Predictors of anxiety and depression among HIV infected pregnant mothers on antiretroviral therapy attending antenatal clinics at leading teaching and referral hospitals in Kenya

INTRODUCTION

Pregnancy is associated with profound changes in the body that can mistakenly be diagnosed as pathological though physiological in pregnancy sense.¹ The changes can lead to depression and anxiety in some women.² It has been established that poor maternal psychological health (anxiety and depression) in pregnancy has a detrimental effect on the socio-emotional development of the unborn child and should therefore be assessed and mitigated.³ It has been proposed that addressing the aforementioned psychosocial factors is associated with improved adherence to antiretroviral therapy (ART) and subsequent reduction in vertical transmission rate among mothers attending antenatal clinics (ANCs).⁴ This is because non-adherence is associated with sub-optimal drug plasma concentration, poor treatment outcome and increased resistance to the antiretrovirals (ARVs).⁵

The global prevalence of anxiety in pregnancy is estimated at 12%.⁶ HIV/AIDS further elevates the anxiety due to the lethality of the disease and the stigma associated with its diagnosis. Studies have reported anxiety prevalence of 23.5% among the seropositive ANC mothers.⁷ Anxiety in pregnancy is associated with poor pregnancy outcome, preterm labor, behavioral and cognitive problems in the newborn, increased cost of social and healthcare, delayed developmental milestones, loss of productivity, increased infant mortality and heightened need for special education.⁸

Stressors causing anxiety among HIV positive ANC mothers include fear of confidentiality breach regarding their status, advanced disease stage, weakened physical condition, fear of infecting the unborn baby and concerns regarding the baby’s future. Additionally, lack of social support, stigma, rejection and isolation further heighten the anxiety.⁹

Globally, concealment of the status from the partner has been reported as the chief cause of anxiety among the seropositive mothers.¹⁰ However, regional studies have documented lifetime experience of violence, relationship status and HIV shame as the main influencers. Single mothers had 3.6 times higher odds of developing anxiety compared to their married counterparts. Additionally, mothers with history of lifetime violence were 2.3 times more prone to anxiety compared to those who did not experience violence.⁷ In Kenya, age and employment status had the highest association. Mothers aged (24-35 years) and those with part time employment reported the highest anxiety burden.³

Depression is defined by loss of interest, feeling of low self-esteem, restlessness, regrets, fatigue and poor concentration.¹¹ It is the commonest psychiatric condition in pregnancy.¹² In seropositive mothers, depression is triggered by stigma, stress, side effects of the ARV drugs and difficult life events.¹³ Low perceived social support and structural barriers to health care further aggravate the depression.¹⁴

The global prevalence of depression among seropositive ANC mothers ranges from 12-30%.¹⁵ In Africa the prevalence rate is at 23.4% whilst in Kenya it is at 32.9%.^16,17 Depression reduces quality of life, increases mortality rate and further worsens the disease burden.¹⁸ A meta-analysis done to compare depression rate among HIV positive and HIV negative ANC mothers has reported a depression rate of 36% and 26%, respectively.¹⁶ Maternal depression is positively associated with impaired socio-economic, behavioral, psychomotor and cognitive development of the child.¹⁹

Several factors have been documented to impact on depression among the seropositive ANC mothers. Globally, low CD4 count was positively associated with heightened depression.²⁰ However, single mothers and those with previous history of depression recorded higher level of depression as per the regional studies.^7,15 Kenyan studies have demonstrated that mother with tertiary level of education were less depressed compared to their counterparts with lower academic achievements.³

There are few studies on the predictors of the psychosocial states among the HIV infected pregnant mothers. The present study therefore sought to assess the predictors of anxiety and depression among HIV infected pregnant mothers on antiretroviral therapy attending antenatal clinics at leading teaching and referral hospitals in Kenya.

METHODS

Study area and site

The study was conducted in Nairobi County, Kenya between the months of April and July 2023. It was a hospital-based study at Kenyatta National Hospital (KNH) and Mbagathi County Hospital. Kenyatta National Hospital is the largest teaching and referral hospital in Kenya. It is situated in the capital city, Nairobi and serves as the teaching hospital for the University of Nairobi and Kenya Medical Training College (KMTC) health science students. Mbagathi County Hospital is a level 5 hospital in Nairobi, Kenya and is approximately 1.7 km away from KNH. It is also a teaching hospital for the University and diploma health science students. The close proximity and busy nature of the hospitals suggest that patients overflow from either institution. The study was carried out at the ANCs of the said hospitals. There were 70 HIV infected mothers attending the ANCs of the selected hospitals with 36 in KNH while Mbagathi County Hospital had 34. The two institutions are major public referral hospitals in Kenya. Antenatal clinics are specialized clinics that provides distinct services and care to pregnant mothers.

