Factors associated with psychological distress among youth and adults living with HIV in South Africa

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Background Mental disorders represent a growing public health challenge globally. Evidence shows that mental disorders like depression and anxiety are more prevalent in people living with HIV (PLHIV) than in the general population. South Africa carries the world's heaviest burden with 7.9 million people (14% of the population) living with HIV in 2017. However, there is limited literature on mental health disorders among PLHIV in South Africa particularly populationbased cross-sectional studies, as most available evidence of mental disorders among PLHIV is from small-scale studies. Studies have shown the relationship between mental disorders and HIV to be complex and bidirectional. The bidirectional nature of the relationship between mental disorders and HIV implies a complex relationship between factors associated with both health conditions where they co-exist. Improved understanding of the relationship between mental disorders, HIV and associated factors is important for designing interventions to mitigate the impact of both conditions among coinfected individuals. In epidemiological surveys, the presence of common mental disorders may be measured in terms of caseness or through a set of defined questions known as an instrument or scale. While there is a relationship between psychological distress, depressive and the anxiety symptoms, psychological distress scales are usually slightly broad but capture construct. Studies that are attempting to describe the prevalence of anxiety and depression sometimes use measures of psychological distress as a proxy. In large epidemiological surveys, psychological distress measures are used, as opposed to smaller and clinical studies. Similarly for this study, psychological distress was measured by both depressive and anxiety symptoms. Aim and objectives The aim of this study was to explore the extent and effect of psychological distress among youth and adults with HIV in South Africa. The specific objectives were as follows: 1) To conduct a systematic review and meta-analysis of studies on prevalence and correlates of depressive and anxiety symptoms among PLHIV in Southern Africa; 2) To determine the prevalence of depressive and anxiety symptoms and associated risk factors among PLHIV in South Africa; 3) To explore the relationship between HIV-related stigma and psychological vi distress among PLHIV in South Africa; 4) To explore the complex pathways linking HIV status as a mediator in the relationship of psychological distress with socio‑demographic and health related factors in South Africa. Methodology Different sub-samples were used for each paper, depending on the focus or aim of the paper. For the first objective, the systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. To fulfil the second objective, descriptive statistics were used to summarize background characteristics of the study sample and the prevalence of psychological distress. Bivariate logistic regression analysis were used to assess the relationship between psychological distress and each explanatory variable. Additionally, statistically significant variables were entered into a multivariate logistic regression analysis to identify factors independently associated with psychological distress. For the third objective, bivariate and multivariate logistic regression models were used to identify factors associated with stigma among PLHIV with psychological distress. Lastly, generalised structural equation modelling (G-SEM) path analysis was used to explore the direct and indirect relationships of socio-demographic, health and HIV-related factors with psychological distress using HIV status as a mediator. Findings The results of this study were published in four papers, which constitute Chapters 2, 3, 4 and 5. Chapter 2, in the systematic review a total of 27 articles met the eligibility criteria out of the 467 articles. The overall pooled prevalence for depression was 23%, and anxiety was 15%. Prevalence of depressive and anxiety symptoms was significantly higher among females, separated or widowed, unemployed and older age. Additionally, depressive and anxiety symptoms were significantly associated with low income, low education, urban residence, low physical activity, violence and/or partner conflict exposure, lack of social support, stigma and alcohol in PLHIV. In Chapter 3, the prevalence of psychological distress was significantly higher among females (38.2%) than males (28.5%). Psychological distress was significantly associated with being female, low socio-economic conditions, low educational attainment, marital status (being divorced/ separated), unemployment, having chronic conditions, hazardous alcohol drinking and low social support. In Chapter 4, the findings showed that psychological distress among HIV positive individuals was 34.4% and of these, 37.9% vii experienced high levels of HIV-related stigmatizing attitudes. Stigmatizing attitudes among PLHIV were significantly associated with no schooling/primary level education, incorrect knowledge about HIV and myths about HIV and never testing for HIV. In Chapter 5, the HIV positive status was shown to be a mediating factor. Psychological distress was significantly associated with female gender, not being married, having no education/primary level education, reproductive age group 25–49 years, 50 years and older, residing in urban areas, high risk drinkers, hazardous drinkers, ever testing for HIV and reporting of fair /poor selfrated health. Conclusion The systematic review and secondary analysis of the nationally representative populationbased household survey confirmed that psychological distress, as measured by depressive and anxiety symptoms was associated with specific socio-demographic, socio-behavioural and HIV-related factors including stigma among PLHIV in South Africa. The findings also suggest that HIV positive status was a mediating factor in the relationship between psychological distress and identified covariates. These findings highlight the importance of integrated screening and management of psychological distress and HIV. Furthermore, the findings underscore the need for highly targeted interventions tailored for identified groups of PLHIV. Lastly, more longitudinal studies are needed to track changes and trends over time on factors associated with mental disorders and HIV and the impact of respective interventions.