Prevalence of Unrecognized Depression and Associated Factors Among Newly Diagnosed People Living with HIV/AIDS in West Shoa Zone, Ethiopia 2019, Cross-Sectional Study

Background: Clinical depression has been associated with various chronic disease conditions. The chronic course of HIV, fostered by the use of antiretroviral therapy in infected patients, puts them at risk of developing clinical depression which unfortunately, is often undiagnosed and therefore untreated. This study aimed to assess Prevalence of unrecognized depression and associated factors among newly diagnosed people living with HIV/AIDS in west shoa zone, oromia regional state, central Ethiopia. Method: Institutional-based cross-sectional study was implemented in 2019. A total of 429 newly diagnosed HIV-positive patients who had regular visit at selected public health facilities in west shoa zone, oromia regional state, central Ethiopia were included in the study. Systematic random sampling technique was used to recruit study participants. Patient Health Questionnaire item nine (PHQ-9) was used to assess depressive symptoms. In addition to this, HIV perceived stress scale was used to assess HIV-related perceived stress. Result: A total of 429 study participants were included in the study, giving a response rate of 100%. The mean age of the respondents was 37 years (SD ± 10.04). This study revealed that 47.3% of HIV-positive patients had depression. Patients who had opportunity infection [AOR = 2.15, (95% CI 1.41, 3.29)], HIV-related perceived stress [AOR = 2.23, (95% CI 1.44, 3.46)] and CD4 cell count < 200 [AOR = 1.94, (95% CI 1.25, 3.02)] were more likely to have depression as compared to individuals who had no opportunity infection, no perceived HIV stress and CD4 cell count > 200, respectively. Conclusion and recommendation: Having HIV-related perceived stress and opportunity infection of participant had statistically signicant association with undiagnosed depressive. Training of health workers in ART clinics and availing manuals on assessing mental health issues is useful to screen and treat among HIV patients.


Background
Depression also known as major depressive disorder or clinical depression is a common mental health disorder that results in persistent sadness and loss of interest in activities previously enjoyed, for a period of at least 2 weeks [1]. It is commonly present as co morbidity in many chronic illnesses adding to the overall burden of disease [2]. One of such chronic illnesses is disease caused by infection with the human immunode ciency virus (HIV) which has become a global pandemic with close to 36.9 million people living with the disease worldwide by the end of 2017, and 1 million deaths from the disease in the same year [3].
Depression is one of the most common mental disorders people with HIV/AIDS experience and negatively affects adherence to and outcomes of antiretroviral treatment (ART) [4][5]. Throughout the course of HIV infection, patients may experience depressive symptoms due to deteriorated health status, di culty functioning, ART side effects, apathy, perceived stress stigma, and discrimination [6][7].
In different studies so far, sex, having co morbid TB illness, perceived HIV stigma, poor social support, HIV stage III, and poor medication adherence and CD4 cell count(< 200) were found signi cantly associated with depression. But site speci c evidence is needed to identify factors associated with depression among adult patients with HIV/AIDS on ART [18, 23, 24, 25 and 26]. More over it is crucial to identify patients with undiagnosed depression for proper management of the disease. Thus, this research was aimed at providing data on the prevalence and factors associated with undiagnosed depression among newly diagnosed people living with HIV/AIDS.

Method Study design and setting
An institutional-based cross-sectional study was employed. The study was conducted in the West Shoa zone, Oromia regional state, Ethiopia. In west Shoa zone there are eight public hospitals and ninety one health center. From those all hospital and twenty four health center have ART clinic. From this public health there are around 12272 ARV patients on follow up. The assessment was conducted from February 1, to April 30, 2020.
Sample size estimation and recruitment of participants Single population proportion formula was used to calculate the sample size using the magnitude of depression in pregnant mothers in Ethiopia, 37.5% [20], with a 95% con dence interval, 5% of margin error and with the calculated design effect of 2.5. A multi-stage sampling technique was used to select the study participants. Initially, three hospitals and ten health centers was selected by simple random sampling from a total of eight hospital and 24 health centers in West shoa zone which have ART clinic.
Then three hospitals and ten health centers was selected proportionally by lottery method. Then total sample size was allocated proportionally to each selected public health institutions based on the number of target population. A total of 429 newly diagnosed PLWHIV on follow up at least for six month were recruited for the study. Those with hearing or cognitive impairment to the extent of impairing capacity to communicate adequately and unable to give informed consent to take part in the study were excluded from the study.

Data collection instrument and data collectors
Data were collected by trained data collectors. The presence of antenatal depression was assessed by the Patient Health Questionnaire item nine (PHQ-9). The prevalence of depressive symptoms, de ned by PHQ-9 scale, this study a positive depression screen was de ned as a PHQ-9 score greater than 9, among newly-diagnosed HIV-infected subjects during initial assessment [30]. We have used tools consisted of structured and standardized locally translated language psychosocial assessment instruments, most of which have previously been used among persons living with HIV (PLWHIV) in Ethiopia by this study group [29].

