Depressive Symptoms Associated with Low Quality of Life Among Pregnant and Postpartum Women Living with HIV in Chiang Mai, Thailand

1.1. Background of the Study

Perinatal depression is one of the several mental health concerns in reproductive-age women globally. In developed countries, the prevalence of depression during pregnancy and the postpartum period ranged from 8-20%.1 A systematic review of 23 studies in low- and middle-income countries among pregnant women documented that depression prevalence widely ranged from 1-30%.2 A 2013 Malawian study conducted among pregnant women at an antenatal clinic reported that 21.1% had either major or minor depressive episodes.3 Socioeconomic factors such as parity, education, income, residential property, and interaction with partner were predictors of depression, as measured in a German study.4 The negative effect of depression on self-care and medical compliance of pregnant women has been documented.5,6

When presented together, both HIV infection and being pregnant or postpartum could affect the mental health of reproductive women. Several studies documented high prevalence of perinatal depression in WLHIV during the early days of ART. A Zambian study published in 2002 found the presence of major depression in as many as 85% WLHIV, particularly in those who had just discovered their HIV status during pregnancy.7 Similarly, studies conducted in Thailand during 2004-2007 documented a high prevalence (>70%) of depression in WLHIV both during pregnancy and the postpartum period.8,9

Currently, the World Health Organization (WHO) recommends ART initiation soon after confirmation of HIV diagnosis to prevent mother to child transmission; ART continuation after delivery is also mandatory.10 Thailand has followed these guidelines since 2014, while simultaneously recommending ART initiation for all HIV-infected individuals regardless of CD4 level.11 When a diagnosis is made during pregnancy, women must come to terms with two life-changing pieces of information; the need for lifelong medication, as well as the physical and physiological changes during pregnancy might affect their mental health and quality of life. A Vietnamese study revealed an association between depressive symptoms and a significant decrease in health-related quality of life in patients living with HIV on ART.12 Those issues are more critical in pregnant and postpartum women living with HIV, as their mental health would not only affect their own quality of life, but also interfere the interpersonal relationship with their child.13 Understanding about their association would allow us to provide appropriate timely intervention.

1.2. Objectives of the Study

This cross-sectional study aimed to determine the prevalence of depressive symptoms among WLHIV during pregnancy up to one-year postpartum, and to assess their quality of life when compared to HIV-negative women.

1.3. Specific Aims and Hypothesis

We hypothesized a higher prevalence of depressive symptoms and lower quality of life would be seen in WLHIV, when compared to those without HIV. Also, demographic and socioeconomic factors would be associated with having depressive symptoms in the study population.

2.1. Study Variables

This cross-sectional study was conducted in 15 hospitals at Chiang Mai, Thailand from January to November 2017. Inclusion criteria for the target group were age ≥ 15 years, HIV infection, and being pregnant or within 12 months postpartum. Those with mental or physical conditions affecting mood/quality of life were excluded. Potential participants were identified by health care providers at antenatal, postpartum, and well-baby clinics. They were approached during their regular visit for health care. Each potential participant was informed about the study, and invited to join the study in a consecutive sampling frame. Pregnant and 1-year postpartum HIV-negative women from each hospital were enrolled for comparison.

Socio-demographic data were collected by face-to-face interviews. Variables included ethnicity, parity, timing of knowing about HIV status, highest educational level, religion, household income, employment status, workplace, history of alcohol and tobacco use for participants and their partners. Depressive symptoms were screened using the Patient Health Questionnaire-9 (PHQ-9). A PHQ-9 score ≥ 10 had a sensitivity of 88% and a specificity of 88% for major depression. Scores between 5-9, 10-14, 15-19, and 20-27 represented mild, moderate, moderately severe, and severe depressive symptoms, respectively.14 The Thai version of PHQ-9 was previously tested for reliability and validity and demonstrated satisfactory internal consistency (Cronbach’s alpha = 0.79).15

Quality of life (QOL) was assessed using WHOQOL-BREF. Participants were asked to rate their QOL in the past two weeks with scores that ranged from 1-5. Higher scores indicated a better QOL.16 The tool was previously assessed for reliability and validity in Thai patients with HIV/AIDS; the Cronbach’s alpha ranged from 0.61 to 0.81 across domains.17

2.2. Statistical Analysis

Statistical analysis was performed using the SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc; 2008. Participant characteristics were described using descriptive statistics, including number (percent), mean [standard deviation (SD)], and median [interquartile range (IQR)]. The two groups were compared using the Mann-Whitney U test, Fisher exact, Chi square, or one-way ANOVA as appropriate. Only variables significant at p ≤ 0.1 in univariate analysis were included in subsequent multivariate analysis. Linear regression analysis determined association between depressive symptom scores and QOL. The study was approved by the Institutional Review Board at the Research Institute for Health Sciences, Chiang Mai University (Certificate approval number 16/2016). Literate participants gave written consent, while low and illiterate participants consented with a thumbprint with an impartial witness present.

