Factors Associated with Anxiety Disorder among ART Clients attending Antiretroviral Therapy Clinic at Hawassa University Referral Hospital, Hawassa, SNNPR, Ethiopia

Introduction: Anxiety is vague, subjective, non-specific feeling of uneasiness, apprehension, tension, a sense of impending doom, irrational avoidance of objects or situation. Anxiety is one of the co-morbidities that are often overlooked in treating patients with Human Immuno Deficiency Virus. Specific prevalence of anxiety is difficult to identify as aresult of the wide variations across the globe, ranging from 7% to 82.3%. Objective: Assessment of prevalence of anxiety and associated factors among ART clients attending ART Clinic at Hawassa Universty Referral Hospital, Hawassa, SNNPR, Ethiopia. Methods and Material: Institutional based cross sectional study design was conducted from March 1 to 30/2016 among 291 patients who attended ART clinic at Hawassa University Referral Hospital. Respondents were selected using Systematic random sampling technique. SPSS 20 was used for data entry and analysis. Crude and adjusted Odds ratio with 95% confidence interval were computed to assess the degree of association between dependent and independent variables, also p-values were used to decide statically significance variables. Result: Out of 291, total of 265 patients were included in the study making the response rate 91%. Out of which, 17.4 % of the study participants had anxiety. Being female was 8.2 times (AOR=8.2, 95% CI (2.67, 25.3) more likely to have anxiety. Also patients who report perceived stigma were 2.7 times more likely to have anxiety (AOR= 2.7 95% CI (1.19, 6.05). CD4 count was another factor associated with anxiety those with CD4 count <500 cells/ml were 2.6 times more likely to have compared those who didn’t remember CD4 count (AOR=2.56, 95% CI 1.22, 5.33). Conclusion: Prevalence of anxiety was found to be high among people living with HIV at Hawassa University Referral Hospital ART clinic. Age greater than or equal to 38 years, being female, CD4 count <500 cells/ml and perceived stigma were significantly associated to anxiety.


Introduction
Anxiety is vague, subjective, non-specific feeling of uneasiness, apprehension, tension (excessive nervousness), fears and a sense of impending doom, irrational avoidance of objects or situation and anxiety attack [1].
HIV attack the body's immune system, specifically the CD4 cells (T cells), which help the immune system fight off infection if left untreated, HIV reduces the number of CD4 cells (T cells) in the body, making the person more likely to get infections or infection related cancers. Over time, HIV can destroy so many of these cells that the body cannot fight off infections and disease [2]. Antiretroviral therapy (ART) is treatment of people infected with human immune deficiency virus (HIV) using anti -HIV drugs. ART has the potential both to reduce mortality and morbidity rates among HIV infected people and to improve their quality of life [3].
Anxiety is highly prevalent in HIV infected individuals and is almost three times more frequent in people living with HIV/AIDS as compared to the general population. The prevalence of anxiety is as high as 38% in clinical studies and it is often associated with depression [4,5].
Anxiety is one of the co-morbidities that are often overlooked in treating patients for Acquired Immune Deficiency Syndrome from Human Immunodeficiency Virus (HIV/AIDS), anxiety is higher among HIV/AIDS than the general population. Anxiety among those that have recently been diagnosed with, HIV has been shown to be more prevalent among patients with stress or excess social stigma related to their diagnosis [6].
General Anxiety Disorder (GAD) affects approximately 6.8 million American adults and is more prevalent among patients with chronic diseases [7]. Notably, the amount of psychological distress among individuals with HIV infection is significantly higher than the general population [8]. Furtherrmore, this population is affected by variable levels of distress throughout the course of their infection with negative consequences [9][10][11]. During periods of distress, individuals with a chronic illness may not only have lower quality of life, but also have difficulty engaging in behaviors that are health promoting [12]. Minimal research has focused on the impact of symptoms of anxiety on HIV management and associated health behaviors [13].
individuals and the effect of anxiety on adherence with antiretroviral therapy (ART) and engagement in high risk and health-compromising behaviors remains to be fully elucidated [14]. With increased understanding of this relationship, simple evidence-based interventions can be administered in clinical settings to reduce anxiety [15].
Globally 33 million people were living with HIV/AIDS and 2 million people died from AIDS related causes worldwide, particular in sub-Saharan Africa 22 million people living with HIV and 1.2 million people died from AIDS [16]. In Ethiopia 170,000 people died due to AIDS which imposes a significant psychological burden. People with HIV often suffer from anxiety as they adjust to the impact of the diagnosis of being infected and face the difficulties of living with a chronic life-threatening illness, for instance shortened life expectancy, complicated therapeutic regimens, stigmatization, and loss of social support, family or friends [17].
HIV infection can be associated with high risk of suicide or attempted suicide. People affected by HIV/AIDS are more prone to developing mental disorders such as anxiety, which, in turn, impair their immune function, reduce their quality of life and adherence to treatment and contribute significantly to their premature deaths [18].
Anxiety may pre-exist to HIV infection or it may be related to risk behaviors for HIV infection (i.e., unsafe sex or drug use); in addition, patients may feel anxious at time of or after HIV diagnosis because of the fear of the unknown, HIV-related stigma, death. Key mo-mentsin the personal and social life of HIV-positive subjects (i.e., the decision to disclosure HIV diagnosis to relatives, partner and friends, desire of parenthood, decisions dealing with sexual activity) may determine isolation and mental illness [20].
In addition, non-HIV-related stigma, i.e., homophobia or unsafe social and economic status, should be considered [21,22]. In presence of depressive and/or anxiety symptoms, patients often refuse to access to social support and to seek treatment [20].

