Depression at antiretroviral therapy initiation and clinical outcomes among a cohort of Tanzanian women living with HIV.
The objective of the study was to assess the relationship of depression at antiretroviral therapy (ART) initiation with mortality and clinical outcomes among Tanzanian women living with HIV.



We conducted a prospective cohort study of 1487 women who initiated ART in Dar es Salaam, Tanzania.



Symptoms of depression and anxiety were assessed using a Tanzanian-adapted and validated version of the Hopkins Symptom Checklist. Participants attended monthly clinic visits during the first 2 years of ART and CD4 T-cell counts were assessed every 4 months. Proportional hazard models were used to assess the relationship of depression with mortality and clinical outcomes.



Symptoms consistent with depression were prevalent among 57.8% of women at ART initiation. After multivariate adjustment, including social support and stigma, depression at ART initiation was associated with increased risk of mortality [hazard ratio (HR): 1.92; 95% confidence interval (CI): 1.15-3.20; P = 0.01] and incidence of severe anemia (hemoglobin <8.5 g/dl; HR: 1.59; 95% CI: 1.07-2.37; P = 0.02). Under the assumption of causality, we estimate 36.1% (95% CI: 13.6-55.1%) of deaths among the study cohort were attributable to depression and its consequences. Depression was not significantly associated with trajectory of CD4 T-cell reconstitution or the risk of immunologic failure (P values >0.05).



Elimination of depression may reduce mortality during the first 2 years of ART by one-third in our study cohort. Randomized trials and rigorous implementation studies are needed to evaluate the individual and population-level effects of integrated mental health interventions and HIV treatment approaches in resource-limited settings.
aDepartment of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA bDepartment of Psychiatry and Mental Health cDepartment of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania dDepartment of Epidemiology eDepartment of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA fDepartment of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania gDepartment of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
Christopher R
CR
Sudfeld
Sylvia
S
Kaaya
Nilupa S
NS
Gunaratna
Fedinand
F
Mugusi
Wafaie W
WW
Fawzi
Said
S
Aboud
Mary C
MC
Smith Fawzi
D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001007:Anxiety; D018791:CD4 Lymphocyte Count; D003863:Depression; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D016019:Survival Analysis; D013636:Tanzania; D016896:Treatment Outcome; D055815:Young Adult
D044966:Anti-Retroviral Agents