The prevalence of depression,anxiety and associated factors among adults with living human immunodeficiency virus in University Malaya Medical Centre

Abstract

Background

This study estimates prevalence of depression and anxiety among adults living with Human Immunodeficiency Virus (HIV) in University Malaya Medical Centre (UMMC) and determines its associated factors.

Methods

This cross-sectional study was conducted between August 2020 and January 2021, in the Infectious Disease clinic and ward. One hundred ninety-one patients were recruited via convenience sampling. Patients’ sociodemographic were obtained, followed by Depression, Anxiety, Stress Scale -21 (DASS-21), Multidimensional Scale of Perceived Social Support (MSPSS), and M.I.N.I. international neuropsychiatric interview (M.I.N.I.) The cut off DASS-21 point for depression is ≥5, for anxiety, ≥ 4. Mann-Whitney U and Chi square test were used to analyse the association between variables, and logistic regression to find predictability.

Results

Of the 191 participants, 89.5% outpatient, mean age 40 years (SD 0.742), 91.1% male, 65.4% single, 71.2% working, 46.1% Malaysian Chinese, 59.8% non- heterosexual, mean 6 years of being HIV positive; mean CD4 count 449/μL; mean viral load 116,690 (median = 20). 85.9% were taking antiretroviral therapy. The prevalence of depression was 35.1% (n = 67); anxiety was 42.9% (n = 82). Regression analysis revealed anxiety and stress increased odds of depression by 3.8 times (p = .001) and 12 times (p < .001) respectively. Those 40 years old and younger had 2.3 times odds of anxiety (p = .048). Increased social support from friends increased odds of anxiety by 1.7 times (p = .018). Depression and stress increased odds of anxiety by 4.4 times (p = .001) and 3.7 times (p = .008) respectively.

Conclusions

Depression and anxiety among people with HIV is often under-recognised. Early identification and treatment of the mental illness is warranted. Screening with DASS-21 is useful to detect depression in patients with HIV.

Keywords

asia homosexual human immunodeficiency virus epidemiology screening

Introduction

Human immunodeficiency virus (HIV) infection, a lifelong infection, causes weakening of one’s immunity, possibly leading to a severe immunodeficiency state, Acquired Immunodeficiency Syndrome (AIDS) making the person susceptible to multiple infections and possible death.¹ There is no cure for HIV, but the disease can be controlled with antiretroviral therapy (ART).¹ Human immunodeficiency virus and acquired immunodeficiency syndrome have become one of the most important worldwide health burdens. In Malaysia, the number of people living with HIV is about 87,000 people. Most of the cases are located in Selangor, Kuala Lumpur and Johor.² Men who have sex with men continue to be the main group affected by HIV infection.⁷

There are many potential crisis points in dealing with HIV, from the initial diagnosis, to co-morbidities, daily strict medication intake, hospitalization, permanent disability, disfigurement and stigma.³ Having a psychiatric condition worsens the prognosis of HIV infection and reduces the likelihood of receiving and adhering to HIV treatment.^3,4

The psychiatric disorders associated with HIV infection are extensive. Depression, psychosis, substance use, and post-traumatic stress disorder are 1.5–8 times higher among people with HIV.⁴ Anxiety disorders are the commonest psychiatric illness associated with HIV, ranging from 2 to 40%, followed by depression at 4.9%–78%.⁵ HIV patients who are 40 years and less and unemployed are more likely to present with depressive symptoms.⁶ A study by Ngum⁶ showed the prevalence of depression is higher in people with CD4 count of 200 cells/mcl and less. Suicidality was also associated with CD4 count <200 cells/mcl.⁸

People with HIV have a three times higher risk of experiencing moderate to severe depressive symptoms,⁹ with more severe and longer durations of depression.¹⁰ Depression was associated with higher viral load counts and lower CD4 counts.¹¹ Depression reduces adherence to antiretroviral therapy among patients with HIV.¹² Keiser¹³ and Robertson¹⁴ reported that suicidality is significantly higher among people with HIV, and anxiety is associated with higher suicidality.¹⁵ Anxiety disorders affect the prognosis of HIV, delays the time to viral suppression and increase the rate of antiretroviral failure even after suppression.¹⁶

