ANXIETY DISORDERS AND THE ASSOCIATED FACTORS AMONG HIV/AIDS OUTPATIENTS IN LAGOS UNIVERSITY TEACHING HOSPITAL, LAGOS, NIGERIA.
A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE IN PART FULFILLMENT OF THE AWARD OF FELLOWSHIP
BY
DR. ANDREW TOYIN OLAGUNJU
NOVEMBER, 2009 TABLE OF CONTENTS
TITLE PAGE 1 TABLE OF CONTENTS 2 LIST OF TABLES 3 DECLARATION 4 DEDICATION 5 CERTIFICATION 6 ACKNOWLEDGEMENT 7 SUMMARY 8-9 INTRODUCTION 10 LITERATURE REVIEW 11-29 RELEVANCE OF STUDY 30 AIMS AND OBJECTIVES 31 METHODOLOGY 32-37 RESULTS 38-51 DISCUSSION 52-57 CONCLUSION 58 LIMITATIONS AND RECOMMENDATIONS 59 REFERENCES 60-65 APPENDIX A. ETHICAL COMMITTEE APPROVAL LETTER B. SOCIODEMOGRAPHIC AND CLINICAL DATA QUESTIONNAIRE C. COPIES OF INSTRUMENTS General Health questionnaire-12 (GHQ-12) and Schedule for clinical assessment in Neuropsychiatry (SCAN)
2
LIST OF TABLES
Table 1: Sociodemographic characteristics of subjects Table 2: HIV/AIDS treatment related characteristics of subjects Table 3: History of other medical problems in subjects Table 4: GHQ score and Diagnosis of Anxiety disorders in subjects using SCAN Table 5: Types of Anxiety disorders in subjects Table 6: Sociodemographic characteristics of subjects with and without Anxiety disorders Table 7: Medical attributes of subjects with and without Anxiety disorders Table 8: Mean values of some sociodemographic and medical variables in subjects with and without Anxiety disorders Table 9: Logistic regression analysis of factors associated with Anxiety disorders
3
DECLARATION
I HEREBY DECLARE THAT THIS WORK IS ORIGINAL AND CARRIED OUT BY ME. IT HAS NOT BEEN SUBMITTED TO ANY OTHER COLLEGE FOR AWARD OF FELLOWSHIP OR SENT ELSEWHERE FOR PUBLICATION.
…………………………………………………………… DR ANDREW TOYIN OLAGUNJU
DATE……………………………….
4 DEDICATION
THIS WORK IS DEDICATED TO GOD ALMIGHTY AND ALL PEOPLE LIVING WITH HIV/AIDS.
5 CERTIFICATION
THE STUDY REPORTED IN THIS DISSERTATION WAS PERFORMED BY DR. ANDREW OLAGUNJU UNDER MY SUPERVISION.
……………………………………………………………………………………… PROF J. D. ADEYEMI
SUPERVISOR
CONSULTANT PSYCHIATRIST, LAGOS UNIVERSITY TEACHING HOSPITAL AND PROFESSOR OF PSYCHIATRY COLLEGE OF MEDICINE, UNIVERSITY OF LAGOS.
6 ACKNOWLEDGEMENT
My profound gratitude goes to Professor J.D. Adeyemi, my supervisor and trainer, whose guidance and personal sacrifice contributed immensely to the success of this work.
I also thank Professor O.O. Famuyiwa; Dr. O. F. Aina, the head of department of Psychiatry, Lagos University Teaching Hospital (LUTH); other consultants, Dr. A. R. Erinfolami, Dr. O. Y. Oshodi and Dr. E. Ogbolu. I am also grateful to my colleagues and fellow resident doctors in the department of Psychiatry, LUTH for their support and encouragement.
My appreciation goes to Dr. A. S. Akanmu and other consultants as well as member of staff of the HIV clinic in LUTH for their support and assistance during the period of data collection.
Lastly, I am grateful to my wife, Dr(Mrs) Tinuke Olagunju, my daughter, Miss Tomi Olagunju, my parents, Rev & Mrs Gabriel Olagunju, and siblings Mrs Joy Adekunle, Emmanuel, Lizzy, Lydia, Eunice, Grace and Peter for their support, love and understanding.
7
SUMMARY
Anxiety disorders are one of the commonly encountered psychiatric disorders in people living with HIV/AIDS. Previous studies have noted that comorbdity of psychiatric disorders in HIV/AIDS often impair treatment compliance and worsen disease progression.
This study assessed the prevalence of Anxiety disorders as well as described factors associated with Anxiety disorders in people with HIV infection.
The subjects were made of 300 patients selected by systematic random sampling attending HIV clinic in LUTH who consented and met the inclusion criteria. The instruments used include: Sociodemographic questionnaire, clinical profile questionnaire, General Health Questionnaire and the Schedule for Clinical Assessment in Neuropsychiatry.
The instruments were administered to the patients by the author over a period of four months. Data obtained were analysed using SPSS-15 to generate frequency table, cross tabulation, chi-square tests and logistic regression analysis.
A total of 300 subjects participated in the study. One hundred and fifteen (38.3%) of the subjects were males while one hundred and eighty-five (61.7%) were females. The mean age was 36.95 (±8.73) years. Majority of subjects were married (53.7%), 21% were single and 13.3% were widowed. Two hundred and thirty-eight (79.3%) subjects were Christians while sixty-two (20.7%) were Muslims. One hundred and forty-three (47.7%) subjects had secondary school education and ninety (30%) had tertiary education. The largest proportion (34.0%) was engaged in semi-skilled employment while 25.7% were unemployed. One hundred and seventy-four (58%) subjects had HIV counselling. The mean duration of HIV disease was 45.7 (±33.7) months
Ninety (30.0%) subjects had GHQ score of 3 and above (cases) and Sixty- five (21.7%) subjects were diagnosed with Anxiety disorders based on SCAN. Eighteen (6%) subjects had Anxiety disorders unspecified and sixteen (5.3%) subjects had
8 mixed anxiety and depressive disorders while one (0.3%) subject had obsessive compulsive disorder. Majority of the subjects (67.7%) diagnosed with Anxiety disorders were females and married (36.9%). The mean age of subjects with Anxiety disorders was 34.96 (±9.08) years. Thirty (46.2%) subjects with Anxiety disorders had secondary education while twenty four (36.9%) had tertiary education. Twenty seven (41.5%) subjects with Anxiety disorders were unemployed. Twenty nine (44.6%) subjects with Anxiety disorders had family support while thirty six (55.4%) had no family support. Anxiety disorders was significantly associated with unemployment status (p-value =0.004), marital status (p-value= 0.016) and lack of family support (p-value =0.000). However, unemployment status and lack of family support were the factors that were still predictive of Anxiety disorders (family support OR=0.396, 95% CI=0.223-0.705, p- value=.002 and employment status OR=0.469, 95% CI=0.256-0.858, p-value=0.014).
A significant proportion of HIV positive subjects had Anxiety disorders and social problems like unemployment and absence of family support was associated as well as predicted the presence of Anxiety disorders. Prompt identification and treatment of mental disorders like Anxiety disorders as well as management of psychosocial problems in HIV patients should be integrated into HIV intervention in this part of the world.
9 CHAPTER ONE
Introduction Acquired immune deficiency syndrome (AIDS) is an immunodeficiency state resulting from infection by the retrovirus called Human immunodeficiency virus (HIV). The core feature of HIV infection is the progressive impairment of human T- cell mediated immune response. AIDS can be associated with multiple medical complications, which may include neuropsychiatric phenomenon (Kaplan, et al., 2003). AIDS was first reported in 1981 in the United States following the development of unexplainable Pneumocystis Carinii pneumonia and Kaposi sarcoma among homosexual men in Los Angeles and New York respectively by the Centre for Disease Control and Prevention CDC, (1981). Patients with HIV/AIDS are often faced with multiple social as well as health related problems. Psychosocial stressors including stigmatisation and mental disability are associated with living with disease which also connote a limited future. In effect, mental health physicians have a major role to play in the care of the different aspects/stages of HIV/AIDS management. HIV/AIDS and the attendant problems which include neuropsychiatric complications like anxiety disorders have changed the pattern of disease burden and health care delivery services throughout the world since the discovery in the 1980s (Kaplan, et al., 1998). This is more so in the developing world where the incidence and prevalence of HIV/AIDS is high. The numerous impacts of HIV/AIDS on diverse aspects of life of large population of people set it out as a challenge for optimal care. The adoption of a ‘holistic’ approach in the care of HIV/AIDS has been suggested thus necessitating evidence based knowledge and information through research in multiple disciplines (Othieno, et al., 2006 and WHO, 1999). There is a need for a study of the prevalence as well as detailed description of the factors associated with anxiety disorders among HIV/AIDS patients. Early treatment of anxiety disorders has the potential to reduce the HIV/AIDS morbidity and the disease progression. The identification of anxiety disorders is often missed due to poor description and dearth of information on the associated risk factors in HIV/AIDS patients. Therefore there is need for a study of anxiety disorders in these subjects to complement the body of existing knowledge in the effort to improve the management of HIV in this part of the world.
