Depression and suicidal behavior among adolescents living with HIV in Botswana: a cross-sectional study

Depression is the leading cause of global disability, and it affects approximately 4.4% of the world’s population [1]. Almost one-third of adolescents aged 10–19 years globally are at risk of developing clinical depression, which is higher than the reported estimates for those aged 18 and 25 years [2]. Low and middle-income countries (LMICs), such as those in the Middle East and Africa, have the highest prevalence of clinical depression, and females are more likely to be affected than males [2].

Suicide is the fourth leading cause of death in youth aged 15–29 years old worldwide, with over 700,000 taking their life every year [3, 4]. Africa had the highest rate of adolescents (13–17 years) suicidal behavior from 2003–2015, with a prevalence of 20.4% and suicide planning of 23.7%, according to the Global School-based Student Health Survey (GSHS) data in the LMICs [3].

Depression and suicidal behavior have been described among adolescents living with HIV (ALWHIV); however, studies conducted among these individuals are limited [5, 6]. For example, a systematic review of global studies found only 10 published articles on depression among ALWHIV [6]. This review reported a pool prevalence of 26% (95% CI 18.9–34.8) among ALWHIV, whilst another review of 15 studies in sub-Saharan Africa reported a pooled prevalence rate of 22% (95% CI 12–34) for depression and 11% (95% CI 7–16) for suicidal behavior [7]. Most of these studies are from countries that have made enormous progress in the fight against new HIV infections, while those lagging, such as Ethiopia and Ghana, have limited output regarding the mental health of the ALWIHV [7].

While Botswana, which ranks among the top countries affected by HIV globally, was listed among those that have made remarkable progress in the fight against new infections, ALWHIV still constitute a third of the source of new infections, suggesting more needs to be done [8]. There was a spike in suicidal behavior and depression rates among young people in Botswana in 2021, as shown by the unpublished hospital record in Botswana’s only mental health referral hospital. Studies on depression focused mainly on university students [9‐12] and adults in community settings [9‐11]. The few studies conducted among individuals living with HIV were mainly in the adult population [13‐16] and conducted more than 10 years ago [13, 14]. At the time of writing, no study was found that estimated the prevalence of depression among the ALWHIV in Botswana, which ranked among the top four countries most affected by HIV [12].

Apart from the direct and psychosocial effect of HIV in the development of mental disorders such as depression and suicidal behavior, comorbid depression can worsen treatment and the quality of life in affected individuals [17, 18]. Even though data have shown some rates and correlates of depression and suicidal behavior in the adult population [14, 15], it is inappropriate to assume the same in adolescents who may have different psychosocial needs and stressors. Therefore, the present study intended to fill this gap by estimating the prevalence of depression and suicidal behavior and exploring their associated factors in Botswana ALWHIV.

This cross-sectional study involved ALWHIV aged 12–19 years attending HIV clinics, including Botswana Baylor children’s clinical center of excellence (BBCCCE), the regional HIV care clinics in Mahalapye and Lobatse. Most of the participants were recruited from BBCCCE, which is in Gaborone, the capital city of Botswana. Almost 70% of the ALWHIV in the country attend this center, which is managed by a government-private partnership, and provides care for 2404 children, mainly from Gaborone, and over 4000 from other sites in Botswana. Their services include screening, six-monthly viral load checks, medication dispensaries, counseling, research, psychosocial services, education and training, and management of other medical needs of ALWHIV. While other centers are not as comprehensive, they provide similar services close to the residents of ALWHIV.

The study sought to estimate the prevalence of depression and suicidal behavior in ALWHIV and explore the associated factors. The prevalences of depression and suicidal behavior among adolescents were 23% and 18.9%, respectively. Female participants were more likely to be depressed and have suicidal behavior, with good support and increased religious participation being protective against both.

More than 23% of the ALWHIV in the study reported current depressive episodes. Although this rate was a little lower than the 26% pooled prevalence reported in a global studies review [6], it is consistent with the pooled rate of 22% reported in those from sub-Saharan Africa [7]. In addition, 18.9% had an elevated risk of suicide, which is supported by an earlier study that reported 17% among children and adolescents attending a pediatric clinic in Uganda [22]. Despite the variability in the tools used in measuring these disorders across different settings and geographical regions, depression and the risk of suicide remain high among ALWHIV compared to the general population [23]. These findings thus reiterate the importance of focus on the psychological needs of ALWHIV, as they suffer from similar psychological disorders as the adult living with HIV [6, 7]. Depressive disorders and suicidal behavior may impact HIV disease and quality of life [6, 7], which makes it important to integrate routine screening into the treatment of ALWHIV.

The finding that participants with higher mean scores on suicidal behavior were significantly more likely to be depressed was consistent with the previously documented trend [11, 24], suggesting the need to look for suicidal behavior while screening ALWHIV for depression.

The present study also sought to explore the common predictors of depression and suicidal behavior in the ALWHIV population in Botswana. Gender was significantly associated with depression and suicidal behavior, with females more likely to be depressed and have suicidal behavior than males. Previous literature had reported this pattern in seropositive [6, 7] and seronegative adolescents with depression [2]. The social context in Botswana further supports the preponderance of female ALWHIV reporting more depressive symptoms than males, as they were disproportionally affected by the HIV epidemic. They had increased exposure to stigma, discrimination, forced/transactional sex, gender-based violence, and unplanned pregnancies [8]. Furthermore, although the completed suicide rate was higher among male university students in Botswana, females were more likely to communicate their intentions regarding suicide [11], as in the present study's finding. Therefore, while we continue to heed female clients' needs, effort should be made to actively screen for suicidal behavior in males in a manner that promotes communicating their feelings.

