Abstract
As a chronic illness, HIV/AIDS requires life-long treatment adherence and retention—and thus sufficient attention to the psychosocial dimensions of chronic disease care in order to produce favourable antiretroviral treatment (ART) outcomes in a sustainable manner. Given the high prevalence of depression in chronic HIV patients, there is a clear need for further research into the determinants of depression in this population. In order to comprehensively study the predictors of depressive symptoms in HIV patients on ART, the socio-ecological theory postulates to not only incorporate the dominant individual-level and the more recent community-level approaches, but also incorporate the intermediate, but crucial family-level approach. The present study aims to extend the current literature by simultaneously investigating the impact of a wide range individual-level, family-level and community-level determinants of depression in a sample of 435 patients enrolled in the Free State Province of South Africa public-sector ART program. Structural equation modeling is used to explore the relationships between both latent and manifest variables at two time points. Besides a number of individual-level correlates—namely education, internalized and external stigma, and avoidant and seeking social support coping styles—of depressive symptoms in HIV patients on ART, the study also revealed the important role of family functioning in predicting depression. While family attachment emerged as the only factor to continuously and negatively impact depression at both time points, the second dimension of family functioning, changeability, was the only factor to produce a negative cross-lagged effect on depression. The immediate and long-term impact of family functioning on depression draws attention to the role of family dynamics in the mental health of people living with HIV/AIDS. In addition to individual-level and community-based factors, future research activities should also incorporate the role of the family context in research into the mental health of HIV patients, as our results demonstrate that the familial context in which a person with HIV on ART resides is inextricably interconnected with his/her health outcomes.
Similar content being viewed by others
References
UNAIDS. Global report (UNAIDS report on the global AIDS epidemic 2013). Joint United Nations Programme on HIV/AIDS (UNAIDS). 2013.
Motsoaledi A. Health budget vote speech by the Minister of Health Dr. Aaron Motsoaledi, MP. In: Health Do, editor. http://www.health-e.org.za/wp-content/uploads/2014/07/Minister-of-Health-Budget-Vote-Speech-2014-15-.pdf. 2014.
Barth RE, Schim van der Loeff MF, Schuurman R, Hoepelman AIM, Wensing AMJ. Virological follow-up of adult patients in antiretroviral treatment programmes in sub-Saharan Africa: a systematic review. Lancet Infect Dis. 2010;10(3):155–66.
Wouters E, Heunis C, Michielsen J, Baron Van Loon F, Meulemans H. The long road to universal antiretroviral treatment coverage in South Africa. Future Virol. 2011;6(7):801–12.
Johnson LF, Mossong J, Dorrington RE, Schomaker M, Hoffmann CJ, Keiser O, et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Med. 2013;10(4):e1001418.
Russell S, Seeley J. The transition to living with HIV as a chronic condition in rural Uganda: working to create order and control when on antiretroviral therapy. Soc Sci Med. 2010;70(3):375–82.
Wouters E, Van Damme W, Van Loon F, Van Rensburg D, Meulemans H. Public-sector ART in the FREE State Province, South Africa: community support as an important determinant of outcome. Soc Sci Med. 2009;69(8):1177–85.
Pence BW. The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS. J Antimicrob Chemother. 2009.
Collins PY, Holman AR, Freeman MC, Patel V. What is the relevance of mental health to HIV/AIDS care and treatment programs in developing countries? A systematic review. AIDS. 2006;20(12):1571–82.
Guaraldi G, Murri R, Orlando G, Squillace N, Stentarelli C, Zona S, et al. Lipodystrophy and quality of life of HIV-infected persons. AIDS Rev. 2008;10:152–61.
Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, Mqeketo A. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med. 2007;64(9):1823–31.
Nakimuli-Mpungu E, Bass J, Alexandre P, Mills E, Musisi S, Ram M, et al. Depression, alcohol use and adherence to antiretroviral therapy in Sub-Saharan Africa: a systematic review. AIDS Behav. 2012;16(8):2101–18.
Tomlinson M, Grimsrud AT, Stein DJ, Williams DR, Myer L. The epidemiology of major depression in South Africa: results from the South African stress and health study. SAMJ. S Afr Med J. 2009;99:368–73.
Ovuga E, Boardman J, Wasserman D. The prevalence of depression in two districts of Uganda. Soc Psychiatr Psychiatr Epidemiol. 2005;40(6):439–45.
Wagner G, Goggin K, Remien R, Rosen M, Simoni J, Bangsberg D, et al. A closer look at depression and its relationship to HIV antiretroviral adherence. Ann Behav Med. 2011;42(3):352–60.
Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir immune Defic Syndr. 2011;58(2). doi:10.1097/QAI.0b013e31822d490a.
Venkatesh KK, Flanigan TP, Mayer KH. Is expanded HIV treatment preventing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the developing world. AIDS. 2011;25(16):1939–49.