10 CHAPTER TWO
Literature Review Historical Perspective HIV/AIDS was first identified in the United States of America and mentioned in medical publication in June 1981 by the CDC following the discovery of Kaposi sarcoma and Pneumocystis Carinii among homosexual men. The analysis of specimen from dead people before 1981 however suggested that HIV infection was present as at late 1950s. Presumably, HIV related cases as well as AIDS were not recognised in 1960s and 1970s, in spite of occurring in South and North America (CDC, 1999 and Kaplan, et al., 2003). AIDS has grown from an obscure disease to spread into all continents of the world and has caused widespread panic, fear and a major threat to health globally in the twentieth century (Kanabus, et al., 2007). It was called different names by CDC and other centres around the world: Kaposi sarcoma and opportunistic infections; ‘’gay compromise syndrome’’; gay-related immune deficiency; ‘’gay cancer’’ or ‘’community-acquired immune deficiency’. Some of these names restrict its occurrence to the gay community. The name was changed to acquired immunodeficiency syndrome with the discovery of the same illness among drug addicts, heterosexual and haemophiliacs who received blood transfusion (CDC, 1982 and Kanabus, et al., 2007). The causative agent of AIDS was reported to be a virus called Lymphadenopathy Associated Virus (LAV), also called French virus by Montagnier et al (1983) of the Pasteur Institute. Following the work of Dr Roberto Gallo, the United States Health and Human Services Secretary reported the isolation of Human T- cell Lymphotropic Virus III (HTLV III) as the viral organism responsible for causing AIDS. The virus was later named Human Immunodeficiency Virus by the International Committee for Taxonomy of Virus in 1986. Private companies started to apply for license to develop commercial tests that would detect the virus in the blood (Altman, 1984). The approval of the first license for commercial production of blood test for HIV was given by the United States Food and Drug Agency in March 1985 (Pear, 1985). This test is the sensitive enzyme linked immunosorbent assay (ELISA), an antibody screening test. Numerous ethical and social issues were subjects of discussion as it
11 relates to positive HIV test and the impact on the larger society. The clinical trial of Azidothymidine as a medical treatment for HIV related illness started in 1986.
The Biology of HIV/AIDS HIV/AIDS is caused by the human immunodeficiency virus (HIV). It belongs to the retrovirus family and invariably the first human lentivirus to be isolated (CDC, 1999 and Kanki, et al., 2006). At least two serotypes of HIV virus: HIV-1 and HIV-2 have been identified as the causative agents of HIV infection and AIDS, though a new subtype called HIV-O is currently being investigated (Kanki, et al., 2006). Although HIV-1 is linked with the cause of majority of the HIV infection, HIV-2 is increasingly being isolated in patients in Africa (Kaplan, et al., 1998 and Meloni, et al., 2006). AIDS was first reported in the United States in 1981 and has since become a major worldwide epidemic. By killing or damaging cells of the immune system, HIV progressively destroys the ability to fight infections and certain cancers (CDC, 1999 and AVERT, 2007). The peculiar ability of HIV to integrate itself into the host genetic material makes its infection to be lifelong in spite of the current treatment modalities.
Pathogenesis
The understanding of the biologic interplay of HIV with the host cellular system provides the biological basis for HIV control and explains the mechanism of action of the available antiretroviral drugs. AIDS occurs after approximately 8 to 11years following infection with HIV, although early treatment with antiretroviral drugs can lengthen this period. Following infection, the entry of HIV involves the fusion of the viral envelope with the cellular membrane. HIV binds to the CD4 (Helper) lymphocyte through a viral surface trimetric glycoprotein (formed by gp- 120 and gp- 41) that has a strong affinity for the CD 4 receptor on the T 4 lymphocyte (Kwong, et al., 1998). Other chemokine receptors like CCR5 and CXCR4 are known to aid in the transmission of HIV in vivo, thus mutation in the encoding genes for this receptor explains resistance to HIV infection in some population (Martinson, et al., 1997 and Doms, et al., 2000). After binding, the virus injects its RNA into the lymphocyte from where the RNA is transcribed into DNA through the action of reverse transcriptase. The resultant DNA can be incorporated into the host genome where it is translated and transcribed once the lymphocyte is stimulated to divide. The
12 production of all viral protein by the host results in the budding of a new virus. The process of budding often results in lyses of the lymphocyte and other pathophysiological mechanisms that impaired the body complement of T4 lymphocyte (Greene, et al., 2003 and Kaplan, et al., 2003).
Clinical Features The clinical presentation of HIV varies widely from one individual to another and may affect any system of the body. Majority usually have initial symptoms that can be characterised by recurrent or unremitting fever, diarrhoea, vomiting, cough, sneezing, body rash and generalised lymph node enlargement among others. The symptoms usually change in severity and pattern with seroconversion and following depreciation in the immune status of the infected patient. The period between HIV infection and when the patient tests positive for HIV virus also known as ‘window’ period could vary on the average from six weeks to six months. The advanced stage of HIV infection called AIDS, if untreated could take up to a decade before occurring. It is typically associated with severe impairment in the immune system. AIDS is usually associated with symptoms like weight loss, poor energy, poor short term memory and secondary opportunistic infection like pulmonary TB and fungi infections among others. The associated symptoms are usually very severe thus impairing the social and occupational functioning of AIDS patients. A CD4 count drop below 200 cells per cubic millilitre is said to be diagnostic of AIDS irrespective of presence or absence of AIDS defining symptoms (CDC, 1993), it is an indication to commence anti-retroviral therapy. In countries with poor resources where diagnostic and monitoring facility is difficult to come by, WHO recommended the use of clinical stages of AIDS in order to guide treatment decision. There has been modification of the initial WHO clinical stages to accommodate the new findings from ongoing researches on HIV/AIDS by CDC and others (Idoko, et al., 2006). A modified clinical staging of HIV by CDC into four main categories is described below.
Clinical Stages of HIV/AIDS. The CDC classified the spectrum of HIV infection into four main clinical stages. This is a modification of the earlier classificatory system.
13 Clinical stage I – Asymptomatic disease Patients are usually asymptomatic and present with symptoms of acute HIV infection, including generalised lymphadenopathy. Clinical stage II –Early (mild) disease Patients usually have symptoms and signs that include weight loss of at least 10% of body weight; minor mucocutaneous manifestations (seborrheic dermatitis, prurigo, fungal nail infection, recurrent oral ulceration and angular cheillitis); recurrent respiratory tract infections such as bacteria sinusitis. Clinical stage III Intermediate (moderate) disease This stage is characterised by weight loss of at least 10%; chronic unexplained diarrhoea of at least one month duration; oral candidiasis (thrush); oral hairy leukoplakia; pulmonary tuberculosis within the past year; severe bacteria infection such as pneumonia and pyomyositis. Clinical stage IV Late (severe) disease AIDS The descriptive features of this clinical stage includes HIV wasting syndrome as defined by the CDC; Pneumocystis carinii pneumonia; toxoplasmosis of the brain; cryptosporidiosis with diarrhoea of at least one month; extra pulmonary cryptosporidiosis, cytomegalovirus disease other than in liver, spleen, or lymph nodes; herpes simplex virus infection; progressive multifocal leukoencephalopathy; disseminated endemic mycosis, such as histoplasmosis and coccidioidomycosis; candidiasis of the esophagus,trachea, bronchi, or lungs; atypical mycobacteriosis; disseminated, nontyphoidal salmonella septicaemia; extra pulmonary tuberculosis; lymphoma, Kaposi sarcoma; HIV encephalopathy as defined by CDC. This late stage is characterised by a CD4 count <200 cells per cubic millilitre.
The clinical staging of HIV has implications for clinical decision and priority setting for treatment because patients with CD 4 cell count of < 200 cells per cubic millilitre, AIDS or all symptomatic patients require urgent attention. Treatment with ARV drug is also commenced in patients with CD4 count of <350 cells per cubic millilitre with features of clinical stage IV.
14 Diagnosis
HIV testing involve serum test that detects the presence of anti-HIV antibodies in human serum. A positive HIV result in an individual indicates exposure to the virus and the presence of HIV virus in the body. Such individual has the potential of transmitting the virus to another person. And a negative HIV result means that such individual has either not been exposed to the virus or has not seroconverted (i.e. the anti-HIV antibody is not yet detectable) despite the presence of the virus in the body. There are two common assay techniques, ELISA and Western blot assay. The ELISA is used initially for screening because it is cheaper than Western blot and applicable in a large-scale screening. The Western blot is more sensitive and specific compared to ELISA. The average period for seroconversion is between 6 to 12 weeks after infection, although occasionally it may be as long as 6 to 12 months (Kaplan, et al., 2003). These are the commonest mode of HIV screening available in sub-Saharan Africa.
Monitoring of Disease progression using CD 4 count The rate of disease progression in untreated HIV positive individual varies, however it is suggested that more than half will develop severe disease within 10 years of HIV acquisition. In clinical setting the rate of decline in CD4 count has been used to monitor the progression of disease and conversely, an increase in CD4 as index of the impact of antiretroviral medications (Badri, et al., 2003). A CD4 count <200/microlitre is used as a reference point to define the AIDS stage of HIV infection. Other parameter for monitoring change in HIV disease progression include viral load, this is however limited in its application since it only reflects the virion in plasma that is available for detection and not those in tissue or cell which may be undergoing replication (Chun, et al., 1998). Virological test that monitors viral load is used to assess the impact of antiretroviral therapy.
Treatment There are currently no curative drugs for HIV/AIDS, however the available drugs have been reported to decrease the progression of HIV illness and improve the life expectancy of the patients. The drugs often result in severe side effects in patients. Preventive education targeted toward the change of risky sexual behaviour is the core of HIV control.