3.1. Sociodemographic Characterisitcs of the participants

One hundred WLHIV were enrolled. Mean age was 29.2 ± 7.5 years; 57 (57%) were between 25-40 years of age. Sixty-four percent were Thai, while 36 (36%) were migrant workers. Thirty-eight (38%) were pregnant while 62 (62%) were within 1-year postpartum. Thirty-nine (39%) were pregnant for the first time or had just delivered their first child. Fifty-three (53%) learned their HIV positive status during this pregnancy, 38 (38%) had prior knowledge, and 9 (9%) did not respond to this question.

One hundred HIV-negative women were enrolled as a control group; 78 (78%) were pregnant and 22 (22%) were within 1-year postpartum. They were younger (mean age 27.7 years), more educated, and had a higher household income than the WLHIV (Table 1).

3.2. Prevalence of Depressive Symptoms

There were 30 WLHIV (30%) with presence of depressive symptoms (PHQ-9 score ≥ 5), with (22) 22% mild, 7 (7%) moderate, and 1 (1%) moderately severe depressive symptoms. None had severe depressive symptoms. Meanwhile, 28 (28%) of HIV-negative women had depressive symptoms. Neither significant difference was seen between the mean depression scores (3.5±3.6 vs. 3.4 ± 2.7, respectively; p = 0.691), nor the prevalence of depressive symptoms (30% (95% CI 21-39) vs. 28% (95% CI 19-37), respectively; p = 0.416) when comparing WLHIV and HIV-negative women.

Looking exclusively at pregnant participants, there was no difference in mean depressive scores (3.6±2.9 vs. 3.7±2.8, respectively; p=0.771) or prevalence of depressive symptoms (13 (34%) vs. 26 (33%), respectively; p=1.000) when compared between the groups of WLHIV and HIV-negative women. Thirty-four percent of WLHIV who recently learned their HIV-positive status had depressive symptoms compared to 21% of WLHIV with prior knowledge, though this was not statistically significant (p=0.179). For the postpartum participants, a significant difference in mean depression scores was seen (3.5 ±4.1 vs. 2.1 ±1.6, respectively; p=0.022), but there was no significant difference in the prevalence of depressive symptoms (17 (27%) vs. 2 (9%), respectively; p=0.136) (Table 2).

3.3. Factors Associated with Depressive Symptoms

In univariate logistic regression, presence of depressive symptoms was associated with familial verbal abuse, and lifetime alcohol use, while age, nationality, education, family income, physical abuse, self- or partner smoking, partner alcohol use, parity, and timing of HIV diagnosis were not associated with having depressive symptoms in this study population. The associations between verbal abuse in the family [b = 3.537 (95% CI = 1.308-9.562), p = 0.013] and lifetime alcohol use [b = 10.863 (95% CI = 2.620-45.031), p = 0.001] with presence of depressive symptoms in WLHIV during `pregnancy or within 1-year postpartum remained significant in multivariate analysis.

3.4. Quality of Life of WLHIV vs. HIV-negative women during Pregnancy and 1-Year after Delivery

When assessed by WHOQOL-BREF, the mean transformed domain scores (ranged from 0-100) of WLHIV were 44.21 ±11.08, 43.29 ±10.27, 36.64 ±14.64, and 39.04 ±11.61 in physical health, psychological, social relationship, and environmental, respectively; all were lower than HIV-negative women, but not reached statistically significant difference. The overall perception on own health as rated by WLHIV were significantly lower than HIV-negative women (2.59 ± 0.99 vs. 2.92 ± 0.80; p=0.010); meanwhile, the overall perception of quality of life was not different.

3.5. Association Between Depressive Symptoms and Quality of Life

The overall perception of QOL as rated by WLHIV with depressive symptoms was significantly lower than by WLHIV without depressive symptoms (2.31 vs. 2.54, respectively; p = 0.039), and the overall perception of own health was also significantly lower (2.50 vs. 2.82, respectively; p = 0.019) in WLHIV with depressive symptoms when compared to those without. The simple linear regression analysis confirmed significant negative correlation between PHQ-9 scores and both overall perception on QOL (b = -0.296, p = 0.030) and on own health (b = -0.214, p = 0.033) (Table 3).

4.1. Limitations

There were several limitations in this study. The cross-sectional design does not explain cause or effect. Language and cultural barriers among migrant workers were possible. Although most were proficient in Thai for daily living, it is possible that they may not have understood certain words used to describe their emotions and feelings. Since many participants were illiterate, the PHQ-9 was completed by face-to-face interviews with study staff rather than self-administered. These participants might hesitate to reveal their actual feelings and the frequency of negative emotions. We asked for lifetime alcohol use, smoking, and partner abuse, and this data did not include the specificity to determine their association with depressive symptoms or current QOL. Lastly, the study was conducted in a hospital setting, so participants may have given socially desirable responses.

4.2. Recommendation for further studies

Future studies should identify societal and resilience factors in WLHIV to better understand the dynamic of mental health in reproductive age women. Qualitative study might be an appropriate approach to further explore issues of mental health to follow-up on baseline data using standard questionnaires.