Identification of Factors Associated with Depression in Hiv Patients in Vct Poly of Hajj

Hospital Medan City

Belli1*, Elmeida Effendy2*, Nazli Mahdinasari Nasution 3*
1
Resident of Psychiatry Residency Program, Faculty of Medicine, Universitas Sumatera
Utara
2
Professor of Biology Psychiatry, Consultant psychiatrist, Universitas Sumatera Utara
3
Lecturer, Department of Psychiatry, Faculty of Medicine, Universitas Sumatera Utara
*Corresponding author: [email protected]
Abstract
Introduction: Human immunodeficiency virus is a virus that is transmitted through several
ways such as sexual intercourse, injecting drugs, blood transfusions and from mothers
suffering from HIV can be transmitted to children from childbirth and breastfeeding.
Depression is the most commonly reported psychiatric disorder in individuals with HIV. By
2020 it is estimated that depression will be the second largest cause of morbidity and
mortality worldwide.
Aim: To identify factors associated with depression in HIV patients at the VCT clinic of the
Hajj Hospital in Medan City."
Methods: This study is a predictive type multivariate study with a cross-sectional approach
to determine the relationship of depression factors in people suffering from HIV at the VCT
clinic of the Medan Hajj Hospital. To assess symptoms of depression using the Beck
Depression Inventory- II (BDI-II) instrument.
Results: A total of 113 subjects participated in this study. With median (min-max) age 38
(23-50) years, median (min-max) monthly income 6 (3-25) million, median (min-max) years
of education 9 (6-16) years, median (min-max) CD4 count 98 (64-854) cells/mm3, median
(min-max) BMI 20. 02 (17.00-20.78) million, median (min-max) body mass index (BMI)
21.10 (18.50-23.80) kg/m 2 , median (min-max) length of illness 9 (3-20) years, majority 59
(52. 2%) subjects were male, the majority of 66 (58.4%) subjects were married, the majority
of 66 (58.4%) subjects smoked, mean±s.b BDI-II score (21.28±3.61), there was a relationship
between age and BDI-II score (p=0. 001 and the value of r + 0.29), the amount of income (p
= 0.003 and the value of r = 0.22), the length of illness (p = 0.001 and the value of r = +
0.29), the number of CD4 (p < 0.001 and the value of r = + 0.41), smoking (p = 0.017 and the
value of r = + 0.13).
Conclusion: Factors associated with depression scores in HIV patients at the VCT clinic of
the Haji Medan hospital are age, income, length of illness, CD4 count, smokers.
Keywords: HIV, depression, Beck Depression Inventory-II (BDI-II).
Introduction.
Human immunodeficiency virus is a virus that is transmitted through several ways such as
sexual intercourse, injecting drugs, blood transfusions and from mothers suffering from HIV
can be transmitted to children from childbirth and breastfeeding. HIV infection develops in
three stages, namely acute infection (or acute seroconversion), asymptomatic infection
(clinical latency) and acquired immunodeficiency syndrome (AIDS).[1] More than 33 million
people living with HIV in 1999 lived in the world, of which 95% lived in developing
countries.[2] Most new infection cases are female.[3] The relationship between HIV and
psychiatric disorders is a complex problem. [4]
Additional behaviors such as discrimination,
social rejection, stigma, isolation, result in the cumulative impact of these stresses which
indicate that HIV has a profound psychological and social impact. [5]
Depression is the most
commonly reported psychiatric disorder in individuals suffering from HIV. [6] Human
immunodeficiency virus is a chronic disease where individuals who suffer generally
experience various problems in terms of physical and psychological health. High levels of
plasma proinflammatory cytokines in individuals with HIV contribute to the development of