15 HIV/AIDS control programmes lay emphasis on prevention and holistic mode. In effect, it requires a multisectoral and multidisciplinary approach. The essential component includes clinical care, nutritional care and support, nursing care, psychological support, health information and counselling, legal protection and economic sufficiency (Idoko, et al., 2006). The treatment of HIV/AIDS can be broadly divided into: Primary – involves preventing new infection. Secondary- modifying the course of disease Pharmacotherapy (Antiretroviral) – The standard care of HIV/AIDS includes the use of Highly Active Antiretroviral Therapy (HAART) targeted towards suppressing viral load levels below detection. Sustenance of drug compliance and viral resistance are important in the use of HAART. This is because of the high risk of viral resistance and permanent loss of efficacy for available medications following any deviation in drug compliance. In effect, drug adherence is of utmost relevance in the management of HIV (Practice guideline for HIV treatment 2000). Triple regimen that includes two drugs from the reverse transcriptase inhibitor group and one protease inhibitor is suggested to address the problem of resistance to HIV subtypes. Reverse transcriptase inhibitors (e.g. Zidovudine) delay progression of HIV Associated Dementia (HAD) Protease inhibitors reduce viral load
Epidemiology Human immunodeficiency virus infection is transmitted through contact with infected body fluids like semen, vaginal fluid, blood, breast milk among others. This occurs during sexual intercourse, use of contaminated sharp objects (for example, needle sharing in drug addicts, barbing with the same clipper by many people), mother to child transmission (vertical transmission) and others. It is of note that the sexual route is the commonest mode of transmission of HIV (CDC, 1999 and McCarthy et al., 2002). Risky sexual behavioural pattern (such as having unprotected sexual intercourse) with either single or multiple sexual partner(s) whose current HIV status is unknown increases vulnerability to HIV infection.
16 The current information on HIV infectivity suggests that the risk of infection with HIV virus after single exposure to an HIV infected person is relatively low as depicted below:
0.8% to 3.2% for unprotected receptive anal intercourse
0.05% to 0.15% for unprotected vaginal sex
0.32% after puncture with an HIV contaminated needle
0.67% following the use of contaminated needle to inject drugs
The probability of transmission could increase depending on the viral load of the contact person as well as the presence of a coexisting sexually transmitted disease like herpes, syphilis among others or any lesion that disrupt mucosa lining or skin integrity. Other common high risk for HIV infection includes transfusion of whole blood, plasma and clotting factors. Transmission through blood occurs commonly when people abusing drugs intravenously share hypodermic needle. There is no evidence of transmission through hugging and hand shake with HIV positive patients (Kaplan, 2003).
The HIV epidemic is currently reported to be stabilized globally inspite of high level of new infection and AIDS death. There are different figures for prevalence for different parts of the world, however, continents like Africa, Asia, South America are worst affected. Africa, with just over 10% of the world population carries well above 75% of the burden of HIV epidemics (UNAIDS, 2008). The reported estimation by UNAIDS stated that, as at 2007, about 33million people globally are living with HIV virus and the annual number of new infection reduced from 3million in 2001 to 2.7million in 2007 while 2million people died of HIV related caues. About three quarters (75%) of all AIDS deaths in 2007 came from the sub-Saharan Africa. This region is characterized by poverty due to its political, economic and social instability (UNAIDS/WHO, 2008).
The two noteworthy points are: firstly, two third (67%) of these people living with HIV/AIDS globally are located in sub Saharan Africa. And secondly, the sub Saharan Africa has the highest rate of new infection among young population. Globally, South Africa and Nigeria were reported to have the second and third highest total number of people living with HIV respectively, trailing after India that has the highest prevalence. The report of the national sentinel survey conducted by the Federal
17 Ministry of Health on HIV infection in Nigeria depicted variation in prevalence rate across different regions of the country. The report documented an increase in the total percentage of infection from 1.8% in 1991 to 5% in 2003, among people between ages 15-49 (Nasidi, et al., 2006).
The WHO (2001) states that over 10% of the population of 16 countries of sub- Saharan Africa in the reproductive age is infected with HIV. In 2002, the National Intelligence council stated that five countries: India, China, Nigeria, Ethiopia and Russia are expected to saddle the heaviest burden of HIV infection in the growing global pandemic (Eberstadt, 2002 and Kanki, et al., 2006). Furthermore, Nigeria and Ethiopia were earmarked as likely to be harder hit, and a projected figure for people living with HIV/AIDS in Nigeria by 2010 would be about fifteen million, which is about 26 percent of the adult population if the trend continues.
The first cases of HIV infection and AIDS in Nigeria were diagnosed in Lagos, the largest city in the country in 1985; this was reported by Nasidi, et al., (1986) in an international forum. Ever since then the AIDS scourge has taken an increased toll. The Nigerian prevalence has varied from region to region and year to year. The latest sentinel survey puts about 48% of the total people infected with HIV in Nigeria to be women and 7.7% are children. Also more than 25 000 deaths results from AIDS annually and about 2millions AIDS orphan live in Nigeria now (UNAIDS, 2004b). The Lagos sentinel survey in 2003 among pregnant women attending antenatal care in Lagos showed that 4.7% were positive for HIV (Salawu, et al, 2003). This portends a relatively high epidemiological burden.
Factors affecting HIV Spread
The infectivity and progression in the HIV/AIDS problem is linked to complex social and psychological factors. A review by Nyindo, 2005 showed that some of the risk factors for HIV-1 infection and AIDS disease in sub-Saharan Africa include illiteracy, poverty, famine, low status of women in society, corruption, naive risk taking perception, resistance to sexual behaviour change, high prevalence of sexually transmitted infections (STI), internal conflicts and refugee status, antiquated beliefs, lack of recreational facilities, ignorance of individual's HIV status, child and adult prostitution, and polygamy. It has been suggested that control programmes both local
18 and donor-driven seeking to mitigate the spread of HIV-1 in sub-Saharan Africa should take into account the blood intended for transfusion, widow inheritance, circumcision, female genital cutting, apparent multiplicity of sub-Sahara African cultures and beliefs, some of which enhance the spread of HIV-1. The influence of culture on HIV pandemic that also impacts the mode of transmission and the resulting epidemiological burden differs from one context to another (Adeokun, 2006).
The lack of awareness or dissemination of false information has also been implicated in the worsening trend of HIV prevalence especially in the developing countries. A survey in Sudan in 1992 confirmed ignorance among the majority of the women (69%) about HIV transmission. The source of information for the small percentage that claimed awareness was largely from friends (81%) however this may not be a valid representation of the current situation. The knowledge about HIV transmission did not translate to a change in sexual behaviour even among the small proportion that had the knowledge of the sexual mode of HIV transmission, as all of them denied ever using condom (Hot, 2003).
The United Nations Security Council described the HIV/AIDS pandemic as the ‘fastest’ growing threat to development and a potential threat to national and regional security since the previous decade. It is implicated in the death of more people than wars/armed conflicts within the corresponding period of the year (WHO, 1999).
The context of this study is Nigeria, which is located in the sub-Sahara region of Africa. Nigeria is significantly affected with HIV/AIDS (Box 1). However, it is an unfortunate paradox that Africa has the least efficient HIV/AIDS intervention strategy.
BOX 1 Socio-demographic description of the study context- Nigeria . Most populous black nation located in the sub-Sahara; Nigeria’s Human Development Index rank is 158 out of 177 countries. . Current population estimate is 140 million people with almost male- female ratio equal . Up to 350 different ethnic groups with distinct socio-cultural identity and life . Two third of Nigerians live on less than one US dollar per day . Prevalence rates show significant geographic variations within the country. . With nearly 1million people dead and >2million children orphaned due to HIV (Kanki et al, 2006)
19 HIV/AIDS and Psychiatric Morbidity The interface between Psychiatry and HIV/AIDS is complex and multifaceted. This may be explained partly from the pathophysiology of HIV infection especially the predilection of HIV virus for the central nervous system: neurotropic nature. The social stigma and psychological stress emanating from the incurable nature of HIV infection and the moral interpretation of the mode of HIV transmission, ‘mainly sexual’ as synonymous with promiscuity represent another linkage with psychiatry. The contexts which psychiatric problems may occur in relation to HIV/AIDS include: People who are worried about the possibility of infection because of their association or contact with HIV positive individual – ‘worried well’. The anxiety of pre HIV testing as well as post test stress may precipitate psychiatric disorders like adjustment, major depressive disorder and suicidality. The stress of living with HIV due to loss of economic power, changed role and associated stigma as a result of societal factors. People who have psychiatric need. Sometimes victims of sexual abuse may be vulnerable to be infected with the virus. Neuropsychiatric symptoms due to direct neurotropic effect of HIV. Neuropsychiatric symptoms resulting from infection by opportunistic pathogens and tumours as a result of susceptibility of HIV positive patients to them. Psychiatric symptoms resulting from the effect of antiretroviral drugs. (Semple, et al., 2005 and Othieno, et al., 2006) In spite of these multiple areas of potential psychiatric problems in relation to HIV, only few studies have discussed all these contexts. Some studies have assessed the prevalence, association, and impact of psychiatric morbidity in HIV/AIDS patients. The presence of psychiatric morbidity in HIV/AIDS patients has been documented in many researches around the world; however varied figures as well as heterogeneous findings are reported for different studies and regions. This presumably may be due to multiple reasons such as demographical correlates, type of instrument used in these studies, study design, sampling technique, contextual factors and interplay of psychosocial factors among others (Pamela, et al., 2006).