Study population

Antenatal clinic mothers with HIV infection who were on ARVs were targeted. This included all adult mothers (>18 years) in the reproductive age bracket. All pregnant mothers were included regardless of the trimester provided they had been on ART for at least a month. It takes about a month for the patient to stabilize and adapt to the treatment, hence the choice of a month’s duration of ART. Pregnant mothers aged less than 18 years were excluded. This is because mothers under the age of 18 years are minors and, in most cases, school going children. Pregnancy at this age is unwanted, stigmatized and can trigger psychosocial illnesses. If considered in the study, they would record an exceedingly high level of anxiety and depression hence the exclusion. Expectant mothers with confirmed diagnosis of HIV/AIDS but who were not on ART and those on ART for less than a month were also excluded.

Sample magnitude and selection method

The major study outcomes were anxiety and depression as measured by the Generalized Anxiety Disorder 7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) respectively. The total target population in the 2 hospitals was less than 100, therefore, participants were sampled based on universal sampling technique. Eligible participants were invited to participate as they came for their clinic appointments. A sample of 36 participants from KNH and 34 participants were recruited from Mbagathi County Hospital based on the total respective population in the 2 hospitals.

Recruitment of participants occurred between 0800 hours to 1300 hours every day excluding the weekends. This continued until the seropositive ANC attendees in the 2 hospitals were exhausted.

Study methods

Approval to undertake the study was sought and obtained from Kenyatta National Hospital /University of Nairobi Ethics and Review Committee (KNH/U.o.N-ERC) vide reference P856/11/2022 as well as National Commission for Science and Technology (NACOSTI) (through NACOSTI/P/23/24868). Permission to conduct the study was further sought and granted by Nairobi City County (Ref NCCG/DHS/REC/365). The study was also approved by Kenyatta National Hospital (Ref RH/535/2023) as well as Mbagathi County Hospital (Ref NCCG/DHS/REC/365).

Structured interviewer administered questionnaire which was tested and standardized before the main study was used as the formal tool for data collection. The questionnaire was organized in sections capturing demographic data including age, trimester of pregnancy, religion, level of education, marital status, employment status, history of alcohol consumption and history of smoking. The second part of the questionnaire focused on assessing the level of anxiety using the Generalized Anxiety Disorder 7 (GAD-7) and the third part was on determining depression among the mothers using the Patient Health Questionnaire 9 (PHQ-9). The aforementioned tools have been validated, are widely accepted and used globally.

The GAD-7 tool is comprised of 7 items for assessing the level of anxiety. The response for each question was rated 0-3. The total score was summed up. A score of 0-4 was classified as minimal anxiety. A score 5-9 as mild, 10-14 as moderate and 15-21 as severe anxiety. The PHQ-9 tool contained 9 questions for assessing depression level based on the Diagnostic and Statistical Manual 5^th edition (DSM-V). There were 4 possible responses for each question with allocated score of 0-3. Once completed, the score was summed up. Scores of <5, 5, 10, 15, 20 represent cut points for minimal, mild, moderate, moderately severe and severe depression, respectively.

Interested participants who fulfilled the inclusion criteria were issued with consent forms and taken through the consent process. Any question or clarification thereof was addressed. Upon getting satisfied and giving the consent to participate, the participant was enrolled into the study. This was done in seclusion in a separate room.

Data management and statistical analysis

The questionnaires were coded to ensure privacy. The filled questionnaires were verified again by the principal investigator to ensure correct data entry and proper coding. Data was then entered into IBM Statistical Package for Social Sciences (SPSS) Chicago Illinois version 23 and cleaned. The verification and cleaning helped in removing erroneous entries. Analysis was done using IBM SPSS version 23. Summary statistics was done with continuous variables such as age summarized using mean and standard deviation while categorical variables such as employment status and level of education presented by calculating proportions. Prevalence and severity of anxiety and depression was computed and presented as percentages. Inferential data analysis was then done with association between the sociodemographic, anxiety and depression determined by use of chi squared test or Fischer’s exact test of association. The outcome variables (anxiety and depression) were dichotomized into low and high and binary logistic regression analysis was used to determine the independent predictors of anxiety and depression. Odds ratios (ORs) and p values were used to determine the strength of association between the variables investigated. The confidence level of 95% was set throughout the data analysis. Result was presented in figures and tables where appropriate.

RESULTS

The mean age of the study population was 32.3 (SD 5.78) years. Majority were aged between 18-35 years at 67.1%, followed by 36-50 years (32.9%). The participants were mainly Christians (94.3%). Most participants had attained at least a secondary school education level at 47.1%, were employed (64.3%) and married at 75.7%. None of the participants had a history of smoking but 10% had a history of alcohol consumption. Only 1.4% had an anxiety diagnosis history while 5.7% had a history of depression diagnosis (Table 1).