Women with HIV tend to experience more anxiety than men,¹⁷ related to stigma, and worries about reproductive health associated with HIV.¹⁷ People living with HIV with poor coping skills, history of abuse, personal or family history of anxiety disorder, and without adequate social support have a higher tendency of developing anxiety disorders.¹⁷ Those who are older, being in a romantic sexual relationship, and having an undetectable HIV viral load have lower anxiety.¹⁷

Higher social support is correlated with lower depression, anxiety and stress among people with HIV in Ghana.¹⁸ People receiving HIV treatment with stable condition, who faced substantial psychological stress had a higher chance for depression without social support.¹⁹

The objectives of the study were to estimate the prevalence of depression and anxiety among adults with HIV in University Malaya Medical Centre, Malaysia, and to determine the associated factors of depression and anxiety, such as social support, and to identify other possible factors associated with depression and anxiety. There is a lack of recent study about prevalence, anxiety and its associated factors among people with HIV in Malaysia.

Methodology

Study setting

This study was conducted in the outpatient Infectious Disease clinic and ward of a teaching hospital. The hospital is a semi-government, tertiary hospital with infectious disease services, psychiatric services and many other subspecialties. There were two infectious disease clinic sessions per week, from 8 a.m., till 2 p.m., with about 20 HIV patients per clinic session. However, during the movement control order period for the Covid-19 pandemic, the clinics were cut down by 70%, around five patients with HIV per clinic session.

Study design and sampling method

This is a cross sectional study, using convenience sampling. The inclusion criteria were patients with documented confirmed HIV infection, ≥ 18 years of age, and able to give written consent. The exclusion criteria were patients who refused to consent, those who could not communicate or were at risk of violence, and patients both medically and psychiatrically unstable.

Study procedures

This study was conducted between August 2020 and January 2021 with face to face interviews by a psychiatry trainee, in the Infectious Disease clinic and ward. Participation was entirely voluntary. Patients’ sociodemographic were obtained, followed by Depression, Anxiety, Stress Scale -21 (DASS-21), Multidimensional Scale of Perceived Social Support (MSPSS), and M.I.N.I. international neuropsychiatric interview (M.I.N.I.). Patients who exhibited suicidality, risk to self, and with disorders diagnosed in M.I.N.I. were referred to see a psychiatrist.

Study instruments

Depression, anxiety, and stress scale – 21 items (DASS-21)

Depression, anxiety, and stress scale -21 items (DASS-21) is a set of three self-reported, quantitative scales.²⁰ It is the shorter version of a the original 42-item questionnaire DASS with good reliability and validity to the original to measure depression, anxiety and stress in adults.²¹ It has seven items per domain, rating experience over the past week using a 4-point severity/frequency scales. The respondents were defined as having depression when DASS-21 scores ≥5 and having anxiety when ≥4. The Cronbach’s alpha for depression and anxiety are 0.84 and 0.74.²²

Multidimensional Scale of Perceived Social Support (MSPSS)

Multidimensional scale of perceived social support is a 12 -items brief self-reported measurement to assess one’s self- perceived social support from significant people, family and friends. The three social support subscales contain four items. It uses a 7-point Likert scale. Each subscale score ranges from 4 to 28. The score of the items are added together, and a total MSPSS score can also be calculated and ranges from 12 to 84. Higher subscale and total scores indicate higher levels of perceived social support. On the other hand, subscale mean score can also be calculated by summing the scores for subscales then divided by 4, the four items in a subscale, where score of 1–2.9: low support, score of three–5: moderate support, and a score of 5.1–7: high support.²³

Multidimensional scale of perceived social support has demonstrated good validity among many populations worldwide including Malaysia.²³ Ng, Amer N²⁵ reported that MSPSS exhibited good internal consistency with Cronbach’s alpha = 0.89, parallel form reliability = 0.9) and a test-retest reliability of 0.77, and Spearman’s rho, p < .01, as well as the Malay version.²⁶

M.I.N.I. International Neuropsychiatric Interview for diagnosis of mental illness (M.I.N.I.)