20 Several studies have suggested an increase in the prevalence of mental health problems among HIV positive patients in comparison with the general population (Atkinson, et al., 1988; Brown, et al., 1992 and Perkins, 1994). Anxiety, depression as well as other emotional distress have been described as the possible ways of reacting to the crisis of the first knowledge of seropositivity in certain individuals or to subsequent symptoms and disability associated with HIV related illness (Perkins, et al., 1994 and Atkinson, et al., 1998). The psychiatric syndromes that have been documented in HIV/AIDS patients include depression, mania, suicide, anxiety, chronic pain, delirium, psychosis and HIV/AIDS associated dementia. Multiple studies have suggested the association of significant psychological distress among people with HIV disease than the general population in spite of the under-detection of psychiatric morbidity among HIV/AIDS positive individuals (Bornstein, et al., 1993; Fell, et al., 1993 and Israelski, et al., 2007). In a controlled study by Atkinson, et al., (1998) on the prevalence of psychiatric disorders among men infected with HIV, about 56 unselected ambulatory homosexual men were assessed with structured diagnostic interviews and rating scale with DSM III criteria for life time prevalence of psychiatric disorder. They were grouped into four groups: men with AIDS, men with AIDS-related complex (ARC), men asymptomatic or mildly symptomatic but seropositive for antibody to HIV and HIV-seronegative men. An age- and demographically matched comparison group of 22 healthy, heterosexual controls were also studied. The study found that the homosexual men had lifetime rates of alcohol or nonopiate drug abuse (22/56 [39.3%]), generalized anxiety disorder (22/56 [39.3%]), and major depression (17/56 [30.3%]) that often preceded diagnosed medical illness or knowledge of HIV status. The six-month point prevalence of these disorders in homosexual men was also high, especially alcohol abuse in patients with AIDS- related complex, and the occurrence of a DSM-III disorder within the previous six months significantly exceeded that in heterosexual controls. The data suggested that there is a higher prevalence of anxiety disorder and major depressive illness in homosexual men when compared with sociodemographically matched heterosexual men and that the psychiatric morbidity may have preceded the onset of the AIDS epidemic. These findings indicate that awareness of psychiatric history is necessary to comprehensive medical care of men at high risk for AIDS, even among the relatively healthy.
21 The extent of generalisation from this study is limited because of small sample size (56) and its target population of homosexual men, a group that has been reported to have elevated psychological risk for mental disorder. Also the study did not delineate between anxiety disorder preceding HIV infection and those that started after the diagnosis of HIV infection. And lastly it is limited in its ability to be representative of the situation in the third world countries where the people living with HIV are faced with peculiar stressful and adverse psychosocial factors such as poverty, stigmatisation and low standard of living. A greater risk for psychopathology has been suggested among HIV patients in developing countries compared to their counterpart in the developed world (Fawole, et al., 2005, Amoran, 2005 and Gureje, et al., 2005).
HIV/AIDS AND ANXIETY DISORDERS
Anxiety is a normal reaction to stress that may enhance performance when an individual is faced with challenges. Thus it is an important coping mechanism. However, it becomes a disabling disorder when it becomes excessive, intense, irrational and unwarranted (NIMH, 2007). Anxiety disorder is a serious medical illness that results in overwhelming fear in the affected patients and often results in impaired functioning as well as productivity. About 19 million Americans are reported to be suffering from anxiety disorder with the potential to benefit from treatment. Adequate treatment of anxiety disorder has been proven to help in the remission as well as mitigation of the impact of anxiety disorder. A large scale community survey by Gureje, et al. (2006) in Nigeria reported that Anxiety disorder has the highest life-time and 12-month prevalence rates for psychiatric morbidity. The study reported 5.7% life-time and 4.1% 12-month prevalence rates for anxiety disorders. This shows a significant prevalence rate for anxiety disorder among the target population. Other significant findings in the study were the poor diagnostic rate of psychiatric disorders in the respondents and poor medical intervention for those with psychiatric morbidity that required treatment. This is similar to the report of Adeyemi, et al., (1999) which stated that most of the treatment of mental illness is carried out by primary health physicians who identify minor psychiatric illnesses poorly. Under-recognition of minor psychiatric disorders
22 may constitute a huge challenge to the actualisation of early diagnosis and optimal treatment of psychiatric problems like anxiety disorders in HIV/AIDS patients as well.
Diagnosis of Anxiety Disorders
Anxiety is part of a normal life experience when encountering stressful, novel or potentially dangerous situations. Anxiety has two components: psychic anxiety that includes increased arousal, subjective tension, unpleasant affect and fearful apprehension; and somatic anxiety which includes bodily sensations of sweating, dyspnoea, palpitation, pallor and abdominal discomfort. The feeling of anxiety is related to autonomic arousal and cognitive appraisal of threat useful as survival reaction (Semple, et al., 2005).
Anxiety symptoms can occur in the setting of many medical and psychiatric illnesses. In certain medical illnesses, anxiety may be secondary to the symptoms of the physical illness and may sometimes be the first complaint of a patient with a physical illness who is worried that certain symptoms connote a serious illness. On the other hand, anxiety symptoms may directly be due to a physical illness: thyrotoxicosis, phaeochromoyctoma and hypoglycaemia among many others. Similarly, many psychiatric disorders such as depression, schizophrenia, psychoactive substance related disorders among many others may have anxiety symptoms as clinical feature in their modes of clinical presentation. (Gelder, et al., 2001 and Semple, et al., 2005). This usually presents a diagnostic challenge because anxiety symptoms in the setting of physical or psychiatric illnesses may be misdiagnosed as the presence of an anxiety disorder (Gelder, et al., 2001).
Anxiety syndrome is the constellation of autonomic nervous system signs and symptoms accompanying the apprehension of danger and dread. The presence of a constellation of anxiety symptoms has given rise to the syndromic classification of subtypes of anxiety disorders. Generalised anxiety disorder, phobic anxiety disorder, panic anxiety disorder, mixed anxiety and depressive disorder among others have characteristic pattern of group of anxiety symptoms as well as characteristic differences in the time course of anxiety as described in various diagnostic tools (Gelder et al., 2001).
23 Anxiety disorders as diagnostic entity have the aforementioned subtypes of anxiety disorders. In anxiety disorders, mental and physical symptoms of anxiety are the striking features that usually occur first as well as not due to any other psychiatric disorder or organic brain disease. The way to differentiate anxiety disorders from normal anxiety is by the use of the word, ‘’excessive’’ and ‘’difficult to control’’ in the criteria and by the specification that the symptoms should cause significant impairment or distress and must be present for a specified duration (APA, 2002).
A broad spectrum of anxiety symptoms is associated with the diagnosis, onset as well as progression of HIV related illnesses. Symptoms may range from essentially normal anxiety (anxiety about HIV testing or anxiety as a normal health response to HIV diagnosis) to more pronounced and pervasive symptoms that meet criteria for anxiety disorders diagnosis (APA, 2006). The experience of anxiety symptoms by people living with HIV related diseases may cut across all the spectrum of anxiety disorders that include post traumatic stress disorder (PTSD), panic disorder and agoraphobia, social phobia and other phobias, obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD), acute stress disorder, anxiety disorder due to a general medical condition and adjustment disorder with depressed mood (APA, 2002 and Othieno, et al., 2006). HIV related illness and the stages of its progression have been linked with the exacerbation of anxiety symptoms and existing anxiety disorder. These stages of HIV illness, otherwise referred to as ‘‘milestones’’ that are associated with the precipitation or ‘’flaring up’’ of anxiety disorders include initial diagnosis of HIV, first opportunistic infection, death of close HIV positive friends/relatives, decline in CD 4 counts as well as other signs defining a worse progression of the HIV illness. HIV infected individuals can be helped if these ‘milestones’ are used as reference point in the anticipation of the occurrence of anxiety disorder (APA, 2002). The diagnosis of anxiety disorders presents with multiple challenges because anxiety is common and sometimes perceived as normal human emotional experience. This is often more complicated in certain cultures where there are no specific words to describe a disease state of ’anxiety’, as such patients present more often with somatic than mental complaints (Leff, 1981). Another challenge in diagnosing anxiety disorders is the high rate of comorbdity of both anxiety and depressive symptoms in a large number of patients (Gelder, et al., 2001).
24 Appropriate diagnosis of anxiety disorders in HIV positive patients is challenging because a large number of HIV/AIDS patients often present with symptoms that are commonly seen in anxiety disorders. For example, symptoms such as sweating, diarrhoea, and headache that are possible somatic manifestation of anxiety (Wise, et al., 1998) may also represent symptoms of HIV or side effects of the drug treatment of the condition (Savard, et al., 1998 and APA, 2002). Furthermore, HIV patients may present with anxiety symptoms that is secondary to another psychic disorder such as schizophrenia, depression among others. The overlap of these symptoms often makes the diagnosis of existing distinct anxiety disorders challenging. Thus, it is important to take a detailed history of onset, duration, and type of anxiety symptoms as well as specific events, stressors, or medical illnesses causing anxiety. Complete drug and medication history: alcohol, over-the-counter preparations, caffeine, herbals, illicit drugs, and prescription drugs, among many others; physical exam directed towards ruling out organic medical diseases that may present with anxiety (such as cardiovascular, pulmonary, endocrine, and neurological disease) and psychiatric examination is indicated for all patients. The patient’s work and family situation should also be discussed (APA, 2006). Although, there are no laboratory tests that can diagnose anxiety, however the doctor may order some specific tests to rule out other disease conditions.
