European Journal of Cardiovascular Medicine

The Human Immunodeficiency Virus (HIV), a retrovirus, the infectious agent that causes AIDS, was discovered in 1983 by Luc Montagnier, Francoise Barre-Sinoussi (Pasteur et al.), and Robert Gallo (National Institute Of Health, Bethesda, Maryland, USA), for which they were awarded the Nobel Prize in Medicine in 2008. The first case in India was documented in 1986 among female sex workers in Chennai¹.

Introduction: Human Immunodeficiency Virus (HIV) assaults the body's immune defenses, leaving individuals vulnerable to infections and select types of cancer. By damaging and inhibiting immune cells, people infected with HIV gradually experience a decline in immune competence. Immune function is commonly evaluated by measuring the count of CD4 cells².

HIV/AIDS patients frequently experience considerable psychological effects. Those living with HIV typically endure anxiety and depression while grappling with the diagnosis's consequences and challenges, like reduced life expectancy.

complex treatment protocols, stigma, and diminished support from social networks and family. Additionally, there is an elevated suicide risk linked to HIV infection³.

Depression, a widespread mental health condition, manifests as persistent sadness, a lack of enjoyment or interest in activities, reduced energy levels, feelings of guilt or inadequate self-esteem, sleep or eating disturbances, and difficulty concentrating. It affects an estimated 350 million individuals globally. Currently ranked as the fourth major contributor to global disability, it is anticipated to rise to the second position by 2020. The prevalence over a person's lifetime is thought to range between 3% and 17%⁴.

Depression is a prevalent mental health issue among those diagnosed with human immunodeficiency virus (HIV). This condition often leads to a decrease in the willingness of HIV/AIDS patients to stick to their antiretroviral (ART) treatment regimens. Promptly recognizing and addressing depression can significantly enhance adherence to ART medications. Furthermore, individuals with HIV/AIDS experience a higher incidence of anxiety, nearly triple that of the non-infected population, with clinical studies indicating a prevalence rate of up to 38%. The early identification and management of anxiety disorders can markedly improve the effectiveness of ART therapy⁵.

A hospital-based observational cross-sectional study design was adopted. 150 patients were selected through systematic random sampling from January 2023 to December 2023. Patients who were known cases of HIV or recently diagnosed and presented in the Department of Medicine and all ART clients who attended the ART clinic in the Department of General Medicine, Eeshan Hospital, Hyderabad, were included in the study, considering the inclusion and exclusion criteria.

Inclusion Criteria

All HIV-positive patients attending the ART Plus center aged 18 years and above will be included in the study.

The study included patients taking ART for < 1 year-100, patients taking ART for 1 - 5 years-100, and patients taking ART for >5 years-100.

Exclusion Criteria

1. Patients are not willing to participate.
2. Hemodynamically unstable patients.
3. Those unable to respond and severely ill, or those with hearing impairment.
4. Those undergoing treatment for psychiatric disorders before the diagnosis of HIV.
5. Female patients in the post-partum period.

Data on socio-demographic details, including age, gender, educational background, employment status, marital situation, earnings, and substance consumption, were gathered through a meticulously designed questionnaire. The study assessed the level of depression among the participants using the Hamilton Depression Rating Scale, and the level of anxiety was measured using the Hamilton Anxiety Rating Scale. Moreover, the CD4 counts were recorded twice—once when the participants joined the ART program and again at the time of their inclusion in the study.

Procedure: The sample consisted of HIV-positive patients on antiretroviral treatment coming for their routine appointment at the ART Plus center in the Department of General Medicine, Eeshan Hospital, Hyderabad. We used the systematic random sampling method for this study. Patients who had a routine appointment during the duration of this study at the ART clinic and who voluntarily were interested in participating in a study were inducted. Patients were assured that participating in the study would not impact their treatment. They were also informed that the interview was one-time and that there would be no follow-up.

The majority of the study participants who were on ART and experiencing anxiety and depression were females, 37.14%, compared to males, 27.7%. The majority of study participants experiencing anxiety and depression were illiterate, 39.43%, followed by those literate with primary plus secondary schooling, 28.35%, graduates, 20.68%, and postgraduates, 11.6%.

Table 1: ANOVA Results of the First Model with Multiple Regression Analysis for Starting CD4 Count

Table 2: Summary of Model-2 with Multiple Regression Analysis for Variables Predicting Starting CD4 Count

Variance Inflation Factor (VIF) values ranged from 1.050 to 2.106, below the threshold of 4.0, which may indicate a multicollinearity concern (Jang et al., 2010). The first model explained 8.8% of the total variance (R=.297, R2=.088; F (5, 298) = 5.683; p<0.01) with five predictor variables (depression, treatment year, gender, age, anxiety) for the starting CD4 count. The second model explained 6.7% of the total variance (R=.259, R2=.067; F (5, 298) = 4.221; p<0.01) with five predictor variables (depression, treatment year, gender, age, anxiety) for the current CD4 count.

Regression weights for Depression, Treatment Year, Gender, Age, and Anxiety of patients obtained from the multiple regression models are depicted in Tables 2 and 5. The age of the participants was negatively associated with the CD4 count at the start (-.247, p<0.01); with increasing age, patients reported a lower CD4 count at the start. Depression in the patients was negatively associated with the CD4 count (-.085, p<0.01), meaning highly depressed patients reported a lower level of CD4 count at the start. The treatment year of the patients was positively associated with the CD4 count at present (-.085, p<0.01), meaning the duration of the ART regimen was associated with a high level of CD4 count at present.

Out of the 150 participants, a total of 45 (30%) individuals showed clinical features of anxiety, depression, and mixed features of both anxiety and depression. Of which, 3 (2%) participants had anxiety, 20 (13%) had depression, and 22 (15%) had combined features of anxiety and depression.

Bedaso et al. reported that 17.4% of people had anxiety, and the majority of them were female. The results of both studies are almost similar. However, data variability may be due to the uniqueness of this study, as this study also has participants with mixed features, i.e., features of both anxiety and depression, which is significant in number. Another reason for data variability could be the different methodologies of both studies. Choi et al. found that the point prevalence of depression is 28%, which is quite similar to what this study describes.

As discussed earlier, data shows differences due to the uniqueness of this study and the different methodologies used. In this study, out of 150 HIV-positive patients who participated, 78 (52.3%) were male, and 71 (47.7%) were female; out of 78 male participants, 01 (.66%) male had anxiety, 10 (6.66%) males had depression, and 8 (5.33%) had combined features of anxiety and depression. Similarly, out of 71 females who participated, 2 (1.33%) females had anxiety, 9 (6.33%) had depression, and 15 (9.66%) had combined features of both anxiety and depression. Hence, this study suggests that 26 (37.14%) females had features of anxiety, depression, and combined features of both^{9, 10}.

30% of individuals reported clinical features of anxiety, depression, and mixed features of both anxiety and depression. Female patients are more affected than male patients. Participants who were on ART for less than 1 year had the maximum depression, anxiety, and combined features of both. Highly depressed patients reported a lower level of CD4 count at the beginning. The treatment year of the patients was positively associated with a higher CD4 count at present; the duration of the ART regimen was associated with a high level of CD4 count at present. Therefore, early psychiatric intervention, psychological assessment, and treatment for depression or anxiety must be initiated to ensure better coping, treatment, and long-term compliance for ART in people living with HIV.

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2. Choi SK, Boyle E, Cairney J, et al. Prevalence, recurrence, and incidence of current depressive symptoms among people living with hiv in Ontario, Canada: results from the Ontario HIV Treatment Network Cohort Study. PLoS One 2016;11(11):e0165816.
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