M.I.N.I. International Neuropsychiatric Interview for diagnosis of mental illness was created for structured psychiatric interview as a tool facilitating data collection and to process symptoms elicited in multicenter clinical trials and epidemiology studies based on DSM 5.²⁷ M.I.N.I. International Neuropsychiatric Interview for diagnosis of mental illness has good validity and reliability, comparing DSM III. M.I.N.I. International Neuropsychiatric Interview for diagnosis of mental illness to the Composite International Diagnostic Interview (CIDI) which showed good kappa coefficient, sensitivity, specificity, inter-rater and test-retest reliability.²⁸ In this study, M.I.N.I. assessment was done solely by the principal investigator.

Data analysis

Data was analyzed using the Statistical Package for Social Sciences (SPSS) Version 26. Descriptive statistics were used to summarize data. All of the continuous variables were skewed and were not normally distributed. Some of the variables were further grouped together into dichotomous variables, such as age 40 and less/more than 40, ethnicity – Malay/non-Malay, availability of partner status- no/yes, residence – Klang valley (Kuala Lumpur and Selangor)/non Klang valley, educational level- primary and secondary school/tertiary education, employment status- working/not working, years of HIV- 1 year and below/more than 1 year, CD4 count- 200 cells/mcl and less/more than 200 cells/mcl, due to the small sample size.

Mann–Whitney U test was used to analyze the relationship between the independent non-parametric continuous variable, i.e. the mean age scores, mean household number, mean CD4 counts, mean viral load, mean DASS-21 scores, and mean MSPSS scores with the presence of depression, anxiety, and stress in DASS-21 as the dependent variables.

Chi square tests were used to analyze the relationship between categorical independent variables such as age, gender, sexuality, admission status, ethnicity, religion, partner status, education level, employment status, household income, family history of mental illness, years of HIV diagnosis, CD4 count, presence of antiretroviral therapy, M.I.N.I. with presence of anxiety/depression in DASS-21 as the dependent variables.

Results

Sociodemographic data and prevalence

Two hundred twenty-six patients attended the infectious disease clinic and admitted to the infectious disease ward were approached; 20 were unwilling to participate, five were aggressive, 10 were in respiratory distress. Referring to Table 1, 191 participants were recruited, 174 (91.1%) were male, 171 (89.5%) were outpatients. Their mean age was 40 years old (SD 0.74). Majority were single, 125 (65.4%), Chinese ethnicity, 88 (46.1%), homosexual 79 (41.4%). All participants received formal education. 126 (66%) received a tertiary education. 136 (71.2%) were either employed or self-employed. 81 (42.4%) were from the middle income M40 group. 175 (91.6%) of the participants did not have family history of mental illness. The mean years of HIV infection was 6.4 years. The mean CD4 count 449 cells/mcl; 144 (75.4%) had CD4 count of >200 cells/mcl. The mean viral load was 116,690 copies/mm³, with median at 20. 164 (85.9%) were taking antiretroviral therapy.

Table 1.

Sociodemographic and clinical characteristics across all the participants.

