Patterns of Comorbid Infections and Associated Suicidal Ideations among Individuals Attending HIV/AIDS Clinic in Benin City

Persons living with HIV/AIDS have been reported to be at significantly greater risk of developing comorbid diseases [1]. These high rates of comorbidities are major causes of morbidity and mortality among HIV infected people [2,3]. Such comorbidities include infectious diseases and non-communicable diseases. The latter include cardiovascular, renal, hepatic, gastrointestinal, pulmonary and neurologic disorders and malignancies [2]. Infectious diseases among HIV/AIDS patients arise mostly as a result of immunodeficiency and some of the common types from literature are Pulmonary Tuberculosis, Hepatitis C, other sexually transmitted infections (gonorrhoea, syphilis, yeast infection, and so on) [4]. Oral Candidiasis, peripheral neuropathy and Herpes zoster have been reported as most common HIV comorbidities [5]. A recent study found that the incidence of these comorbidities increases with age, smoking and duration of ART use [1]. This latter association appears surprising as it is known that with the introduction of HAART since 1997, mortality from HIV/AIDS has declined, however HAART use has been linked to accumulation of certain breakdown products which may contribute to development of increased risk of comorbid diseases [1]. Many clinicians have anecdotally observed relative increase in cases of Tuberculosis associated with Patients infected with HIV (especially those not on HAART) compared to other patients and the general population. If true, could these be a result of poor adherence to HAART, to evolution of multi-drug resistant viral strains, or to some other reasons not yet appreciated. There is paucity of information on the recent trends of comorbid infections among HIV/AIDS patients especially in sub- Saharan Africa which suffers the highest prevalence of HIV infection globally. This study seeks to explore the nature of comorbid infections and associated features among HIV/AIDS patients in resource-poor setting.

In addition, the bidirectional nature of relationship between severe mental illness and HIV has been well documented. Psychiatric patients are at high risk for acquiring HIV [6,7]. On the other hand, patients infected with HIV are more susceptible to develop psychiatric illnesses [8].

Completed suicide, attempted suicide and suicidal ideations are significantly commoner among persons with HIV/AIDS compared to non-infected controls and have been reported in most cases to be associated with a concomitant psychiatric disorder [9-11]. Patterns of adaptation to disease and appraisal of HIV infection, other than disease severity alone, are reported significant predictors of suicidal ideation among the HIV infected population [11].

In a study of 51 HIV infected persons, findings revealed persistent suicidal ideations in 14%, and suicide attempts in 8% [12]. A similar study of 100 HIV infected persons admitted to a care center, reported a higher prevalence of 41% suicidality. Demographic risk factors for suicidal ideation reported in this study included female sex (56%), lower education level (mean education=5.68 yr in suicidal subjects compared to 8.58 yr in non-suicidal subjects), lower monthly income level (1938 rupees versus 3175 rupees) and presence of physical distress (mean score 15.83 versus 11.75). Psychiatric variables significantly associated with suicidal ideations were similar to those found in western studies and include presence of depression (73% of suicidal patients), hopelessness (mean score on Beck’s hopelessness scale=11.07) and anxiety (29% of suicidal patients) [13].

Homosexual orientation, partner’s HIV status, loss of an infected partner, past history of deliberate self-harm and presence of physical symptoms have been reported as risk factors for suicidality among these patients [14,15]. Some of the psychiatric variables predicting suicidal ideation included stigma, concurrent substance abuse, past history of depression and presence of hopelessness [9,10].. Another aim of this study is to relate the presence of suicidal ideations to the presence and types of comorbid infections.

It is pertinent to state that most of the studies in literature have been conducted outside Africa. It is hoped that this study would access similar information in our environment and serve as basis for further studies and investigations on related issues.

Design

This was a cross-sectional study involving patients with HIV infection attending an Out-patient clinic.

Sample size

Using appropriate statistical formula for single population [16] and a reported prevalence of 14% [12] suicidal ideations among persons with HIV/AIDS, at 80% power, a sample size of 150 participants was arrived at.