The aforementioned shortcomings in the diagnosis of anxiety disorders in HIV/AIDS are often improved with the use of standardised interview schedules where the criteria for the diagnosis of anxiety disorders are well spelt out. Screening instruments for detecting states of anxiety as well as psychological distress especially among medical outpatients are commonly used to assess patients for anxiety disorders. Diagnostic criteria from a diagnostic schedule (for example, International classification and Diagnostics schedule (ICD) 10) are used to classify specific psychiatric disorder. (Wrong Diagnosis, 2008). The use of structured clinical interview schedules like Scheduled for Clinical Assessment in Neuropsychiatry (SCAN), Scheduled for clinical interview for DSM IV non-patients (SCID N-P) and modified Hamilton Anxiety Depression Scale (HADS) by physicians have been documented to assist in accurate and reliable diagnosis of anxiety disorders in HIV/AIDS (Savard et al., 1998 and APA, 2002).
25 Epidemiology of Anxiety disorders in HIV related illness. The prevalence rate of anxiety disorders reported among HIV/AIDS patients range between 2-40% (APA 2006). The wide range in the prevalence rate has been linked to multiple factors like methodological issues, sampling techniques as well as psychosocial correlates like social support, presence of co-morbid psychiatric condition like depression/substance use and lastly the illness progression. The increasing life expectance of HIV infected people due to the administration of ARV is reported to have the potential to increase the prevalence of anxiety disorders (Shear, et al., 1995 and APA, 2006). The available studies (APA, 2002 and Grant, et al., 2004) have suggested an increase in the occurrence of symptoms of anxiety and anxiety disorders in HIV positive people compared to the general population. A recent study that assessed the pattern and prevalence of the use of psychotropic medications among HIV patients by Vitiellio, et al (2003) in USA reported that 20.3% of the studied subjects have an anxiety disorder. About 12.3% of the subjects met the criteria for panic disorder while 10.4% and 2.8% prevalence rate was documented for PTSD and generalised anxiety disorder respectively. The Composite International Diagnostic Instrument (CIDI) was used to assess the prevalence of mental health disorders among the HIV/AIDS subjects. The study by Vitiellio, et al., (2003) found a prevalence of anxiety disorders, 20.3% that is similar to the given range reported in the west (APA, 2006) as well as discussed the possible predictors of the pattern of psychotropic use in HIV positive patients. The African American ethnic group and those with co-morbid psychiatric disorders were found to correlate negatively with increased use of psychotropic medications. The study did not describe many of the factors associated with anxiety disorders in HIV/AIDS patient which may be useful in predicting risk of anxiety disorder or help in the recognition of an existing one in such patients. The significance of a high prevalence of anxiety disorders in HIV/AIDS may also be buttressed from the current treatment of HIV/AIDS with highly active antiretroviral therapy (HAART) which makes HIV related illness assume a chronic course. And there are increasing evidences from researches linking an increase in the prevalence of emotional disorders like anxiety disorders with chronic medical illness like hypertension than what obtains in the general population (Rogers, et al., 1994 and
26 Gliatto, 2000). Anxiety disorder has also been implicated to influence the course of medical illness negatively (Shear, et al., 1995).
Factors Associated with Anxiety disorders in HIV/AIDS The factors associated with anxiety disorder in HIV/AIDS patients include psychosocial stressors like stigma, terminal nature of the illness that results in existential concern for HIV/AIDS patients, fear of loss of financial security and changed roles (George, et al., 1989, Katalan, et al., 1989, George, 1996 and Yakassai, 2004). Other factors associated with increased risk of anxiety disorders in HIV illness include poor social support, poor coping strategies, and previous history of abuse - physical, sexual or emotional (APA, 2002). People with positive past psychiatry history as well as family history of anxiety disorder have increased risk of anxiety disorder and the presence of unresolved grief also makes the need for screening for anxiety disorder essential (APA, 2002). The presence of anxiety symptoms and anxiety related disorders have been associated with psychological distress which affects the progression of the HIV disease and can result in poor adherence to ARV (Sternhell, et al., 2002). Factors associated with the anxiety disorder in HIV patients have been reported to affect the disease progression, pattern of use of mental health facility, HAART adherence and the quality of life. HIV patients with limited social support are more likely to develop anxiety symptoms (Anita, et al., 2003 and National Guideline Clearinghouse, 2007).
Psychiatric morbidity and antiretroviral drugs adherence The current pharmacological management of HIV/AIDS is based on the use of multiple drugs to reduce the occurrence of resistance, thus making treatment effective. The use of triple regime is often cumbersome and difficult because of the side effects, thus it is associated with negative implications for drug/treatment adherence. Increasing evidence from research suggests that there is a negative correlation between antiretroviral drug adherence and the presence of co-morbid psychiatric disorders (Angelino, et al., 2001). Sternhall, et al., (2002) found from a survey among patients attending HIV public clinic in Sydney that 45% of the subjects suffered from psychological distress using
27 GHQ-28. The study also reported poorer antiretroviral medication compliance compared to those without psychological distress (Odds ratio 4.5).
Psychological distress and Progression to AIDS Golub, et al., (2003) did a study among HIV seropositive patients who were injection drug users (IDU) in Baltimore where 451 patients were enrolled and followed up between 1998 and 1999. An eleven items questionnaire was administered to screen for recent psychological distress in the patients. The presence of emotional distress was found to be significantly associated with lower CD4 count (<200 cells/mm3) and female gender. The major finding of the study was that psychological distress was significantly associated with more rapid onset of AIDS among intravenous drug users over a 2-year follow-up period. However, psychological distress was not predictive of mortality in this cohort. It was concluded that further study of the effects of psychological distress on the progression of AIDS within this target population is warranted.
Treatment of Anxiety Disorder in HIV/AIDS illness The treatment of anxiety disorders in the setting of HIV related illness is done using three different methods: pharmacological, non-pharmacological as well as combination of both. Each patient is treated individually though. Clinicians need to refer patients to psychiatrists for evaluation and possible ongoing treatment when: the diagnosis of anxiety disorder is difficult; if anxiety symptoms are severe or persistent; when treatment of anxiety symptom fails to respond to standard pharmacological or non-pharmacological treatment modality; and when there is co-morbidity of other disorders (as in substance related disorders) causing a significant distress and impairment of function in patients (Vitiello et al., 2003 and HIV Clinical Resource, 2006).
Non Pharmacological/ Psychological Treatment Supportive and psychological interventions are useful in effectively managing some anxiety symptoms in primary care setting in some patients. Some of the useful supportive intervention includes expressing empathy, educating patients about anxiety, reassuring patients that anxiety is the cause of physical symptoms during panic attack and teaching of relaxation techniques. However, severe anxiety symptoms may
28 require specialised psychotherapeutic or behavioural modification treatment like cognitive behavioural therapy (APA, 2002).
Pharmacological Intervention HIV/AIDS patients are sensitive to psychotropic drugs as such the use of psychotropic medication should be judicious and rational. It is often advisable to start with low dose and increase slowly, based on the symptoms remission. No single medication is enough to treat the spectrum of symptoms in anxiety disorders in HIV patients (APA, 2002). Selective serotonin reuptake inhibitors such as Sertraline and Fluoxetin among many others are commonly used because of good side-effects profile. Other drugs used include buspirone and venlafaxine. These drugs may take 3-6weeks before noticeable remission in symptoms.
Psychiatry and HIV/AIDS in Nigeria The dearth of information on AIDS related neuropsychiatric disorders in African population was reported by Abiodun (1990) following a survey of the available literature on the neuropsychiatric manifestations of HIV globally. Data from Europe and America documented the presence of varieties of psychiatric syndromes such as anxiety disorder, depression, manic illness and schizophreniform disorders in HIV/AIDS patients. Yakassai (2004) reported anxiety related mood disorders in his review of the neuropsychiatric complications of HIV/AIDS in Nigeria. Other neuropsychiatric complications documented in the report include cognitive impairment, AIDS dementia, HIV encephalopathy, delirium, affective disorder, substance use disorder and psychosis. The report did not assess the prevalence of neuropsychiatric disorders such as depression, anxiety disorders and psychosis among others in HIV/AIDS. The rate of psychiatric co-morbidity in HIV/AIDS reported in studies done in Nigeria (Olisah, 2007 and Shehu, 2007) is similar to the findings of Strydom et al (1998) in which a high rate of psychiatric morbidity was documented in South African HIV/AIDS patients. The reasons proffered for such findings in developing countries include psychosocial stressors, poverty and poor medical care among others.
29
CHAPTER THREE
Relevance of Study
The incidence and prevalence figure for HIV/AIDS in Nigeria is high. Also, the diverse psychosocial correlates of HIV as well as other physical complications have impacted adversely on the health care delivery system of the country. Psychiatric morbidity like Anxiety disorders has been well reported to be significantly high in the setting of HIV related illness (Vitiello et al., 2003). However, majority of co-morbid psychiatric conditions in HIV patients are undiagnosed (Judd et al., 1997, Shehu, 2007 and Olisah, 2007). The presence of psychiatric morbidity in HIV has been associated with poor antiretroviral therapy compliance (Olisah, 2007) and impaired quality of life (sherbourne et al., 2000 and Olisah, 2007). Poor ARV adherence often leads to poor viral load control as well as worsening of HIV/AIDS progression. Therefore, prompt diagnosis and treatment of psychiatric disorders are very important in holistic care of HIV/AIDS patients. Studies have suggested a higher rate of occurrence of anxiety symptoms and anxiety disorders in HIV positive patients compared to the general population (APA, 2002 and Grant et al., 2004). Many clinicians that attend to patients at the primary care setting are unaware of the extent and impact of anxiety disorders in HIV related illness. This often leads to poor evaluation of patients and under diagnosis of co- morbid anxiety disorders thus impairing optimal care of HIV/AIDS patients. This is due to dearth of data on anxiety disorders and the description of the associated factors in HIV/AIDS patients in this part of the world. The above mentioned issues present a challenge for the care of HIV/AIDS patients, which invariably makes the role of research on the study topic imperative. This study seeks to examine the prevalence of anxiety disorders and describe the associated factors in HIV subjects attending LUTH outpatient clinic. It is expected that the result of this study will be helpful in evaluating the association between HIV/AIDS and Anxiety disorders, thus adding to the existing information and data on HIV studies which would be useful for setting guideline for the planning and implementation of evidence based integration of mental health into the HIV/AIDS treatment.
