Depression and Adherence to Antiretroviral Therapy in Low-, Middle- and High-Income Countries: A Systematic Review and Meta-Analysis

Abstract

We investigated the associations between depressive symptoms and adherence to antiretroviral therapy (ART) among people living with HIV (PLHIV). We searched the PubMed, EMBASE and Cochrane CENTRAL databases for studies that studies that reported an association between depression and adherence to ART as a primary or secondary outcome. We used a random-effect model to pool the risk estimates from the individual studies. The odds ratio (OR) with their 95% CIs were used as summary estimates. Of 2,861 citations, 111 studies that recruited 42,366 PLHIV met our inclusion criteria. When reported, the rate of PLHIV with depressive symptoms ranged from 12.8% to 78% and the proportion of PLHIV who achieved good adherence (≥ 80%) ranged from 20% to 98%. There were no significant differences in rate of depressive symptoms in PLHIV by country income group; however, the proportion of PLHIV who achieved good adherence was significantly higher in lower-income countries (as defined in the 2012 World Bank Country Income Groups) (pooled rate = 86%) compared to higher-income countries (pooled rate = 67.5%; p<.05). We found that the likelihood of achieving good ART adherence was 42% lower among those with depressive symptoms compared to those without (pooled OR = 0.58, 95% CI 0.55 to 0.62). The relationship between depressive symptoms and adherence to ART was consistent across the country’s income group, study design, and adherence rates. We found that the magnitude of the association significantly decreases with more recent publications and increasing study sample size. The higher the prevalence of depressive symptoms of PLHIV recruited in the studies, the lower the likelihood of achieving good adherence to ART. In conclusion, the likelihood of achieving good adherence was lower among those with depressive symptoms compared to those without.

Avaliação dos sintomas depressivos somáticos e afetivo-cognitivos de pessoas vivendo com HIV/AIDS

“…(6) Despite the high depression rates identified in this population, however, knowledge gaps about depression remain among PLHA in low and middle-income countries. (4) And the difference in the depressive symptoms of men and women living with HIV in Brazil according to the BDI domains is not understood yet, which made it difficult to compare these results with other studies developed in the country.…”

“…(12,13) In the same perspective, there are studies that suggest that female vulnerability to depression is also associated with socioeconomic disadvantages (4) and lack of social support. (7) In addition, other authors argue that women are more prone to experiencing negative social determinants, assuming a disproportional load in care delivery, and mostly correspond to a low and middle-income population, besides the accumulation of housework and child raising activities.…”

“…This decrease in sexual desire in women can be explained by a coping strat- egy of PLHA who, in the attempt to protect their serum status and the health of third parties, avoid sexual relationships or even affective relationships, which can aggravate the effect of depressive symptoms even further. (4) The lack of disposition for work, as well as other symptoms (fatigue and social isolation) were appointed as important predictors for the development of depression and associated with the use of antiretroviral drugs. (24) People living with HIV generally present a form of coping through isolation (elusion, selfblame, confrontation, distancing) instead of active coping (problem solving, search for social support, acceptance of responsibility, positive reappraisal).…”

“…(4) In PLHA, it is known for being negatively associated with worse compliance with antiretroviral treatment, (5) therapeutic outcomes and risk behaviors, (6) besides its considerable impact in the treatment and social relationships (7) and in the more rapid progression to Aids and death. (1) Hence, the importance of measuring and understanding the influence of depression in this population is highlighted.…”

Aspectos psicológicos e psicossociais em indivíduos vivendo com HIV/AIDS

“…Por outro, os fatores acima, se não diagnosticados e tratados adequadamente, podem interferir com a adesão à terapia antirretroviral e aumentar o risco de complicações e óbito secundá-rios ao HIV. Devido a esse contexto, a adequada caracterização do impacto das comorbidades psiquiátricas na epidemia do HIV é de fundamental importância [7]. …”