Depression Associated With Higher HIV Incidence for South African Girls

Among all new HIV infections in adolescents, 3 in 4 occur in sub-Saharan Africa. Adolescent girls and young women in South Africa are at substantial risk of contracting HIV, with 1 in 4 South African girls living with HIV by adulthood. Understanding risk factors during adolescence is essential to developing better prevention strategies.

The most common route of HIV transmission globally is unprotected heterosexual intercourse which accounts for nearly 70% of new infections. There has been limited success in reducing HIV incidence by focusing on sexual behavior alone; however, there is increasing recognition among clinicians and public health officials of a need to address upstream factors which inform risk behavior.

Results from a new study published in the American Journal of Epidemiology indicate that adolescent girls and young women in South Africa with symptoms of depression had higher cumulative HIV incidence compared to those without depressive symptoms.

Study authors assessed whether depressive symptoms were longitudinally associated with HIV incidence and identified potential social mediators of transmission.

The study cohort was originally established in 2012 as part of the National Institutes of Health-funded randomized controlled trial, HPTN 068. HPTN 068 evaluated the effects of HIV incidence among adolescent girls of cash transfers conditional on school attendance. The study took place in the rural province of Mpumalanga.

Eligibility required girls to be unmarried, able to read, and not pregnant at time of enrollment. Participants included 2533 aged 13 to 21 years. Only 7% of eligible individuals declined due to parent/guardian or participant refusal. The study did not exclude girls who tested positive for HIV at baseline, so as to prevent undesired disclosure of HIV status.

In order to assess depressive symptoms in participants, investigators used a 10-item short version of the Children’s Depression Inventory scale. The depression inventory scale was administered at baseline visits. Each question in the scale had 3 levels, which were coded 0 to 2 from most positive to most negative response. Investigators summed responses and dichotomized the index at 7, the prorated equivalent to the cut off of 19 employed in the full 27 item index.

HIV status was assessed at each follow-up visit. Cumulative incidence of HIV was evaluated through the 5^th follow up visit, spanning a period of up to 6 years.

Of the 2553 adolescent girls and young women in the study, 118 tested HIV positive or had no information on HIV status at baseline or 1st follow-up visit. This reduced the sample size to 2415. Overall, 18.2% of study participants were classified as having depressive symptoms at baseline.

The cumulative incidence of HIV after the first follow-up visit was 0.072. Those with depressive symptoms had 0.107 cumulative HIV incidence over the study period, whereas those without depressive symptoms had 0.065 cumulative HIV incidence. When study authors adjusted for covariates, depressive symptoms at baseline were associated with a risk difference of 3.5 (95% confidence interval, 0.1, 7.0).

The most prominent mediators of the association between depressive symptoms and incidence of HIV were parental involvement and reporting that a partner would use violence if she asked to use a condom.

The study team reported that positive parenting has been connected previously to reduced HIV risk behavior, but that the directional relationship between parental involvement and child mental health is not well-studied, and pointed to a bi-directional relationship revealed by previous studies in the United States.

Study authors wrote that the study results “suggest that lack of parental monitoring and involvement plays an important role in mediating the association of adolescent depressive symptoms with HIV incidence, such that depression leads to less involvement from parents, which then increases risk of HIV.”

Power imbalances in relationships were also tied to the association between depressive symptoms and HIV incidence.

“Depressive symptoms may reduce the ability of adolescent girls and young women to negotiate condom use during sex and increase their risk of HIV,” the authors remarked. “Depression may also be associated with choosing sexual partners who are less open to negotiation or who are more likely to commit intimate partner violence.”

Study authors concluded that their results suggest interventions to improve mental health among adolescent girls and young women may also improve HIV prevention efforts, and that mental health in turn is mediated by a variety of social factors. They noted that while access to mental health care services in South Africa is limited, relatively low-cost interventions have been shown effective in low and middle-income countries.