psychiatric disorders such as depression, such as significantly higher IL-6 and IL-17
compared to very low CD4 T cell counts.[4] Chronic immune activation and adrenal
hypothalamic pituitary dysregulation, which can exacerbate HIV infection, are factors that
contribute to the development of depression and likely contribute to higher rates of
depression. Inflammatory proteins such as, C-Reactive protein, cytokines cause oxidative
stress and neuronal injury resulting in chronic inflammatory response to HIV infection which
can trigger a chain reaction. Tryptophan depletion leads to reduced serotonin levels and
increased kynurenine and its metabolites which are neurotoxic and associated with
depression."[20] Consistent findings of neurological deficits, in general, suggest the severity of
neurological and neuropsychological impairment increases with the severity of HIV-related
disease, particularly higher viral loads."[4]
Methods
The research study design - This study is a multivariate predictive type with a cross-
sectional approach, which analyzes the relationship between several independent variables
and the dependent variable using an instrument (BDI-II).[31,32,33]
Population - HIV patients at the Voluntary Counseling Test (VCT) Polyclinic of RS Haji
Medan who visited from December 2021 to May 2022, who met the inclusion and exclusion
criteria. Inclusion criteria in this study are HIV patients who have records of routine
treatment polyclinic status. Age 18 to 50 years. this study has obtained approval from the
Research Ethics Committee at the Faculty of Medicine, University of North Sumatra
regarding Health Research with number : 14/KEPK/USU/2022
Statistical analysis - In this study determining the sample size formula by looking for
bivariate relationships for each independent variable, the largest sample size became the
sample size in this study. Categorical independent variables used unpaired numerical
comparative analytic research diagnosis of two groups of one measurement to see the
bivariate relationship. Numerical independent variables are used numerical-numerical
correlative analytic research diagnosis to see the bivariate relationship. [32] Determination of
the minimum mean difference that is considered meaningful is determined through researcher
judgment Based on several sample size formulas above, it is concluded that the largest
number of samples in the education length group variable is 113 subjects. Linear regression
analysis can only be used if the conditions of the linear regression test are met, for
independent variables that meet the criteria for p <0.25 criteria will be included in the linear
regression multivariate analysis to be analyzed: [31,33].
Results
Demographic characteristics in Table 1 shows that the variable sex most are male, namely 59
subjects (52.2%), variable marital status of HIV sufferers most are married, namely 66
subjects (58.4%), variable smokers suffering from HIV most are smoking, namely 66
subjects (58.4%), variable age suffering from HIV 38 years, variable amount of income per
month in HIV sufferers is 6 million per month, variable length of illness is 9 years, variable
CD4 count is 98, variable BMI in HIV sufferers is 20 kg/m2, variable length of education in
HIV sufferers is 9 years.
Table 1. Demographic characteristics of HIV patients at the VCT clinic of RS Haji Medan
Variable Median (min-max) n (%)
Age 38 (23-50) tahun
Gender
Male 59 (52.2%)
Female 54 (47.8%)
Income/month 6 (3-25) juta
Marital status
Married 66(58.4%)
Not married 47 (41.6%)
Years of education 9 (6-16) tahun
CD4 count 98 (64-854) sel/mm3
IMT 20.02(17.00-20.78) kg/m2
Smoker
Yes 66 (58.4%)
No 47 (41.6%)
Length of illness 9 (3-20) tahun