30
CHAPTER FOUR
Aims and Objectives of the study
Main Objective The main objective of this study is to determine the prevalence as well as the pattern of anxiety disorders and the description of the associated factors among HIV/AIDS patients attending an outpatient clinic in the Lagos University Teaching Hospital (LUTH).
Specific Objectives To determine the prevalence of Anxiety disorders among the HIV/AIDS patients in the President Emergency Plan for AIDS Relieve (PEPFAR) outpatient clinic in LUTH. To determine the pattern of Anxiety disorders among the HIV/AIDS patients in the PEPFAR outpatient clinic in LUTH. To identify the sociodemographic attributes of HIV/AIDS patients in LUTH. To identify the medical attributes associated with HIV/AIDS patients in LUTH.
Hypothesis Testing Hypothesis to be tested is the null hypothesis that – There is no relationship between Anxiety disorder and HIV/AIDS. That sociodemographic variable is not related to the presence of Anxiety disorders in HIV/AIDS patients.
The null hypothesis will be rejected at P≤ 0.05
31
CHAPTER FIVE
Methodology
Location The study was conducted in the antiretroviral clinic located at the Lagos University Teaching Hospital, Idi-Araba, Lagos. The clinic was started in 1997, when antiretroviral therapy was still at its infantile stage in Nigeria and the need for the care of HIV patients was pressing. At that time, therapy was uncoordinated and there was no governmental support. Clinical services were rendered in the clinic by Consultants in Haematology department. However, because of the impact of the services, a number of drug companies collaborated with Lagos University Teaching Hospital for clinical trials of some of the newer antiretroviral drugs that were in use at the time. The clinical trials involved the use of the following drugs in combinations by Glaxowellcome; Combivir with Amprinavir and Combivir with Nevirapine. Other trial drugs included Saquinavir, Hivid and Efavirenz which took place between 1999 and 2001. By 2001, the antiretroviral clinic in Lagos University Teaching Hospital became one of twenty-five centres designated in Nigeria for conducting clinical trials of some generic antiretroviral drugs (d4T, 3TC and Nevirapine) by the Federal Government of Nigeria. The clinic is situated in the metropolitan city of Lagos. It is fed by patients from all parts of the densely populated Lagos metropolis and renders health service to all categories of HIV/AIDS affected people. The patient load is appreciably large: currently about 4000 Nigerians are enrolled and attendance averages 100 patients per clinic, presumably due to the availability of free as well as effective health care services for HIV/AIDS patients in the facility. Patients usually start arriving as early as 6:30 a.m. to drop their appointment cards for registration by the Records Officer. The tertiary nature of the hospital which affords access to specialist expertise also encourages the patronage of different groups of the populace referred from peripheral medical centres.
32 Study Population The study population was made up of subjects attending the PEPFAR HIV/AIDS outpatient clinic. The criteria for selection are listed below:
Inclusion Criteria Patients with confirmed HIV/AIDS attending clinic on outpatient basis. Patients who consented to the study. Age between 18 to 60years. Literate patients. Exclusion Criteria Age below 18 and above 60years Patients with history of chronic medical condition that is associated with Anxiety symptoms or disorder e.g. thyroid disorder. Patients who are currently using medication that is known to cause Anxiety symptoms e.g. amphetamines, modanifil and thyroxin among others. New patients who are attending the clinic for the first time for investigation. Acutely-ill patients that may require in-patient care.
Sample Size Calculation The sample size was calculated using the formula for calculating sample size in cross sectional studies for population less than 10,000 (Araoye, 2004). The formula for sample size is n= (Z2 Pq/ D2) n=required sample size Z=standard score corresponding to a given confidence level. It is a constant 1.96 D= Precision of the study which is 0.05 P= Known prevalence of condition in the study population q=1-P The prevalence of Anxiety disorders among HIV positive patients in Nigeria was not known from the available literature reviewed. Prevalence rates reported in the literature range from 2-40% (APA, 2002). In a more recent survey Vitiellio et al, (2003) reported 20.3% prevalence rate in South Africa. A prevalence of 20% was used to calculate the sample size.
33 Calculation n= (1.96)2 . 0.23. 0.8/ (0.05)2 =245.9 n=246 Since the study population size, total clinic enrolment was less than 10,000, the final sample size (nf) was obtained after applying the correction factor (Araoye, 2004): nf= n 1+ (n/N) nf=final sample size n=Sample size in a cross-sectional study as obtained above N=estimate of study population =4000 (total number of enrolled patients). nf=246/1+246/4000 =231.75. An additional 10% was added to make room for patients that might be lost to attrition. This was approximately equal to 23 subjects totalling 255. A sample size of 300 was used to make room for poorly filled questionnaires or incomplete data.
Sampling technique The subjects were recruited by systematic sampling of patients that attended the PEPFAR HIV outpatient clinic at the Lagos University Teaching Hospital. This was done on every clinic day by recruiting every 5th patient that met the inclusion criteria who had registered by 8.00 a. m. while waiting for their doctors. The sampling interval of 5 was calculated by dividing the population of interest (40) which is the average number of patients seated by 8a.m. by the sampling size (8) which is the maximum number of patients that could be studied in a day in this case. The first patient was selected randomly from the first 5 patients according to their sitting position and every 5th patient starting from the first was recruited. If he/she failed to meet the criteria the next person that met the criteria was recruited and assessed. On each clinic day, 6-8 patients were interviewed and about 30 in a week. This continued over 4 months until the total number of calculated sample size was completed.
Ethical Consideration Ethical clearance was obtained from the institution by sending the proposal to the ethical committee of the Lagos University Teaching Hospital and the Harvard/ PEPFAR partner. Verbal consent of the patients was sought before their inclusion in the study.
34 Measurement Questionnaire A general assessment questionnaire designed for this study was administered to enquire about the sociodemographic information, medical attributes, HIV/AIDS status of the patients and antiretroviral treatment adherence. Sociodemographic Information The sociodemographic characteristics of each patient were ascertained. This included items like: age, marital status, occupation, educational level, tribe, state of origin, religion and duration of current domicile. Medical attributes of the respondents This included questions to elicit the past psychiatry history with the details of the longitudinal mental disorder suffered by the patients, the characteristics of the episodes suffered and the mode of therapy administered. Mental disorder, especially anxiety disorder occurring before the diagnosis of HIV/AIDS was delineated by asking about the time of onset of symptoms. Other issues for enquiry included family history of mental disorder and the relationship of the participants to the patients with the psychiatric disorder; history of use of psychoactive substance(s) by the patient was determined. The perception of patients and reaction to the disease was enquired about during the interview. Other psychosocial stressors like financial constraints, anticipated alteration in role by the patient and history of chronic medical ailments with its full description if present were ascertained. HIV/AIDS Status Enquiries about HIV status of patients that included pre and post HIV test counselling as well as the time of first diagnosis were made. Antiretroviral therapy adherence This included enquiry about onset of antiretroviral medications, treatment compliance, and reasons for non adherence of antiretroviral therapy that the patient is using as well as the side effects the patient was currently experiencing.
General Health Questionnaire- 12 (GHQ -12) The GHQ was devised by Goldberg (1972) as a self administered screening instrument to aid the detection of non-psychotic psychiatric illness particularly in general practice. It is an instrument that is reliable and has known validity. It consists
35 of 60 items in its original form but shorter version of 30, 20 and 12 are available. GHQ-12 using the bimodal scoring scale (0, 0, 1, 1) was used for this study. A cut - off point of 3 was used. This cut off has been found reliable in this environment (Gureje and Obikoya, 1990).
Schedule for Clinical Assessment in Neuropsychiatry (SCAN) The Scheduled for Clinical Assessment in Neuropsychiatry (SCAN) is the latest version in the development of standardised clinical interview incorporating the present state examination (PSE) by the WHO (1992). It is used to evaluate, classify and measure psychopathology and behaviour in adults. SCAN has four components: 10th edition of present state examination (PSE 10), item group check list (IGC), the clinical history schedule and the glossary of definitions. The PSE 10 section of SCAN was used for this study. It assesses psychiatric disorders like anxiety, dissociative, somatoform, depressive and bipolar disorders as well as alcohol and psychoactive substance use disorders. There is a second section that screen for the presence of Part II items. Part II items include psychotic and cognitive disorders as well as observed abnormalities of behaviour, speech and affect. The core principle of the PSE which was also retained in SCAN is the preservation of the features of clinical examination despite the structured nature of the interview. The interviewer attempts to elicit a comprehensive list of phenomena present within a designated illness episode time frame and rate the degree of severity. The examination involves comparing the described subjective experience of the respondents against glossary description of clinical phenomenon. The elicited phenomena are used to generate ICD 10 diagnosis through the use of SCAN computer soft ware. The SCAN has the advantage of providing comprehensive description and reliable classification of psychiatric phenomenon. Training The author was trained and certified for the use of SCAN during the special training organised by the Faculty of Psychiatry of the National Postgraduate Medical College in Lagos, Nigeria from 10-14th December, 2007. Pilot Study A Pilot study was carried out randomly on 15 subjects who met the inclusion criteria. This was carried out to determine the clarity or ambiguity, acceptability of the items
36 in the questionnaire and to determine the average time needed to administer them. These subjects were excluded from the main study.