The prevalence of anxiety was 23.8% with a mean anxiety score of 5.0 (SD=4.8). Minimal anxiety (52.9%) was most prevalent followed by mild anxiety (34.3%), moderate anxiety (4.3%) and severe anxiety at 8.6%. The study recorded depression rate of 22.6% with mean depression score of 6.1 (SD= 5.8). The prevalence of the levels of depression were minimal (42.9%), mild (32.9%), moderate (15.7%), moderately severe (2.9%) and severe depression at 5.7% (Figure 1 and 2).

There was no statistically significant association between anxiety and the sociodemographic and clinical characteristics of the study participants. However, patients with negative history of anxiety and depression had 8 times more likelihood of having reduced anxiety compared to their counterparts with positive history (OR= 8.625, 95%CI= 4.496-16.547, p= 0.129) and (OR= 8.429, 95%CI= 1.021-69.574, p= 0.078) respectively (Table 2).

There was no statistically significant association between depression and the sociodemographic and clinical characteristics of the study participants. However, participants who were in employment were twice more likely of having reduced depression (OR= 1.909, 95%CI= 0.355-10.258, p= 1.000). Additionally, negative history of depression diagnosis was associated with 4 times more likelihood of having reduced depression (OR= 4.067, 95%CI= 0.354 – 46.653, p= 0.307) (Table 3).

There was a statistically significant association between anxiety and depression (p= 0.002) (Table 4).

Anxiety and depression were independently associated with each other. Decreased anxiety was associated with decreased depression and vice versa (aOR= 0.099, 95%CI: 0.012-0.797, p= 0.03) and (aOR=0.100, 95%CI: 0.014-0.707, p= 0.021) respectively (Table 5 and 6).

DISCUSSION

The present study characterizes the level of anxiety and depression among HIV infected pregnant mothers attending ANCs of two leading hospitals in Kenya. The hospitals are situated around Nairobi, the capital city of Kenya. The study demonstrated low levels of general anxiety at 23.8% (low anxiety) which corroborates a prevalence of 23.5% reported in Kilimanjaro region, Tanzania.⁷

The overall prevalence of depression was 22.6%. This low level is in tandem with a study conducted in Zimbabwe to determine depression among HIV positive pregnant women using the Edinburgh Postnatal Depression Scale (EPDS) which cited depression rates of 12-30%.¹⁵ Additionally, a systemic review and meta-analysis on prevalence of perinatal depression among HIV positive women cited antenatal depression rate of 23.4% among the seropositive mothers.¹⁶

In contrast to the present study, higher levels of antenatal depression among HIV infected mothers have been reported elsewhere in the world. For instance, a higher prevalence rate of 35.0% has been reported in Kibera south, Nairobi in an effort to determine the association between depression using EPDS and non- adherence to ART among pregnant women living with HIV.²¹ The contrast in the findings could be attributed to the differences in the population characteristics. The Kibera study encompassed slum dwellers only.

A study in India determining the prevalence of depression among seropositive ANC mothers reported depressive symptomology of 52.5% among the participants with 23.0% having suicidal ideations.²² The Indian study used a bigger population from 8 centers across 4 states in India and considered both pregnant and post-partum women hence the difference in the findings.

There was a statistically significant association between anxiety and depression in the study (p=0.002). Regional studies in Kilimanjaro, Tanzania reported such associations, citing the comorbid depression and anxiety among HIV infected expectant mothers at 18.1%.⁷ Similarly, a study in KwaZulu Natal, South Africa reported a strong association between anxiety and depression.²³ In Bangalore, India anxiety in pregnancy was found to be positive predictor of prenatal depression.²⁴ Contrastingly, findings from a similar study done in Kibera slums, Nairobi, Kenya revealed no association between anxiety and depression among HIV infected mothers probably due to differences in study methodologies and population characteristics.³

This study has few strengths and limitations. The major limitation of the study was the reliance on self-report of anxiety and depression. This was not ascertained by objective diagnostic review and therefore patients may have over or under reported the factors under study. However, to limit the subjective reporting of mental health burden by the patients, the care giving nurses ensured that patients were comfortable and could confide with their care providers throughout the data collection process. Using universal sampling technique ensured that, all the seropositive mothers at the clinics enrolled in the research thereby increasing power of the study.

CONCLUSION

There was a considerable level of anxiety and depression among the seropositive ANC mothers. Anxiety and depression were positively related. Therefore, counselling, psychosocial education and multidisciplinary team management should be integrated into the management of HIV infected pregnant mothers attending the ANCs. There was no statistically significant association between the anxiety and depression with sociodemographic characteristics of the mothers. Future studies should be aimed at mitigating the anxiety and depression among these patient population.

ACKNOWLEDGEMENTS

We would like to thank the patients at Kenyatta National Hospital and Mbagathi County Hospital for their consent, cooperation and contribution to the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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