The participants with a higher viral load had more depressive symptoms than those with below 400 copies. Although this present cross-sectional study cannot explore the causal relationship between depression and viral failure, studies have associated HIV viral load with psychological disorders such as depression [25]. For example, a study found an association between depression with increased subsets of CD8 cells, which represent activated CD8 T-lymphocyte, and this may be detrimental to the host's defense against HIV later in the course of the disease [18]. Moreover, as loss of appetite and poor sleep are important symptoms of depression and related to reduced immunity [17], it could be hypothesized that they were responsible for viral failure in ALWHIV. Although this deserves further investigation, the authors proposed that depression negatively impacts HIV disease progression, underscoring the need to routinely screen for depression in ALWHIV.

Significantly, maternally orphaned participants were more likely to have depressive symptoms than those whose mothers were alive. Kim and colleagues [26] associated death in the family with depression among ALWHIV, which may also be the case in Botswana, particularly with the loss of mothers, who not only play a huge role in children’s upbringing and family headship but may be the main household provider in single-parent families [27, 28]. Losing a mother may be traumatic or for some children in Botswana, with most participants being raised by single parents in this study. In Botswana, mothers are generally the primary caregivers, as they usually accompany their children to the health care facilities and oversee their treatment, even though they provide for the family financially [27]. This observation thus emphasizes the need to empower mothers in the fight against new HIV infections in Botswana, specifically among young people [29].

Perceived support from the family and healthcare providers was protective against depression in this sample, as reported in a previous study [30]. Lee and colleagues [31] reported the effect of negative social support on depression, while Goin [30] emphasized the impact of parent involvement in adolescent treatment and support. ALWHIV have increased vulnerability to negative emotions such as catastrophizing, negative rumination, self-blaming, and abnormal emotional responses to adverse life events than their seronegative counterpart [32]. Since these factors are prominent internalizing problems such as depression [33], ALWHIV require active probing, constant reassurance, frequent psychoeducation, and counseling. Therefore, health care providers should pay more attention to the social needs of these individuals in addition to clinical treatment. In addition, parents, and other family members, including friends, should also be educated, empowered, and encouraged to give their support to them.

HIV-infected adolescents who had negative feelings toward their HIV status were eight times more likely to have suicidal behavior. Although studies have not fully explored this relationship in ALWHIV, it is possible that this subgroup found it challenging to adjust to or cope with their status. It may be related to multiple psychosocial issues, including stigma, discrimination, being different from peers, and having to visit clinics or take medication. A review of the literature blamed shame as one of the reasons for poor adjustment to status in the people living with HIV (PLWHIV) [34]. Perhaps the constant thoughts of suicide resulted from seeking a way of escape or maladaptive coping and may also explain the hazardous use of alcohol among the participants.

Alcohol use had been linked to suicidal behavior as PLWHIV with drinking problems were more likely to have suicidal behavior [35]; this finding was replicated in the present study among adolescents. Against the popular belief that alcohol numbs psychological pain, it is a depressant that enhances the prevailing mood and promotes negative thoughts such as hopelessness and suicidal behavior [36]. Furthermore, alcohol lowers inhibition sufficiently for an individual to act on suicidal thoughts. It also inhibits activity in the brain regions such as the prefrontal cortex, caudate nucleus, and subthalamic nucleus, which are responsible for inhibition [37]. Suicide and alcohol are ‘escape coping’ maladaptive strategies. ALWHIV should be routinely screened for these, adequately educated, and trained on better coping strategies.

Conversely, this study identified a potentially adaptive coping style; increased participation in religious activities negatively correlated with suicidal behavior. A study that examined the influence of religious affiliation and suicidal behavior found no relationship between them as in the present study [38]. However, more frequent attendance at religious activities was associated with decreased suicidal behavior scores even after adjusting for social support [38, 39]. Religious coping promotes positive appraisals and may help individuals perceive adverse events such as living with HIV as less stressful. It can also increase social support networks and discourage maladaptive coping such as substance use and ultimately suicidal behavior. Therefore, further studies should explore how religious activity can be integrated into the care plan of ALWHIV.

This study has a number of limitations that may have affected the findings. Some of the data were collected during COVID-19 and may have affected the clinic attendance and thus who was available for participation; hence, it should be cautiously interpreted. It may not be generalizable to the rural settings in Botswana; however, the sample was drawn from the largest center, which serves over 60% of the ALWHIV in the country. In addition, it was the first study to establish the prevalence of depression and suicidal behavior using a rigorous diagnostic tool in the ALWHIV in Botswana.

As reported in other settings, depression and suicidal behavior rates were high in the ALWHIV in Botswana. Females were more vulnerable than their male counterparts. Those with elevated viral load counts and maternally orphaned ALWHIV were more likely to have depression, while those with AUD who had difficulty adjusting to status had a significant risk of committing suicide. Conversely, family and care provider support protected against depression, whereas increased religious participation appeared protective against suicidal behavior. Therefore, routine psychologic screening, which includes identifying disorders, psychological stressors, and maladaptive coping, should be part of the management package for ALWHIV in Botswana. In addition, integrated HIV care programs such as adolescent-friendly services, family and caregiver support services, and psychosocial support platforms should be implemented.