Myer L, Smit J, Roux LL, Parker S, Stein DJ, Seedat S. Common mental disorders among HIV-infected individuals in South Africa: prevalence, predictors, and validation of brief psychiatric rating scales. Aids Patient Care STDS. 2008;22(2):147–58.
Pappin M, Wouters E, Booysen F. Anxiety and depression amongst patients enrolled in a public sector antiretroviral treatment programme in South Africa: a cross-sectional study. BMC Public Health. 2012;12(1):244.
Brandt R. The mental health of people living with HIV/AIDS in Africa: a systematic review. Afr J AIDS Res. 2009;8(2):123–33.
Yeji F, Klipstein-Grobusch K, Newell M-L, Hirschhorn LR, Hosegood V, Bärnighausen T. Are social support and HIV coping strategies associated with lower depression in adults on antiretroviral treatment? Evidence from rural KwaZulu-Natal, South Africa. AIDS Care. 2014;26(12):1482–9.
Nyirenda M, Chatterji S, Rochat T, Mutevedzi P, Newell M-L. Prevalence and correlates of depression among HIV-infected and -affected older people in rural South Africa. J Affect Disord. 2013;151:31–8.
Van Damme W, Kober K, Kegels G. Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: how will health systems adapt? Soc Sci Med. 2008;66(10):2108–21.
Petersen I, Lund C. Mental health service delivery in South Africa from 2000 to 2010: one step forward, one step back. SAMJ. S Afr Med J. 2011;101:751–7.
Petersen I, Bhana A, Baillie K. The feasibility of adapted group-based interpersonal therapy (IPT) for the treatment of depression by community health workers within the context of task shifting in South Africa. Community Ment Health J. 2012;48(3):336–41.
Petersen I, Lund C, Bhana A, Flisher AJ. The mental health poverty research programme consortium. A task shifting approach to primary mental health care for adults in South Africa: human resource requirements and costs for rural settings. Health Policy Plan 2012;27(1):42–51.
Chibanda D, Mesu P, Kajawu L, Cowan F, Araya R, Abas M. Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. BMC Public Health. 2011;11(1):828.
Masquillier C, Wouters E, Mortelmans D, le Roux Booysen F. The impact of community support initiatives on the stigma experienced by people living with HIV/AIDS in South Africa. AIDS Behav. 2015;19(2):214–26.
Wouters E. Mobilising the community in the fight against HIV/AIDS. Lancet. 2009;374(9693):1501.
Wouters E, Van Damme W, van Rensburg D, Masquillier C, Meulemans H. Impact of community-based support services on antiretroviral treatment programme delivery and outcomes in resource-limited countries: a synthetic review. BMC Health Services Res. 2012;12(1):194.
Pfeiffer PN, Heisler M, Piette JD, Rogers MAM, Valenstein M. Efficacy of peer support interventions for depression: a meta-analysis. Gen Hosp Psychiatr. 2011;33(1):29–36.
World Health Organisation (WHO). Treat, train, retain. Task shifting. Global recommendations and guidelines. Geneva: WHO, PEPFAR & UNAIDS. 2008.
Yaw Amoateng A. Towards a conceptual framework for families and households. In: Yaw Amoateng A, Heaton TB, editors. Families and households in post-apartheid South Africa: socio-demographic perspectives. HSRC Press, Cape Town, South Africa; 2007, p. 27–42.
Wouters E. Life with HIV as a chronic illness: a theoretical and methodological framework for antiretroviral treatment studies in resource-limited settings. Soc Theory Health. 2012;10(4):368–91.
Chandra PS, Ravi V, Desai A, Subbakrishna DK. Anxiety and depression among hiv-infected heterosexuals—a report from india. J Psychosom Res. 1998;45(5):401–9.
Dyer T, Stein J, Rice E, Rotheram-Borus M. Predicting depression in mothers with and without HIV: the role of social support and family dynamics. AIDS Behav 2012:1–11.
Rotheram-Borus M, Stein J, Jiraphongsa C, Khumtong S, Lee S-J, Li L. Benefits of family and social relationships for Thai parents living with HIV. Prev Sci. 2010;11(3):298–307.
Olley BO, Seedat S, Nei DG, Stein DJ. Predictors of major depression in recently diagnosed patients with HIV/AIDS in South Africa. Aids Patient Care STDS. 2004;18(8):481–7.
Wolitski R, Pals S, Kidder D, Courtenay-Quirk C, Holtgrave D. The effects of HIV stigma on health, disclosure of HIV status, and risk behavior of homeless and unstably housed persons living with HIV. AIDS Behav. 2009;13(6):1222–32.
Wright K, Naar-King S, Lam P, Templin T, Frey M. Stigma scale revised: reliability and validity of a brief measure of stigma for HIV + youth. J Adolesc Health. 2007;40(1):96–8.