Study Design and Data Collection The study is cross sectional and descriptive in nature. Data collection was done over a period of four months with the cooperation and understanding of the consultants in charge of the PEPFAR HIV clinic. A brief assessment to ascertain if patients met the inclusion criteria for the study was conducted. The questionnaire designed for the study was administered to all recruited patients after obtaining informed consent from them. Information on the aims and objectives of the study and assurance about the confidentiality of information were given to the patients. This was followed by the administration of GHQ-12 to screen the recruited patients. All patients who met the cut-off score of 3 in the screening test with GHQ-12 were interviewed with the SCAN. Ten percent (10%) of the sample size from subjects who did not meet the cut-off score of 3 when screened with GHQ-12 were interviewed with SCAN to increase the yield probability. The subjects were interviewed with PSE 10 section 1 (Beginning the interview), section 3 (Worrying, tension) and section 4 (Panic, anxiety, and phobias) of the interview schedule version of SCAN. Relevant parts of sections 6 (Depressed mood and ideation), section 7 (Thinking, concentration, energy and interest) and section 9 were used to rate the presence of both anxiety and depressive symptoms in patients where they coexisted. The data collected was fed into the computer SCAN software to generate an ICD 10 diagnosis.
Data Analysis All data collected were coded and entered into the computer for analysis. Data was analysed using the statistical package for social sciences (SPSS) for windows Version 15.0. Descriptive statistics like means, frequencies and percentages were used to analyse the data. Student t-test, chi square and other relevant tests were used to ascertain the association and correlation between the variables. The level of significance was set at 5% confidence limit.
37 CHAPTER SIX
Results A total of 300 subjects took part in the study. Sociodemographic data was obtained from responses to the sociodemographic questionnaire.
Sociodemographic Characteristics of Subjects The sociodemographic characteristics of the subjects are shown in table 1. Out of the 300 subjects who participated in the study, 115 (38.3%) subjects were males and 185 (61.7%) were females. The median age of the subjects was 37years, while the mean age for all the subjects was 36.95 (±8.73) years. The majority of subjects, 120 (40%) belonged to the age group of 31 to 40 years while only 5 (1.7%) subjects belonged to the age group of 20 years and below. The majority of subjects (53.7%) were married, 10% were separated and only 2% were divorced. Majority of the subjects 238 (79.3%) were Christians. In terms of education, 143 (47.7%) subjects had secondary school education, 90 (30%) had tertiary education and only 10 (3.3%) had postgraduate education. The largest proportion of the subjects with employment (34%) had semi-skilled jobs, only 0.3% was retired while 25.7% were unemployed. The mean duration of time lived in current domicile was 115.3 (±105.1) months. The largest proportion of the subjects 123 (41%) reported that they have been living in their current domicile for a period of 1-5years; while only 15 (5%) subjects have been living in their current domicile for less than 1year.
38
Table 1: Sociodemographic characteristics of subjects Variable value Frequency (n) Percentage (%) Mean(±SD)
Age (Years) ≤ 20 5 1.7 36.95(±8.73) 21-30 72 24.0 31-40 120 40.0 41-50 79 26.3 51-60 24 8.0 Total 300 100.0
Sex Male 115 38.3 Female 185 61.7 Total 300 100.0
Marital status Single 63 21.0 Married 161 53.7 Separated 30 10.0 Divorced 6 2.0 Widowed 40 13.3 Total 300 100.0
Religion Christianity 238 79.3 Islam 62 20.7 Total 300 100.0
Education Primary 57 19.0 Secondary 143 47.7 Tertiary 90 30.0 Postgraduate 10 3.3 Total 300 100.0
Occupational status Unemployed 77 25.7 Unskilled 18 6.0 Petty trader 55 18.3 Semi-skilled 102 34.0 Highly skilled 47 15.7 Retired 1 0.3 Total 300 100.0
Duration in current domicile (Years) <1 15 5.0 115(±105.1) 1-5 123 41.0 6-10 63 21.0 >10 99 33.0 Total 300 100.0
39 HIV/AIDS Treatment Related Characteristics of Subjects Table 2 shows the HIV/AIDS treatment related characteristics of the subjects. The largest proportion of the subjects, 174 (58%) had HIV test counselling and a substantial proportion of the subjects (32.0%) had both pre and post-test HIV counselling, 13.3% had only pre-test HIV counselling while 12.7 % had post-test HIV counselling only. The mean duration of HIV disease was 45.7 (±33.7) months. Ninety seven (32.3%) subjects had HIV disease for a period of less than 24 months, and only 5.7% of the subjects interviewed had HIV disease for a period that is more than 95 months. The largest proportion of the subjects (23.3%) had been on Highly Active Antiretroviral Therapy (HAART) for between 12 months and less than 24 months while 21.7% had been on treatment for less than 12 months and only 9.7% had been on treatment for more than 71 months. The mean duration of HAART treatment was 34.7 (±28.3) months. In terms of family support, 192 (64%) subjects were supported by their family members.
40
Table 2: HIV treatment related characteristics of subjects Variable value Frequency (n) Percentage (%) Mean(±SD)
HIV test counselling Pre-test 40 13.3 Post-test 38 12.7 Both 96 32.0 None 126 42.0 TOTAL 300 100.0
Duration of HIV disease (Months) < 24 97 32.3 45.7(±33.7) 24-47 87 29.0 48-71 63 21.0 72-95 36 12.0 > 95 17 5.7 TOTAL 300 100.0
Duration of HAART treatment (Months) < 12 65 12.7 34.7(±28.3) 12-23 70 23.3 24-35 53 17.7 36-47 43 14.3 48-59 16 5.3 60-71 24 8.0 > 71 29 9.7 TOTAL 300 100.0
Family support Financial 55 18.3 Emotional 38 12.7 Both 99 33.0 None 108 36.0 TOTAL 300 100.0
41 History of other medical problems in subjects The clinical characteristics of the subjects in respect of other medical problems are shown in table 3. Only twelve (4%) subjects had positive history of past mental illness and majority of the subjects (91%) had no family history of mental illness. Ninety-three (31%) subjects had positive history of psychoactive substance use and eighty-nine (29.7%) subjects had a positive history of other medical illnesses.
Table 3: History of other medical problems in subjects Variable value Frequency (n) Percentage (%)
Past history of psychiatric illness Yes 12 4.0 No 288 96.0 TOTAL 300 100.0
Family history of mental illness Yes 27 9.0 No 273 91.0 TOTAL 300 100.0
History of psychoactive substance use Yes 93 31.0 No 207 69.0 TOTAL 300 100.0
History of other medical illness in subjects Yes 89 29.7 No 211 70.3 TOTAL 300 100.0
42 GHQ Score and Prevalence of Anxiety Disorders among HIV/AIDS patients Table 4 shows the GHQ score and diagnosis of Anxiety disorders in subjects. Ninety (30.0%) subjects had GHQ score of 3 and above (cases) while two hundred and ten (70.0%) subjects had GHQ score that was less than 3 (non cases). Sixty five (21.7%) subjects were diagnosed with Anxiety disorders based on SCAN while two hundred and thirty five (78.3%) subjects had no Anxiety disorders. The prevalence rate of Anxiety disorders was 21.7% and the positive predictive value of GHQ 12 was 0.6 while the negative predictive value was 0.961. The kappa score and calculated accuracy were found to be 0.647 and 0.86 respectively.
Table 4: GHQ Score and Diagnosis of Anxiety disorders by SCAN GHQ score SCAN Diagnosis Anxiety disorders No Anxiety disorders N (%) N (%) Total Cases (GHQ≥3) 57(19.0) 33 (11.0) 90(30.0)
None cases 8(2.7) 202(67.3) 210(70.0) (GHQ <3 )
TOTAL 65(21.7) 235(78.3) 300(100)
43 Types of Anxiety Disorders in HIV positive subjects Table 5 shows the types of anxiety disorders in HIV subjects in this sample. The largest proportion (6%) of subjects with Anxiety disorders had Anxiety disorders unspecified while sixteen (5.3%) subjects had mixed anxiety and depressive disorder and one (0.3%) subject had obsessive and compulsive disorder.
Table 5: Types of Anxiety disorders in HIV subjects Types of Anxiety Frequency (n) Percentages (%) Cumulative percent disorders (%) Agoraphobia 2 0.7 0.7 Social phobia 12 4.0 4.7 Specific phobia 5 1.7 6.3 Panic disorder 5 1.7 8.0 Generalise Anxiety disorder 4 1.3 9.3 Mixed Anxiety and Depressive disorder 16 5.3 14.7 Anxiety disorders unspecified 18 6.0 20.7 Phobic anxiety disorder unspecified 2 0.7 21.4 Obsessive compulsive disorders 1 0.3 21.7 No Anxiety disorders 235 78.3 100.0
Total 300 100.0
44
Socio-demographic attributes of Subjects with and without Anxiety disorders Table 6 depicts the socio-demographic characteristics of subjects with and without anxiety disorders. Majority of the subjects (67.7%) diagnosed with Anxiety disorders were females. Subjects with no diagnosis of Anxiety disorders had a preponderance of female 141 (60%) as well. There was no significant difference in sex distribution between subjects with and without Anxiety disorders (X2 =1.275, df=1, p value =0.259).