Participants

This study involved 150 consecutive adult patients attending the HIV outpatient clinic at the University of Benin Teaching Hospital, (UBTH). These patients understood the nature of the study and voluntarily agreed to participate.

Ethical considerations

Permission for this study was obtained from the Research Ethics Committee of the UBTH. Written informed consent was also obtained from the patients. The Consultants in charge of the patients and other attending Physicians also approved the study and gave necessary assistance and information. Participants who declined consent were reassured of routine quality care.

Instruments/Measures

Participants were assessed for suicidal ideations using the 9^th item of the Beck Depression Inventory (BDI) [17]. The BDI is 21- item instrument used to assess the severity of depression. It has been widely used in local and international studies [18]. The 9^th item assesses suicidality.

The presence of comorbid infections was ascertained from the medical records of participants with the help of the attending physicians.

An author-administered questionnaire was used to collect sociodemographic data. The questionnaire also contained a 14-symptom checklist to enable staging of HIV infection.

Procedure

Consecutive Out patient’s attendees were administered BDI item- 9 and the questionnaire. Clinical information on them were subsequently obtained from their case notes and attending Physicians.

Data analysis

Data were summarized using descriptive statistics and presented in tables. Categorical and continuous comparisons were performed using the Chi- squared test (Fisher’s exact where needed) as well as the Student’s t‑test.

Statistical Package for Social Sciences version 16 (SPSS Inc, Chicago, Ilinois) was used and level of significance set at P<0.05

Socio demographic characteristics

The mean age of participants was 35.57 (SD 9.605) years, with most of them in the age group 28-37 years (n=56, 37.3%). There were more females (n=119, 79.3%) and majority were Christians (n=141, 94%) and stopped at the secondary level of education (n=63, 42%). One hundred and sixteen (77.3%) participants were employed and most were traders (n=37, 24.7%) and married (n=65, 43.3%). Of all, 50 (n=33.3%) had no child while 51 (34%) had 3 or more children. Majority (n=132, 88%) lived with other people such as spouses, children, and so on, while 18 (12%) lived alone. Within the last month before the study, 90 participants (60%) were sexually active and 40 (26.7%) were having unprotected sex, some with different sexual partners (7.3%) (Table 1).

Table 1: Socio demographic Characteristics of Participants.

Characteristics of HIV infection

HIV type 1 viral infection was found among 143 (93.3%) of participants with 63 (42%) of all participants in the stage 1 of the infection. Most of them have been diagnosed positive for a period of at least 13-36 months (n=78; 52%) and 66 (44%) had a sexual partner who had been diagnosed HIV positive also, while 135 (90%) were receiving antiretrovirals (Table 2).

Table 2: Clinical and Behavioural Characteristics of Participants.

Profile of comorbidities

Comorbidities were found among 46 (30.7%) participants with some having more than one condition. These are pulmonary tuberculosis 30 (20.1%), Herpes Zooster 5 (3.4%), oral thrush 3 (2.1%), skin disorders 3 (2.1%), genital warts 3 (2.1%), vaginal discharge 2 (1.4%), Tuberculous adenitis 2 (1.4%), stroke 2 (1.4%) and hypertension 1 (0.7%). Of the 46 that presented with comorbidities, 1 (0.7%) had stroke without any comorbid infection (Table 2).

Suicidal ideations

Suicidal ideations were present in 63(42%) participants, most of them, 38 (25.3%), experiencing it daily. Three people (2.1%) had very intense thoughts of committing suicide (Table 2).

Correlates of comorbidities and suicidal ideations

Suicidal ideations were significantly higher (x²=24.08, p=0.002) and more intense among participants with comorbid infections than those without (x²=29.66, p=0.004). Comorbid infections were commoner among those who had unprotected sex (x²=8.041, p=0.015), those in stages 3 and 4 infection (x²=89.27, p=0.011) and those whose sexual partners are also diagnosed HIV positive (x²=12.03, p=0.001). Comorbid infections were also significantly commoner among the recently diagnosed (under a year), those living alone and those who are unemployed or earning low income (below 10,000 naira per month). There was no significant relationship between comorbid infections and participants’ sex, type of HIV virus infected with or use of antiretroviral medications.