Study design and setting
Institutional based cross sectional study design were conducted on patients who attend ART clinic at Hawassa University Referral Hospital. This study were conducted in Hawasssa University Referral Hospital (HURH) from April 1 to April 30, 2008 E.C. Hawassa University Referral Hospital is located in Hawassa city, SNNPR, which is 275 km far from Addis Ababa. It provides service in surgery, gynecology and obstetrics, medicine, pediatrics, dentist, physiotherapy, ophthalmology, different Outpatient department, Hospital pharmacy, diagnostic facilities, ART clinic, psychiatry and intensive care unit.

Source and study population
All ART clients who attended ART clinic at Hawassa University Referral Hospital were considered as source population.
All ART clients who attended ART clinic at Hawassa University Referral Hospital during data colletion period who fullfill inclusion criteria were taken as study population.

Inclusion criteria and exclusion criteria
All HIV postive clients who have follow up at Hawassa University Referral Hospital ART clinic with age18 years and above were included in the study.
Those who are unable to respond and severely ill, who have hearing impairment and those with currently known psychiatric disorder were excluded from the study.

Sample size determination and sampling procedure
The sample size was determined by using a single proportion formula considering the following the assumption; standard normal distribution with confidence interval of 95% (Z=1.96), absolute precision or tolerable margin of error (d=0.05), The prevalence rate of anxiety disorder in ART clients was 22.2% [23]. Taking 10% nonresponse rate, the final calculated sample size was 291.
Systematic random sampling technique was used to select 291 patients coming to Hawassa University Referral Hospital during the study period. There are 6904 and 575 ART clients who have follow up in ART clinic annually and monthly respectively. The sampling fraction were 575/291=2 hence, the sample were collected every 2 clients. The first individual was selected using lottery method.

Data collection instruments and quality control measures
A structured questionnaire was used to collect data on sociodemographic characteristics (age, sex, ethnicity, religion, education, occupation, marital status, and income). Anxiety was assessed using Beck anxiety scale. The Beck anxiety scale was translated and validated for use in Ethiopia. Oslo social support scale and Perceived stigma scale were used social support of ART clients. Current substance use was considered for using commonly available substances (Khat, Cigarret and alcohol) for the past 3 month.
The pre-test was conducted at Adare Hospital one week prior to the actual data collection period on 5% of sample population to check the reliability and consistency of the tool. Each and every questionnaire were checked for completeness and consistency every at the end of data collection of time. Also there were close supervision to reduce mistakes that were happen during data collection.

Data analysis
The collected data were checked for the completeness and consistency by investigators. SPSS 20 were used for data entry and analysis. After cleaning the data, frequencies and percentages were calculated to all variables which were relate to the objectives of the study. Crude and adjusted Odds ratio with 95% confidence interval were computed to assess the presence and degree of association between dependent and independent variables, also p-values were used to decide whether observed difference were statically significant or not. Finally, the result were presented using text, tables and figures.