Variable	Frequency (n)	Percent %
Age	40 (SD 0.74)
Status
Outpatient	171	89.5
Inpatient	20	10.5
Gender
Male	174	91.1
Female	17	8.9
Ethnicity
Malay	59	30.9
Chinese	88	46.1
Indian	32	16.8
Others (Sabahan, Sarawakian, Punjabi, Foreigner)	12	6.2
Religion
Islam	66	34.6
Buddhism	56	29.3
Hindu	26	13.6
Christianity	29	15.2
Others: - Sikhism, No religion	14	7.3
Relationship status
No partner	133	69.6
Has partner	58	30.4
Sexuality
Non- heterosexual	114	59.7
Heterosexual	77	40.3
Education level
Primary & secondary	65	34.0
Tertiary	126	66.0
Employment status
Employed/working (include housewife)	141	73.8
Not working & retired	50	26.2
State
Kuala Lumpur	73	38.2
Selangor	105	55.0
Others (Perak, Kedah, Terengganu, Pahang, Negeri Sembilan, Johor)	13	6.8
Household number	3.47 (SD 0.16)
Household income
B40	79	41.4
M40	81	42.4
T20	31	16.2
Family history of mental illness
Yes	16	8.4
No	175	91.6
Years of HIV diagnosis	6.40 (SD 0.44)
CD4 count (cells/mcl)	449 (SD 21.87)
200 cells/mcl	47	24.6
201 cells/mcl and above	144	75.4
Viral load (undetectable – 1 billion copies/mm³)	116690.00 (SD 46235.77)	Median: 20
Taking antiretroviral therapy
Yes	164	85.9
No	27	14.1

SD = Standard deviation.

Out of the 191 participants, 67 were depressed, giving a prevalence of 35.1%. 82 were anxious, giving a prevalence of 42.9%.

Correlation statistics

Correlation analysis showed significant relationship between age (p = .03), and years of HIV infection (p = .04) with depression on DASS-21. Referring to Table 2, depression on DASS-21 was significantly associated with M.I.N.I. diagnosis of current major depressive episode (p = .012), M.I.N.I. diagnosis of current depression and suicidality (p < .001), M.I.N.I. diagnosis of past and current depressive episode (p < .001), M.I.N.I. diagnosis of suicidality, (p < .001), and M.I.N.I. diagnosis of current anxiety disorder (panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder) among people with HIV in UMMC (p = .012). Depression on DASS-21 was significantly associated with anxiety (p < .001), stress (p < .001) on DASS-21.

Table 2.

Demographic and social determinants of anxiety on DASS-21.

Characteristics	Frequency (n = 191)	No anxiety (n = 109)Frequency (%)	Anxiety (n = 82)Frequency (%)	X²	P value	Odds ratio	95% confidence interval (cl)
Characteristics	Frequency (n = 191)	No anxiety (n = 109)Frequency (%)	Anxiety (n = 82)Frequency (%)	X²	P value	Odds ratio	Lower	Upper
Age
40 and less	117	58 (49.6)	59 (50.4)	6.93	.01**	0.44	0.24	0.82
More than 40	74	51 (68.9)	23 (31.1)	6.93	.01**	0.44	0.24	0.82
Partner status
No partner	133	68 (51.1)	65 (48.9)	6.31	.01**	0.43	0.22	0.84
Partner available	58	41 (70.7)	17 (29.3)	6.31	.01**	0.43	0.22	0.84
Sexuality
Non- heterosexual	114	57 (50)	57 (50)	5.77	.02*	0.48	0.26	0.88
Heterosexual	77	52 (67.5)	25 (32.5)	5.77	.02*	0.48	0.26	0.88
Education level
Primary and secondary	65	44 (67.7)	21 (32.3)	4.54	.03*	1.97	1.05	3.68
Tertiary	126	65 (51.6)	61 (48.4)	4.54	.03*	1.97	1.05	3.68
Employment status
Not working	50	35 (70)	15 (30)	4.62	.03*	2.11	1.06	4.21
Working	141	74 (52.5)	67 (47.5)	4.62	.03*	2.11	1.06	4.21

*Statistically significant p < .05, p < .01**, M.I.N.I.: Mini International Neuropsychiatry Interview; DASS-21: Depression, Anxiety, and Stress scale -21; PTSD: Post- Traumatic Stress Disorder.

Factors associated with anxiety

Correlation analysis showed in Table 2, revealed that anxiety on DASS-21 was associated with age (p = .01), partner status (p = .01), sexuality (p = .02), education level (p = .03), and employment status (p = .03).

Depression, Anxiety, and Stress scale -21 rating of anxiety was significantly associated with M.I.N.I. diagnosis of current major depressive episode (p = .042), M.I.N.I. diagnosis of current major depressive episode and suicidality (p = .001), M.I.N.I. diagnosis of past and current major depressive episode (p = .024), M.I.N.I. diagnosis of suicidality (p = .005). Depression, Anxiety, and Stress scale -21 rating of anxiety was significantly associated with DASS-21 rating of Stress (p < .001).