Fleishman J, Fogel B. Coping and depressive symptoms among young people with AIDS. Health Psychol. 1994;13(2):156–69.
Smith PN. Resilience in Xhosa families. Stellenbosch: University of Stellenbosch; 2006.
Niehof A. Conceptualizing the household as an object of study. Int J Consum Stud. 2011;35(5):488–97.
Randall S, Coast E, Leone T. Cultural constructions of the concept of household in sample surveys. Popul Stud. 2011;65(2):217–29.
Black K, Lobo M. A conceptual review of family resilience factors. J Fam Nurs. 2008;14(1):33–55.
McCubbin MA, McCubbin HI. Resiliency in families: A conceptual model of family adjustment in response to stress and crises. In: McCubbin HI, Thompson AI, McCubbin MA, editors. Family assessment: resiliency, coping and adaptation—inventories for research and practice. Madison: University of Wisconsin-Madison; 1996. p. 1–64.
McCubbin HI, Thompson AI, Elver KM. Family attachment and changeability index 8 (FACI 8). In: McCubbin HI, Thompson AI, McCubbin MA, editors. Family assessment resiliency, coping and adaptation-inventories for research and practice. Madison University Wisconsin System; 1996. p. 725–51.
Wouters E, Masquillier C, Ponnet K, le Roux Booysen F. A peer adherence support intervention to improve the antiretroviral treatment outcomes of HIV patients in South Africa: the moderating role of family dynamics. Soc Sci Med. 2014;113:145–53.
Braveman PA, Cubbin C, Egerter S, et al. Socioeconomic status in health research: one size does not fit all. JAMA. 2005;294(22):2879–88.
Chandola T, Bartley M, Wiggins R, Schofield P. Social inequalities in health by individual and household measures of social position in a cohort of healthy people. J Epidemiol Community Health. 2003;57(1):56–62.
Freeman M, Nkomo N, Kafaar Z, Kelly K. Factors associated with prevalence of mental disorder in people living with HIV/AIDS in South Africa. AIDS Care. 2007;19(10):1201–9.
Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale: an updated literature review. J Psychosom Res. 2002;52(2):69–77.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–70.
Chandra PS, Deepthivarma S, Jairam KR, Thomas T. Relationship of psychological morbidity and quality of life to illness-related disclosure among HIV-infected persons. J Psychosom Res. 2003;54:199–203.
Snaith RP. The hospital anxiety and depression scale. Health Quality Life Outcomes. 2003;1(1):29.
Wouters E, Booysen FIR, Ponnet K, Baron Van Loon F. Wording effects and the factor structure of the hospital anxiety & depression scale in HIV/AIDS patients on antiretroviral treatment in South Africa. PLoS ONE. 2012;7(4):e34881.
Hu L-t, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model Multidiscip J. 1999;6(1):1–55.
Muthen L, Muthen B. Chi square difference testing using the S-B scaled Chi square. Note on Mplus website. 2005.
van de Schoot R, Lugtig P, Hox J. A checklist for testing measurement invariance. Eur J Dev Psychol. 2012;9(4):486–92.
Burkholder GJ, Harlow LL. An illustration of a longitudinal cross-lagged design for larger structural equation models. Struct Equ Model Multidiscip J. 2003;10(3):465–86.
Adewuya AO, Afolabi MO, Ola BA, Ogundele OA, Ajibare AO, Oladipo BF, et al. Relationship between depression and quality of life in persons with HIV infection in Nigeria. Int J Psychiatr Med. 2008;38(1):43–51.
Kaharuza F, Bunnell R, Moss S, Purcell D, Bikaako-Kajura W, Wamai N, et al. Depression and CD4 cell count among persons with HIV infection in uganda. AIDS Behav. 2006;10(1):105–11.
Carrico A, Antoni M, Durán R, Ironson G, Penedo F, Fletcher M, et al. Reductions in depressed mood and denial coping during cognitive behavioral stress management with hiv-positive gay men treated with haart. Ann Behav Med. 2006;31(2):155–64.
Kim J, Jeong Yeob Han H, Shaw B, McTavish F, Gustafson D. The roles of social support and coping strategies in predicting breast cancer patients’ emotional well-being: testing mediation and moderation models. J Health Psychol. 2010;15(4):543–52.
Savard J, Laberge B, Gauthier JG, Ivers H, Bergeron MG. Evaluating anxiety and depression in HIV-infected patients. J Pers Assess. 1998;71(3):349–67.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Wouters, E., Masquillier, C. & le Roux Booysen, F. The Importance of the Family: A Longitudinal Study of the Predictors of Depression in HIV Patients in South Africa. AIDS Behav 20, 1591–1602 (2016). https://doi.org/10.1007/s10461-016-1294-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10461-016-1294-0