The requirement for independent variables to be included in the linear regression multivariate
analysis is for bivariate analysis, the p value <0.25.[31,32] The variable sex of HIV patients, the
results of the independent t test in table 2, found a significant relationship between the sex of
HIV patients with a value of p=0.002, so that the sex variable deserves to be included in the
linear regression multivariate analysis test with a predictive conceptual framework. [Marital
status of HIV patients, the results of the independent t test found a very significant
relationship between the marital status of HIV patients with a value of p<0.001, so that the
marital status variable deserves to be included in the linear regression multivariate analysis
test with a predictive conceptual framework. Smoking variable in HIV patients, there is a
significant relationship between smokers with HIV patients with a value of p = 0.009, so the
variable of smokers with HIV patients deserve to be included in the multivariate linear
regression analysis test with a predictive conceptual framework. [31.32]
Table 2. Bivariate analysis of categorical variables

Variabel rerata ± s.b. n p

Gender p=0,002
Male 20.31± 3.26 59
Female 22.35 ± 3.70 54
Marital status
Married 22.29±3.40 66 p<0,001
Not Married 19.87±3.46 47
Smokers
Yes 22.03 ± 3.17 66 p=0,009
No 20.23 ± 3.95 47
Independent t test

Independent variables with numerical measurement scales such as age in HIV sufferers are
carried out Pearson correlation tests because if at least one of the variables is normally
distributed with the Kolmogorov-Smirnov test and linearity requirements are met, there is a
very significant correlation between the age of HIV sufferers and BDI-II scores with a value
of p< 0.001, with a value of r = 0.39 so that the age variable of HIV sufferers is eligible for
inclusion in the multivariate linear regression analysis test with a predictive conceptual
framework.[32] The variable length of education of HIV patients, there is a very significant
correlation between the length of education of HIV patients and BDI-II scores with a value of
p<0.001, with a value of r= 0.33. So that the variable length of education in HIV sufferers
deserves to be included in the linear regression multivariate analysis test with a predictive
conceptual framework. [31,32]
The variable length of illness of HIV sufferers, there is a very
significant correlation between the length of illness in HIV sufferers and BDI-II scores with a
value of p <0.001, with a value of r = 0.36 So that the variable length of illness in HIV
sufferers deserves to be included in the linear regression multivariate analysis test with the
predictive conceptual framework. [31,32] The BMI variable of HIV patients, there was a very
significant correlation between BMI in HIV patients and BDI-II scores with a value of p <
0.001, with a value of r = 0.38. So that the IMT variable in HIV patients deserves to be
included in the linear regression multivariate analysis test with a predictive conceptual
framework. 31,32] The variable CD4 count of HIV patients, there is a very significant
correlation between the number of CD4 and BDI-II scores with a value of p <0.001, with a
value of r = 0.58 So that the variable CD4 count in HIV patients deserves to be included in
the linear regression multivariate analysis test with a predictive conceptual framework. [31,32]
The variable number of CD4 in HIV patients, there is a very significant correlation between
the amount of income and BDI-II score with a value of p <0.001, with a value of r = 0.34 So
that the variable amount of income in HIV patients deserves to be included in the multivariate
linear regression analysis test with a predictive conceptual framework. [31.32]
Resume of
multivariate linear regression analysis of factors associated with BDI-II scores in HIV
patients at the VCT clinic of Haji Hospital Medan.

Discussion

This study is an observational analytic study. The research diagnosis in this study is linear
regression with a predictive concept framework to find the relationship of several
independent variable factors to the dependent variable, the dependent variable in this study is
the Indonesian version of the BDI II score. This study was conducted at the VCT Poli of the
Hajj Hospital Medan, the subjects of this study were 113 subjects who met the inclusion
criteria. The sampling method in this study was non-probability sampling, namely
consecutive sampling. The variables in this multivariate study were eligible for inclusion in
the linear regression analysis p<0.25, the multivariate study used the backward method for
analysis. This study found an association between the variables of age, income, smoking,
length of illness and CD4 count with the Indonesian version of the BDI-II score. High levels
of plasma proinflammatory cytokines in individuals with HIV contribute to the development
of psychiatric disorders, one of which is depression, such as significantly higher IL-6 and IL-
17 compared to very low CD4 T cell counts. Depression is also associated with biological
aging that can affect other biological processes, including muscle mass, motor and nerve
conduction velocity. Stressful and traumatic experiences typically accumulate with age and
are risk factors for the development of depression, thus the functional consequences of
biological shifts associated with aging and depression are likely driven by the interaction of
many different mechanisms. The results of this study suggest that the observational findings
of the association of smoking status with psychological distress in later life may be the result
of shared vulnerabilities, residual confounding or reverse causality (e.g., psychological
distress associated with smoking behavior in later life). The variable of gender of HIV
sufferers in the VCT clinic of the Haji Medan Hospital is mostly male, namely 59 people
52.2% and is not associated with the Indonesian version of the BDI-II score, the results
obtained with a value of p=0.75 Poor economic conditions can lead to mental health
problems in individuals suffering from HIV, certain stressors such as financial dependence
and social rejection that cause adverse effects on people with HIV. Depression in HIV
sufferers is in marital status, namely not having a partner (p<0.001). The factor associated
with depression in HIV patients was having HIV for more than 10 years (p=0.01). Mental
health problems can arise at any stage of HIV infection, such as the initial state of being
diagnosed HIV positive, disease progression and are associated with many mental, physical
and spiritual adjustments and losses faced. Factors associated with depression in HIV patients
were low CD4 count (p<0.001). Prolonged exposure to nicotine results in disruption of the
hypothalamus, pituitary and adrenal systems resulting in hypersecretion of cortisol and
changes in the activity of the monoamine neurotransmitter system whose function is to
regulate reactions to stress. The term weight gain is used to describe weight gain among
individuals with severe immune disorders who start ARVs after a period of weight loss.28
Above-average BMI is a protective factor for depressive symptoms (p=0.01).

Conclusion

In sociodemographic characteristics in HIV patients who experience depression based on

BDI-II, the most gender is male, married, HIV patients are more smokers, age is 38 years,
length of illness is 9 years, CD4 count is 98 cells/mm3, BMI is 20 kg/m2.

Thank you

Acknowledgments - nothing to declare

Competing interests - none to declare

Author contributions - All authors contributed equally to the production of this study. The
primary investigation was conducted by BSP. BSP as correspondence author also made major
contributions to the writing of the original manuscript. Initial conceptualization and
validation were contributed by EE, and statistical methodology was supervised by NMN.

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