Logistic regression

The regression model examined the predictors of depression, after controlling for other variables. Presence of anxiety in DASS-21 increased the odds of depression on DASS-21 by 3.5 times (p = .003). Presence of stress in DASS-21 increased the odds of depression on DASS-21 by 12 times (p < .001). Presence of M.I.N.I diagnosis of past and current major depressive episode increases the odds of depression on DASS-21 by 4.7 times (p = .006).

The regression model examined the predictors of anxiety, controlling for the other independent variables as in Table 3. Patients with HIV who are 40 years old and less, had 2.3 times odds of having anxiety on DASS-21 (p = .048). More social support from friends had higher odds of anxiety on DASS-21 by 1.7 times (p = .018). Presence of depression in DASS-21 increased the odds of anxiety on DASS-21 by 4.4 times (p = .001). Presence of stress in DASS-21 increased the odds of anxiety on DASS-21 by 3.7 times (p = .008).

Table 3.

Logistic regression models examining factors associated with anxiety on DASS-21.

Variables	B	Standard error	P value	Adjusted odds ratio/Exp (B)	95% confidence interval
Variables	B	Standard error	P value	Adjusted odds ratio/Exp (B)	Lower	Higher
Depression on DASS-21	1.486	0.4480	.001**	4.420	1.837	10.636
Stress on DASS-21	1.320	0.4980	.008**	3.743	1.410	9.933
Social support from friend	0.526	0.2229	.018*	1.693	1.094	2.620

*Statistically significant, p < .05*, p < .01**, M.I.N.I.: Mini International Neuropsychiatry Interview; DASS-21: Depression, Anxiety, and Stress scale -21; MSPSS: Multidimensional Scale of Perceived Social Support.

Discussion

The prevalence of depression among adults with HIV in UMMC is 35.1% is higher than the general population, and consistent with previous studies done in same setting in UMMC at 32%,²⁹ in east coast Malaysia at 33.3% using a similar screening tool,³⁰ and also in South Africa, China and Nigeria (reported as 25.4%, 32.9% and 39.6% respectively).³¹

On the other hand, the prevalence of anxiety in this study, 42.9%, was higher than general population, higher than the study done in East Coast Malaysia with a prevalence of 28.5% using similar screening tool,³⁰ and also higher than Nigeria, South Africa, China, with prevalence of anxiety at 32.6%, 30.6%, 27.4%, respectively.³¹ The variation of the prevalence is likely due to diverse diagnostic tools, sample size differences and different locations of the study.

This study, which took place in UMMC, is heavily populated with people of all races due to urbanization.³³ Despite female being the predominant gender in Klang Valley compared to male,³³ the majority of the patients with HIV were single homosexual men. This is in line with the international findings that male to male sexual transmission is the main mode of HIV transmission. Men who have sex with men (MSM) with HIV infection are more vulnerable to have mental health issues, particularly depression and anxiety³⁴ and this is relevant to the finding of significant correlation between anxiety and sexuality (p = .02). Pachankis et al.³⁵ found that homosexual men have more fear for negative comments, more social anxiety and lower self-esteem than heterosexual men.

There were eight million people living in Klang Valley. Malaysians with more education were likely to migrate to the Klang Valley, and the majority of them were of younger age group between 20–49 years of age.³³ This migration was motivated by better job opportunites in the urban city,³³ in line with this study that majority of participants have tertiary education and were working adults. In this study, education level is significantly associated with anxiety (p = .03). Hu et al.³⁶ demonstrated that MSM who received higher education and higher income were less likely to suffer from anxiety and depression. Depression, anxiety, suicide and self-harm were associated with lower education and lower income.³⁷ People with higher education levels were more likely to be aware, seek and receive mental health services than individuals with lower education levels.³⁸ Hu et al.³⁶ pointed out that patients with HIV who were HIV knowledge deficient were more likely to have anxiety.