Operational definitions
Individual who s c ore d ≥ 22 on Beck Anxiety Inventory scale. Current Substance use: using of specific substance chat, cigarette and alcohol in the last three month repeatedly. Good Social support: Individual who scored ≥ 9 on Oslo social support scale. Income: under extreme poverty <1.25 USD per day (20*1.25*30=750 ETB per month) and under poverty <2 USD but >1.25 USD per day (20*2*30=1200 ETB per month) and above poverty line ≥ 2 USD per day (20*2*30=1200

Ethical statement
Ethical clearance were obtained from ethical review board of Hawassa University, College of Medical and health science. Ethical issues of the participants were addressed throughout the study. All participants of the study were provided with an informed consent, clearly stating the objectives of the study and their right to refuse and if any question they do not want to answer they have the right to do so. All participants were randomly selected without any discrimination on any ground. Filled out questionnaires were carefully handled and all access to results were kept strictly to members of the group.

Socio-demographic characteristics
Out of 291 respondents, 265 of them were used for the data analysis, making the response rate 91%. The mean age of the respondents was

Social support respondents
Regarding social support of the respondents, most of respondents 208 (78.5%) have poor social support and do not have good social support.

Prevalence of anxiety
Based on the cut of point ≥ 22 for case on Beck Anxiety Inventory the prevalence of anxiety among PLWHA at Hawassa University Referral Hospital ART clinic was found to be 17%.

Association of socio-demographic and clinical variables with anxiety
On bivariate analysis the factors found to fulfill the minimum requirements (P-value <0.2 in this study) were age, sex, income, marital status, educational level, CD4 cell counts, perceived stigma and social support, these factors were entered into multivariate logistic regression for further analysis in order to control confounding effects. The result of multivariate analysis showed that anxiety was significantly associated with sex, age, CD4 count and perceived stigma. Sex was significantly associated with anxiety, Being female was 8.2 times (AOR=8.2, 95% CI (2.67, 25.3) more likely to have anxiety as compared to male. Also patients who report perceived stigma were 2.7 times more likely to have anxiety as compared to patients who didn't report perceived stigma (AOR=2.7, 95% CI (1.19,6.05). CD4 count was another factor associated with anxiety, those <500 cells/ml were 2.6 times more likely to have compared those who didn't remember CD4 count (AOR=2.56, 95% CI 1. 22, 5.33). The association between anxiety and variables has been shown in Table 3.

Discussion
In the current study, the result showed that the prevalence was 17.4% and this study was similar with the study conducted in Singapore 17.9% [19]. However; in the present study the prevalence of anxiety was higher the study done in Tanzanian 15.5% [25], Nigeria 15.6%, [26]. The possible reason might be different instrument and socio-cultural variation.
The finding of this result was lower than the result reported from Debretabor which showed that the prevalence of anxiety was 22.2% [23], other study conducted in Kenya 22.75% [27] and Nigeria 21.7% [25]. Also the current result was lower than the result reported from India 44% [28], China 45.6% [29], Brazil 35.8% [30], Albania 82.3% [6], Italy 47% [31], USA 33%, 35.5% [32], respectively which indicated that the prevalence of anxiety among people living with HIV/ADIS. The possible reason for the different might be different instrument and socio-cultural difference.
Regarding associated factors, in this study, being female were to have anxiety as compared to males which was similar with the study done in Debretabor, Brazil, India, China respectively [23,[28][29][30]. The possible reason might be increased exposure to acute life events, chronic social stresses, lower social status, lower income, and smaller social networks.
When anxiety was in relation to divorce, those who divorced were more likely to have anxiety as compared to who were single. One of the effects of divorce was it destroys the whole dynamic of the family. The possible reason might be due to the stress of divorce, current financial hardship and lack of confidence.
The result of the present study also revealed that the prevalence of anxiety was significantly influenced by perceived stigma about their HIV status which was consistent with study done in Albania [6]. One of the most distressing factors of individuals with HIV infection is stigma. The possibility of stigmatizing situation serving as the event of provoking anxiety. The possible reason might be Illiteracy and lack of knowledge regarding the nature of transmission and possible treatment of HIV infection contributes to the high level of stigma and low selfesteem.