Data analysis
The Statistical Package for Social Science (SPSS) version 21.0 was used for data analysis. Newly diagnosed PLWHIV on follow up socio-demographic, economic and clinical related characteristics were described using the statistics of frequency and percentage distributions. Further, bivariate logistic regression analysis was conducted to identify correlates of HIV/ AIDS depression. Variables with a pvalue < 0.25 during bivariate analysis were entered into a multivariate logistic regression analysis to identify potential confounders. Then, adjusted OR was calculated using multivariate logistic regression analysis and the level of signi cance of association was determined. Signi cance level was declared at < 0.05.

Results
Socio-demographic characteristics of respondents A total of 429 PLWHIV were included in the study yielding a response rate of 100%. The mean age (± SD) of the PLWHIV was 37.68 ± 10.04 years, with ages ranging between 19 and 65 years. Out of 429 PLWHIV, 356 (83%) were from the Oromo ethnic group, 183(42.7%) had primary school education and249 (58%) were married (Table 1)

Discussion
In this study, the prevalence of undiagnosed depression among adult newly diagnosed HIV/AIDS patients on ART was 47.3%, which is in line with a study conducted in Hawassa University Comprehensive specialized hospital Ethiopia (48.6%) [18], 45.8% in Harar [21],in Alert Hospital Addis Ababa, Ethiopia 41.2% [20], in Gimbi general hospital 41.7% [22]. But it is relatively low as compared to 63.1% in Khartoum Sudan [17], in Cameroon 63% [16] and Delhi (India) 58.75% [14], on the other hand it is relatively higher than in Cameroon 26.7%, in Nigeria 23.4% [13] in China 40.9% [10], in Brazil 42.3% [9], in gurage zone Ethiopia 37.5% [19]. The difference might be related to study design, data collection tool, sample size and study participant's variation.
Clients who had perceived HIV/AIDS stress were 2.2 times more likely to have depressive symptom when compared to clients who had had perceived HIV/AIDS stress [AOR = 2.23, 95% CI (1.33, 3.46)]. The justi cation might be due to the fact that those who isolated themselves from others lead to worsening the depression.
In this study, we found a positive correlation between HIV/AIDS related perceived stress and depression.
Su et al. found that perceived stress was associated with depression and perceived stress mediates the relationship between perceived discrimination and depression [27].
Furthermore, it can increase the psychological stress of patients and the risk of having depression. It was estimated that there are approximately about 550,000 MLWHA in China in 2011 [28]. Therefore, perceived stress is a psychological burden that may be associated with the occurrence of depression, and the elimination of discrimination requires active interventions at different levels.
Individuals who had ≤ 200 CD4 cell count had signi cant association with undiagnosed depression. This was similar to the study conducted in Hawassa University Compressive Specialized hospital Ethiopia [18], and Nigeria [25]. This might be due to severe immune depression and HIV illness is underlining causes of depression The nding of this study also showed that those who had history of opportunistic infection were more likely to develop depression. This might be due to the fact that opportunistic infection may lead to dissatisfaction with one's physical appearance, which might be a reason for the occurrence of depression. This nding is consistent with study done in Gimbi general hospital [22].

Conclusion
Undiagnosed depression was high (47.3%) among the current study population. Perceived HIV-related stress, had opportunity infection and CD4 count (< 200) had signi cant association with depression.
Hence, depression is highly prevalent among newly diagnosed HIV-positive patients, still under diagnosed and undertreated but it needs further research. Therefore, Ministry of Health should give more emphasis to those clients with depression. Further research on effect of depression should be conducted to strengthen and broaden the current ndings.

Declarations Acknowledgements
The authors express their deep appreciation to the college of medicine and health science of ethics committee of the Ambo University, as well as the West Shoa zone health bureau ethical committee for allowing this study to be conducted in the selected public health facilities. The authors would also like to acknowledge all the data collectors and supervisors as well as the study participants for their participation.
Authors' contributions TT conceived the study and was involved in the study design, reviewed the article, analysis, report writing and drafted the manuscript. TL, ET and MG were involved in the study design and analysis. All authors read and approved the nal manuscript Funding This study was funded by the Ambo University, Research and community service core process. The funder had no role in study design, data collection, analysis and decision to publish.

Availability of data and materials
The dataset pertaining to this study will be shared upon reasonable request.
Ethics approval and consent to participate Before data collection, ethical clearance letter was obtained from the ethical clearance committee of Ambo University, college of medicine and health sciences. Formal letter of permission was obtained from the selected public health facilities. Finally, oral and written informed consent was requested from the study participant after clearly explaining the objectives of the study. The participants were also informed that they may withdraw themselves at any stage of the data collection period.

Consent for publication
Not applicable.   Prevalence of undiagnosed depression among newly diagnosed PLWHIV on follow up in west shoa zone health facilities, oromia regional state, Ethiopia 2020