This study found that years of HIV infection (p = .041) has a significant relationship with depression on DASS-21. This was strengthened by Bhatia et al.,³⁹ whereby people with newly diagnosed HIV were two to three times at higher risk for depression, likely adjusting to the social stigma.³⁹ Physical illness due to HIV opportunistic infection, malignancies and co-morbidities often accompanied with the new diagnosis especially in people with low CD4 counts.³⁹

This study noted that being 40 years old or less has odds of 2.3 times having anxiety compared to older patients (>40 years). This is in line with the study by Camara et al.³¹ among HIV patients, that being younger (<40) has higher odds of 2.81 times of having anxiety. Younger MSM had higher prevalence of anxiety than older MSM with higher resilience.³⁶ Current studies also noted a significant relationship between age with depression on DASS-21 (p = .027), in line with the study by Abebe,⁴⁰ that young adults may have difficulty conceptualizing their HIV status and having poorer coping while facing challenges.

Anxiety is found to be significantly related to employment status (p = .03). Young adults may be more vulnerable to mental health challenges when exposed to unemployment.⁴¹ When there were maladaptive coping strategies along with loss of job, mental health may be compromised.⁴¹

Social support was found to be statistically significantly associated with depression in this study. Ng’s²⁶ study among the psychiatry outpatients found significant inverse relationship between total subscales of MSPSS-M and depression subscale in DASS. In addition, the current study found that family support was significantly associated with depression. This is in line with Abebe et al.’s⁴⁰ finding that people with HIV who had low social support were 2.7 times more likely to experience depressive symptoms than those with high social support. Social support safeguards the harmful influences of stressful events and lessens the risk of depression.¹⁹ Despite being on ART, those without social support tended to face extensive psychological stress and had greater risk of depression.¹⁹

Interestingly, this study found that more social support from friends was associated with higher odds of anxiety on DASS-21 by almost 2 times (p = 0.009). Many studies have found that social support benefits mental health.^18,19,42,43

There are a few possibilities for this study finding. As this is a cross sectional study, we were unable to establish a cause-effect association. It can be postulated that these adults with HIV may have friends who are overinvolved, creating a high level of anxiety. This concept was adapted from Coyne⁴⁴ and Hogan et al.⁴⁵ stating that close relationships with family ties may be a potential source of stress and may have a deleterious influence on mental health. Rodebaugh et al.⁴⁶ found that the perception of an individual towards social support of friends are different depending on various other factors, such as presence of mental disorder, number of friends, frequency and quality of interaction, years of relationship etc. which are the determinants of the friendship’s quality.

Welcome⁴⁷ found that anxiety symptoms in isolation did not appear to influence friendship functioning or friends’ anxiety, and negatively impact positive friendship quality. Youth with elevated anxiety symptoms were able to sustain meaningful and high-quality friendships.⁴⁷

In addition, there could be possible confounders such as substance use, used among friends as a form of bonding, which was not included in the regression model because the variable of substance use disorder on M.I.N.I. did not meet the assumption of analysis, creating a high level of standard error during the analysis.

The majority of literature reviews demonstrated inverse relationships between social support and depression, but rarely between social support and anxiety. Hardan²⁴ had pointed out that the three MSPSS subscales were significantly inversely correlated to depression. However only the family subscale was significantly inversely correlated with anxiety.

The significant association between the DASS rating of anxiety and M.I.N.I diagnosis of suicidality (p = .005), was in line with Dabaghzadeh's³² finding on people with HIV in Tehran that anxiety and depression were significantly associated with the patients’ negative suicidal ideation. The suicide rate is 7.4 times much higher among people with HIV than among general population.³²

The regression model found that anxiety and stress were significant predictors of depression on DASS-21. DASS-21 and M.I.N.I were associated with statistical significance for measurement of depression, with the correlation and regression analysis after controlling possible confounders. Hence, DASS-21 can be a useful tool in detecting depression.