Suicidal ideations were commoner and more intense among age group 18 to 27 years (x²=18.804, p=0.001), females (x²=9.88, p=0.001), those in stages 3 and 4 HIV infection (x²=33.85, p=0.002), the recently diagnosed (x²=30.17, p= 0.015). Other factors associated with increased suicidal ideations are unemployment, low income, living alone, being separated/widowed, unprotected sex, having no offspring and having a sexual partner who is also known HIV positive. Suicidal ideations were less among those who had regular protected sex and those on antiretroviral therapy. No association was found between suicidal ideations and religion, level of education or type of HIV virus infected with.

From the results we note that suicidal ideations occurred more among those participants who had comorbid infections. The presence of these infections add to the morbidity and suffering experienced by these patients and can account for why they habour more suicidal ideations. Although previous studies did not single out comorbid infections, they also reported increased rates of suicidality among HIV patients who had comorbid disorders [12,14,15]. Suicidal ideations were highest among adolescent and young adult patients. This has been previously reported [19]. Young people are just beginning their lives with lots of hope and aspirations unlike older ones; thus being infected with a potentially life-threatening disease may be very demoralising. We note that our sample had predominantly more females; however they significantly reported more suicidal ideations than males. This has been reported by other studies [12,19]. It may be that females are more open in expressing emotions or males may utilize coping mechanisms, such as alcohol use, to mask their true emotions. Unemployment, low income, marital disharmony, and living alone were found to be associated with increased suicidal ideations; other studies have also reported similar associations [12,19]. These factors involve financial constraints and disrupted social support, both of which are known poor indices in illness outcomes.

Similarly, comorbid infections were found more among the unemployed and those earning low income. These factors present with financial constraints which may negatively affect patient’s nutrition or access to treatment and medication adherence. These fallouts obviously worsen the already depleted immune status and predispose to more infections.

Having unprotected sex and a partner who is also known HIV positive are associated with more comorbid infections and suicidal ideations. One study had also reported similar associations [12]. It would appear that if a couple are both infected it would lead to greater hopelessness than if only one is. Worries of who will continue with the family legacies and who will take care of the children in the potential events of death are likely to abound. Also if both partners are infected and continue unprotected sex, mutual re-infections occur severally and transmission of other STDs becomes more likely. Those patients in stages 3 and 4 of HIV infections had more comobid infections and reported more suicidal ideations. At these stages of HIV infection, the immunity would have become severely compromised, predisposing to further infections and other comorbidites. Those affected are likely to suffer more from these morbidities and feel more hopeless and suicidal. Comorbid infections and suicidal ideations were also more among those who were recently diagnosed. Olley [20] had reported similar associations in their work. Most people diagnosed with HIV did not just routinely present for HIV testing; they were diagnosed because they became ill or for some other reason. Hence it seems very possible that the newly-diagnosed may present with significant morbidity including infections. Getting to know that one is HIV positive can be distressing and demoralising; these may involve going through some sort of grief process as described by Kubler-Ross [21]. Therefore it is not unexpected that the newly diagnosed experienced significant suicidality.

Unlike in a previous study [1], use of Antiretroviral Therapy (ART) was not associated with comorbidity. Differences in study population and possibly types of medications that patients used may account for this disparity. However, ART use was associated with less suicidal ideations probably because patients improved with treatment leading to reduction in hopelessness.

This study involved predominantly more female participants and was hospital-based and cross-sectional in design. These factors may limit its generalizability. A follow up study may yield more additional data. However, it provides vital data for further elaboration.

The care of people living with HIV/AIDS has to incorporate routine surveillance for co-occurring infections (especially tuberculosis) and psychiatric morbidities. Otherwise, their quality of life and treatment outcomes will be adversely affected. Studies of this kind should be encouraged especially in this environment where HIV infection quite prevalent.