Prevalence of depression, syndemic factors and their impact on viral suppression among female sex workers living with HIV in eThekwini, South Africa

Abstract

Introduction Over half of female sex workers (FSW) in South Africa are living with HIV and clinical depression has been frequently documented among FSW. Data characterizing structural determinants of depression and the role of syndemic theory, synergistically interacting disease states, on viral suppression among FSW in South Africa are limited. Methods Between July 2018-March 2020, non-pregnant, cisgender women (≥ 18 years), reporting sex work as their primary income source, and diagnosed with HIV for ≥ 6 months were enrolled into the Siyaphambili trial in eThekwini, South Africa. Using baseline data, robust Poisson regression models were used to assess correlates of depression and associations between depression and syndemic factors on viral suppression. Results Of 1,384 participants, 459 (33%) screened positive for depression, defined as a score of ≥ 10 on the PHQ-9. Physical and sexual violence, drug use, alcohol use, anticipated stigma and internalized stigma were univariately associated with depression (all p’s < 0.05) and included the multivariate model. In the multivariate regression, prevalence of depression was higher among participants experiencing sexual violence (PR = 1.47 95% CI:1.24,1.73), physical violence 5 times or more in < 6 months (PR = 1.38 95% CI:1.07, 1.80), using illicit drugs in the last month (PR = 1.23 95%:CI 1.04, 1.48), and reporting higher levels of internalized stigma (PR = 1.11, 95% CI:1.04,1.18). Depression in the absence of the Substance Abuse, Violence and AIDS SAVA syndemic factors was associated with increased prevalence of unsuppressed viral load (aPR 1.24; 95% CI:1.08,1.43), and the SAVA substance use and violence syndemic was associated with an increase in unsuppressed viral load among non-depressed FSW (aPR 1.13; 95% CI:1.01, 1.26). Compared to those experiencing neither factors, those jointly experiencing depression and the SAVA syndemics were at increased risk for unsuppressed viral load (aPR 1.15; 95% CI:1.02,1.28). Conclusion Substance use, violence, and stigma were all associated with depression. Depression and syndemic factors (substance use + violence) were related to unsuppressed viral load; we did not observe higher unsuppressed viral load amongst those experiencing both depression and syndemic factors. Our findings point to the need to understand the unmet mental health needs of FSW living with HIV. Trial registration Clinical Trial Number: NCT03500172.

Prevalence and factors associated with viral non‐suppression in people living with HIV receiving antiretroviral therapy in sub‐Saharan Africa: A systematic review and meta‐analysis

“…Bhardwaj et al. (2023) 24 employed a viral load threshold of ≥50 copies/mL to examine factors associated with VNS among female sex workers aged 18 years and above. In contrast, Nyakato et al.…”

“…Bhardwaj et al (2023) 24 employed a viral load threshold of ≥50 copies/ mL to examine factors associated with VNS among female sex workers aged 18 years and above. In contrast, Nyakato et al (2022) 44 and Goldman et al (2008) 29 utilised a viral load threshold of ≥400 copies/ mL to Investigate factors associated with VNS among adults.…”

Mental health burden among females living with HIV and AIDS in sub-Saharan Africa: A systematic review

“…Most of the scales used were developed and validated in high income settings and therefore lacked contextual (cultural and non -specificity to the HIV population) validity. The reliability coefficient of the scales was not reported in a majority of the studies (n = 11) [6,26,29,30,32,33,35,[37][38][39]43].…”

“…Other risk factors included loss of selfesteem, experiences of discrimination, loss of life partners and or other family members, poverty, educational status, victimization, living with people other than direct family members, homelessness, being single or divorced. In 11 of these studies [6,26,[28][29][30][31][32][33][41][42][43], a univariate, multivariate or logistic regression analysis showed that sexual abuse, physical intimate partner violence, loneliness, enacted stigma, childhood trauma, post-traumatic stress disorder, young age, high viral load, having no formal education, divorce, unemployment and low social support increased the odds of depression and anxiety in FLWHA and was statistically significant (P � 0.005). However, one study [36] showed there was no significant correlation (P � 0.005) between depression/anxiety symptoms and educational status, employment status, and ART treatment status.…”

“…Among the 19 studies included in this review, seven (7) representing 36.8% reported on protective factors against anxiety and depression symptomatology in different countries [6,27,32,34,36,38,43]. Specifically, five (26.3%) of these studies [6,27,34,36,43] reported on social support as a buffer against anxiety and depression.…”