This study has its limitations. Firstly, it was conducted throughout the Covid-19 pandemic. UMMC was a Covid-19 hospital during the pandemic. Malaysians were undergoing a series of movement control orders. Many patients refrained from attending clinics due to risk of contracting Covid-19 virus. There was reduction on the number of patients attending the clinic, to maintain social distancing. Admissions were reserved for severe cases in order to reduce the risk of patients’ exposure to Covid-19 virus and to reserve beds for patients with Covid-19 infection. The numbers of patients recruited into the study from inpatients were much less than the outpatient group, creating selection bias. Hence, the study period was short, and the number of participants recruited were not optimal with respect to the topic studied.

The second limitation is that about 9% of the patients who fulfilled the recruitment criteria refused to participate, as they were concerned about confidentiality. In these circumstances, there were high chances of patients who were having a mental issue not being detected in this study.

Thirdly, the study was mainly hospital based, using convenience sampling. Patients presenting to clinic were mostly patients with insight and showed willingness to comply with medication, and thus possibly likely to be less depressed or anxious. Patients who were severely depressed or anxious with impaired function may not present themselves to the hospital. Hence, the findings cannot be generalized to the entire HIV population in Malaysia. There were more males selected compared to female due to relatively more male patients from the patient pool, creating selection bias.

Fourthly, there were six foreigners recruited into the study as they presented themselves to the infectious disease department of UMMC. These patients may alter the figures of the prevalence of the mental illness among Malaysians, however the study design did not exclude the non-Malaysians. This study design was representative of the real scenario in Malaysia whereby there are significant numbers of foreigners living in Malaysia who also need healthcare.⁴⁸

Subsequently, this is a cross sectional study, designed to find the association between depression, anxiety and its associated factors. In order to determine the cause-effect relationship, prospective studies are needed.

Lastly, there were several potential confounders in this study such as stigma, HIV co-morbidities, and efavirenz being a potential cause of depression noted in many studies.^49,50 They were not included in this study due to its large variety of HIV comorbidities and ART.

Conclusion

The strength of this study are that the sample size was adequate, validated measuring tools were used, a doctor working in a psychiatry department administered the M.I.N.I., and there was after-care plan for participants who were found to have M.I.N.I. diagnosis to be referred to a psychiatrist.

The prevalence of depression among people with HIV in UMMC is on par with previous study in the same study site and many other countries. Meanwhile, the prevalence of anxiety among people with HIV in UMMC was found to be higher than other countries. Both prevalence of depression and anxiety among people with HIV were higher than the general population.

The implications of the study are that intervention and efforts to prevent, detect and treat depression and anxiety among adults with HIV are needed to provide a holistic treatment for people living with HIV. More focus is needed to be given to adults with HIV from the younger age group 40 years old and below who are prone to getting anxiety. Efforts to gather social support regardless of sources could help preventing and reducing depression among people with HIV. Screening with DASS-21 is useful in assessment of mental health of adults with HIV.

Supplemental Material

Supplemental Material - The prevalence of depression, anxiety and associated factors among adults with living human immunodeficiency virus in University Malaya Medical Centre

Supplemental Material for The prevalence of depression, anxiety and associated factors among adults with living human immunodeficiency virus in University Malaya Medical Centre by Jen Yeung Ong, Anne Hway Ann Yee, Amer Siddiq Amer Nordin, Mahmoud Danaee and Raja Iskandar Azwa in International Journal of STD & AIDS

Footnotes

Acknowledgements

We would like to thank for the support from the Faculty of Medicine, University Malaya, and the University Malaya Medical Centre.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical considerations

This study was conducted as per 1964 Declaration of Helsinki and in accordance with the standards of Medical Research Ethics Committee of the University Malaya Medical Centre (UMMC) (MREC ID: 2020317-8384). Informed consent was obtained from all study participants.

Availability of data and materials

The datasets used and analysed for current study are with the corresponding author and available upon reasonable request.

ORCID iDs

Jen Yeung Ong

Anne Yee

Supplemental Material

Supplemental material for this article is available online.

Abbreviation

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