpsteinS, MwangiA, LitzelmanD, AtwoliL. Prevalence of psychiatric morbidity in a community sample in Western Kenya. BMC Psychiatry. 2017;17(1):30. https://doi.org/10.1186/s12888-017-1202-9UwadiaeE, AdayonfoE. Psychiatric morbidity including substance use among HIV/AIDS patients at the University of Benin Teaching Hospital, Benin City, Nigeria. Niger Med Practitioner. 2019;74(5–6):62–68.AdefaluMO, Tunde-AyinmodeMF, IssaBA, AdefaluAA, AdepojuSA. Psychiatric morbidity in children with HIV/AIDS at a tertiary health institution in north-central Nigeria. J Trop Pediatr. 2018;64(1):38–44. https://doi.org/10.1093/tropej/fmx025AlfordK, VeraJ. Cognitive impairment in people living with HIV in the ART era: A review. Br Med Bull. 2018;127(1):55–68. https://doi.org/10.1093/bmb/ldy019CarricoAW, RubinLH, PaulRH. The interaction of HIV with mental health in the modern antiretroviral therapy era. Psychosom Med. 2022;84(8):859–862. https://doi.org/10.1097/PSY.0000000000001134WändellP, LjunggrenG, JallowA, WahlströmL, CarlssonAC. Health care consumption, psychiatric diagnoses, and pharmacotherapy 1 and 2 years before and after newly diagnosed HIV: A case-control study nested in the greater Stockholm HIV cohort study. Psychosom Med. 2022;84(8):940–948. https://doi.org/10.1097/PSY.0000000000001121OboCS, SoriLM, AbegazTM, MollaBT. Risky sexual behavior and associated factors among patients with bipolar disorders in Ethiopia. BMC Psychiatry. 2019;19(1):1–7. https://doi.org/10.1186/s12888-019-2313-2AshabaS, Cooper-VinceCE, VořechovskáD, et al. Community beliefs, HIV stigma, and depression among adolescents living with HIV in rural Uganda. Afr J AIDS Res. 2019;18(3):169–180. https://doi.org/10.2989/16085906.2019.1637912KenediCA, GoforthHW. A systematic review of the psychiatric side-effects of efavirenz. AIDS Behav. 2011;15(8):1803–1818. https://doi.org/10.1007/s10461-011-9939-5BrandtC, ZvolenskyMJ, WoodsSP, GonzalezA, SafrenSA, O’CleirighCM. Anxiety symptoms and disorders among adults living with HIV and AIDS: A critical review and integrative synthesis of the empirical literature. Clin Psychol Rev. 2017;51:164–184. https://doi.org/10.1016/j.cpr.2016.11.005IngersollK. The impact of psychiatric symptoms, drug use, and medication regimen on non-adherence to HIV treatment. AIDS Care. 2004;16(2):199–211. https://doi.org/10.1080/09540120410001641048OlagunjuAT, AdeyemiJD, OgboluRE, CampbellEA. A study on epidemiological profile of anxiety disorders among people living with HIV/AIDS in a sub-Saharan Africa HIV clinic. AIDS Behav. 2012;16(8):2192–2197. https://doi.org/10.1007/s10461-012-0250-xFathiM, AbbasiM, KhakranginM. Exploring the problems and challenges of HIV-infected women: A qualitative study. Iran J Health Psychol. 2021;4(4):59–66.TsaiY-T, PadmalathaS, KuH-C, et al. Suicidality among people living with HIV from 2010 to 2021: A systematic review and a meta-regression. Psychosom Med. 2022;84(8):924–939. https://doi.org/10.1097/PSY.0000000000001127WolffH, SeboP, HallerDM, et al. Health problems among detainees in Switzerland: A study using the ICPC-2 classification. BMC Public Health. 2011;11(1):245. https://doi.org/10.1186/1471-2458-11-245National Bureau of Statistics. Annual abstract of statistics [homepage on the Internet]. [cited 2021 Mar 27]. Available from: https://nigerianstat.gov.ng/elibraryTagurumYO, ChirdanOO, ObindoT, et al. Prevalence of violence and symptoms of post-traumatic stress disorder among victims of ethno-religious conflict in Jos, Nigeria. J Psychiatry. 2015;18(1):1–6. https://doi.org/10.4172/Psychiatry.1000178AluhDO, OkoroRN, ZimbohA. The prevalence of depression and post-traumatic stress disorder among internally displaced persons in Maiduguri, Nigeria. J Public Mental Health. 2019;19(2):159–168. https://doi.org/10.1108/JPMH-07-2019-0071LanmanT, LetendreS, MaQ, BangA, EllisR. CNS neurotoxicity of antiretrovirals. J Neuroimmune Pharmacol. 2021;16(1):130–143. https://doi.org/10.1007/s11481-019-09886-7CliffordDB. Viral escape in cerebrospinal fluid--an achilles heel of HIV therapy?J Infect Dis. 2010. 15;202(12):1768–1769. https://doi.org/10.1086/657343AdeotiAO, DadaMU, FadareJO. Prevalence of depression and anxiety disorders in people living with HIV/AIDS in a tertiary hospital in South Western Nigeria. Med Rep Case Stud. 2018;3(1):1–5.Federal Ministry of Health. Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) 2018: Technical report. Abuja: Federal Ministry of Health; 2019.GeorgeS, McGrathN, OniT. The association between a detectable HIV viral load and non-communicable diseases comorbidity in HIV positive adults on antiretroviral therapy in Western Cape, South Africa. BMC Infect Dis. 2019;19(1):348. https://doi.org/10.1186/s12879-019-3956-9AdewuyaAO, OlaBA, CokerO, et al. The one-month prevalence and correlates of psychotic-like experiences in the general adult population in Nigeria. Curr Psychol. 2022;1–11. https://doi.org/10.1007/s12144-022-03258-wFuenmayorA, CournosF. Addressing depressive disorders among people with HIV. Top Antivir Med. 2022;30(2):454–463.BatterhamPJ, Van SpijkerBA, MackinnonAJ, CalearAL, WongQ, ChristensenH. Consistency of trajectories of suicidal ideation and depression symptoms: Evidence from a randomized controlled trial. Depress Anxiety. 2019;36(4):321–329. https://doi.org/10.1002/da.22863BarkleyRA, AnastopoulosAD, GuevremontDC, FletcherKE. Adolescents with ADHD: Patterns of behavioral adjustment, academic functioning, and treatment utilization. J Am Acad Child Adolesc Psychiatry. 1991;30(5):752–761. https://doi.org/10.1097/00004583-199109000-00009BrownMJ, SerovichJM, KimberlyJA, HuJ. Psychological reactance and HIV-related stigma among women living with HIV. AIDS Care. 2016;28(6):745–749. https://doi.org/10.1080/09540121.2016.1147015HinkinC, CastellonS, AtkinsonJ, GoodkinK. Neuropsychiatric aspects of HIV infection among older adults. J Clin Epidemiol. 2001;54(12):S44–S52. https://doi.org/10.1016/S0895-4356(01)00446-2
How to cite this article: Oyedun AR, Oluwatoyin GO. HIV associated psychiatric comorbidity among attendees at a tertiary hospital, North-Eastern Nigeria. S Afr J Psychiat. 2023;29(0), a2022. https://doi.org/10.4102/sajpsychiatry.v29i0.2022