The largest proportion of subjects (36.9% and 40.9%) with and without Anxiety disorders respectively belonged to the age range of 31 to 40years, while only 3.1% belonged to the age group of less than 20 years. The age range 21-30 years was over represented among the subjects with Anxiety disorders compared to those without Anxiety disorders.
The largest proportion of the subjects (36.9%) with Anxiety disorders and subjects (58.3%) with no anxiety disorders were married. There was statistical significance with respect to difference in marital status between subjects with and without Anxiety disorders (X2=12.21, df=4, p=0.016). Thirty (46.2%) subjects with Anxiety disorders compared to (48.1%) subjects with no Anxiety disorders had secondary school education. There was no significant difference in educational status between subjects with and without Anxiety disorders statistically (X2= 2.738, df=3, p=0.434).
The largest proportion 27(41.5%) of subjects with Anxiety disorders were unemployed, seventeen (26.2%) were engaged in semi-skilled jobs. On the other hand, eighty five (36.2%) of the subjects with no Anxiety disorders were semi-skilled, while fifty (21.3%) were unemployed and one (0.4%) was retired. There was significant difference in the employment status between subjects with and without Anxiety disorders statistically (X2=13.074, df=5, p=0.023).
45
Table 6: Sociodemographic characteristics of subjects with and without Anxiety disorders
Variable Anxiety disorders No Anxiety disorders Total Value N (%) N (%) N (%) X2 df p-value
Age (Years) ≤20 2(3.1) 3(1.3) 5(1.7) - - - 21-30 22(33.8) 50(21.3) 72(24.0) 31-40 24(36.9) 96(40.9) 120(40.0) 41-50 12(18.5) 67(28.5) 79(26.3) 51-60 5(7.7) 19(8.1) 24(8.0)
Sex Male 21(32.3) 94(40.0) 115(38.3) 1.275 1 0.259 Female 44(67.7) 141(60.0) 185(61.7)
Religion Christianity 51(78.5) 187(79.6) 238(79.3) 0.038 1 0.845 Islam 14(21.5) 48(20.4) 62(20.7)
Marital status Single 17(26.2) 46(19.6) 63(21.0) 12.21 4 0.016 Married 24(36.9) 137(58.3) 161(53.7) Separated 12(18.5) 18(7.7) 30(10.0) Divorced 1(1.5) 5(2.1) 6(2.0) Widowed 11(16.9) 29(12.3) 40(13.3)
Educational status Primary 10(15.4) 47(20.0) 57(19.0) 2.738 3 0.434 Secondary 30(46.2) 113(48.1) 143(47.7) Tertiary 24(36.8) 66(28.1) 90(30.0) Postgraduate 1(1.5) 9(3.8) 10(3.3)
Type of Employment Unemployed 27(41.5) 50(21.3) 77(25.7) 13.074 5 0.023 Unskilled 1(1.5) 17(7.2) 18(6.0) Petty trader 10(15.4) 45(19.1) 55(18.3) Semiskilled 17(26.2) 85(36.2) 102(34.0) Highly skilled 10(15.4) 37(15.7) 47(15.7) Retired 0(0.0) 1(0.4) 1(0.3)
Duration in current domicile (Years) < 1 3(4.6) 12(5.1) 15(5.0) - - - 1-5 26(40.0) 97(41.3) 123(41.0) 6-10 15(23.1) 48(20.4) 63(21.0) > 10 21(32.3) 78(33.2) 99(33.0)
46 Medical attributes of Subjects with and without Anxiety disorders Table 7 depicts the medical attributes of subjects with and without Anxiety disorders.
Thirty three (50.8%) subjects with Anxiety disorders had HIV counselling. Majority of the subjects with Anxiety disorders that had HIV counselling (63.6%) had both pre and post HIV test counselling. On the other hand, one hundred and forty one (60%) subjects with no Anxiety disorders had HIV counselling. HIV counselling was not significantly different between those with and without anxiety disorders (X2 =1.781, df=1, p value =0.182).
Twenty nine (44.6%) subjects with Anxiety disorders had family support while thirty- six (55.4%) had no family support. Majority of subjects with Anxiety disorders who had family support (27.7%) had both financial and emotional support. On the other hand, majority of the subjects (34.5%) with no Anxiety disorders who had family support also had both financial and emotional support. Family support was significantly different between the subjects with and without anxiety disorders (X2=13.533, df=1, p value =0.000).
Twenty five (38.5%) subjects with Anxiety disorders belonged to the group with HIV disease duration of 0 to 23 months while one (1.5%) subject belonged to the group with HIV disease duration of greater than 120 months. On the other hand, seventy- three (31.3%) subjects without Anxiety disorders belonged to the group with HIV disease duration of 24 to 47 months while six (2.4%) subjects belonged to the group with HIV disease duration of greater than 120 months.
Majority of the subjects with Anxiety disorders (32.3%) belonged to the group that has been on HAART treatment for less than 12 months and only 3.1% has been on treatment for 48 to 59 months. On the other hand, majority of subjects with no Anxiety disorders (24.7%) belonged to the group that had been on treatment for 12 to 23 months.
Three (4.6%) subjects with positive history of psychiatric illness had anxiety disorders while nine (3.8%) subjects with no anxiety disorders had positive history of past psychiatric illness. Seven (10.8%) subjects with anxiety disorders had positive family
47 history of mental illness while on the other hand, majority of the subjects with no Anxiety disorders, two hundred and fifteen (91.5%) had no family history of mental illness. Twenty three (35.4%) subjects with Anxiety disorders had positive history of medical illness while sixty-six (28.1%) subjects with no Anxiety disorders had a positive history of medical illness. There was no significant difference in the positive history of psychiatric illness (X2=0.082, df=1, p-value =0.775), family history of mental illness (X2=0.317, df=1 p-value =0.573) and positive history of medical illness (X2=1.300, df=1, p value =.254) between subjects with and without anxiety disorders.
48 Table 7: Medical attributes of Subjects with and without Anxiety disorders
Variable Anxiety disorders No Anxiety disorders Total Value N (%) N (%) N (%) X2 df p-value
HIV counselling Yes 33(50.8) 141(60.0) 174(58.0) 1.781 1 0.182 No 32(49.2) 94(40.0) 126(42.0)
Family support Yes 29(44.6) 163(69.4) 192(64.0) 13.533 1 0.000 No 36(55.4) 72(30.6) 108(36.0)
Types of family support Financial 8(12.3) 47(20.0) 55(18.3) 15.259 3 0.000 Emotional 3(4.6) 35(14.9) 38(12.7) Both 18(27.7) 81(34.5) 99(33.0) None 36(55.4) 72(30.6) 108(36.0)
Duration of HIV disease (Months) ≤23 25(38.5) 72(30.6) 97(32.3) - - - 24-47 14(21.5) 73(31.1) 87(29.0) 48-71 19(29.2) 44(18.7) 63(21.0) 72-95 4(6.2) 32(13.6) 36(12.0) 96-119 2(3.1) 8(3.4) 10(3.3) ≥120 1(1.5) 6(2.6) 7(2.3)
Duration of HAART treatment (Months) < 12 21(32.3) 44(18.7) 65(21.7) - - - 12-23 12(18.5) 58(24.7) 70(23.3) 24-35 9(13.8) 44(18.7) 53(17.7) 36-47 10(15.4) 33(14.0) 43(14.3) 48-59 2(3.1) 14(6.0) 16(5.3) 60-71 7(10.8) 17(7.2) 24(8.0) > 71 4(6.2) 25(10.6) 29(9.7)
History of past psychiatric illness Yes 3(4.6) 9(3.8) 12(4.0) 0.082 1 0.775 No 62(95.4) 226(96.2) 228(96.0)
Family history of mental illness Yes 7(10.8) 20(8.5) 27(9.0) 0.317 1 0.573 No 58(89.2) 215(91.5) 273(91.0)
History of medical illness Yes 23(35.4) 66(28.1) 89(29.7) 1.300 1 0.254 No 42(64.6) 169(71.9) 211(70.3)
49 Mean values of some variables in Subjects with and without Anxiety disorders
Table 8 shows the mean values of some variables and result of t-test among subjects.
The mean age of subjects with Anxiety disorders was 34.96 (±9.08) years, while the mean age of subjects with no Anxiety disorders was 37.5 (±8.58) years. There was a statistical difference between the mean ages of subjects with and without anxiety disorders (t-test =2.080, df=298, p value= 0.038)
The mean duration in current domicile for subjects with Anxiety disorders was 112.4 (±112.9) months, while the mean of duration in current domicile for subjects with no Anxiety disorders was 116.1(±103.0) months. The mean duration in current domicile was not significantly different between subjects with and without Anxiety disorders (t-test= 0.254, df=298, p value =0.8)
The mean duration of HIV disease in subjects with Anxiety disorders was 41.9 (±30.25) months while the mean duration of HIV disease in subjects with no Anxiety disorders was 46.7 (±34.6) months. There was no significant difference with respect to the mean duration of HIV disease between subjects with and without anxiety disorders (t-test=1.026, df=298, p value = 0.306).
The mean duration of treatment for subjects with anxiety disorders was 30.7 (±26.01) months while the mean duration of HAART treatment in subjects without Anxiety disorders was 35.9 (±28.9) months. There was no significant difference in the mean duration of treatment between subjects with and without anxiety disorders (t-test= 1.304, df=298, p- value = 0.193).
50 Table 8: Mean values of some sociodemographic and medical variables in subjects with and without Anxiety disorders
Variable Anxiety disorders No Anxiety disorders (Mean±SD) (Mean±SD) T-test df p-value
Age (Years) (34.96 ±9.08) (37.5 ±8.58) 2.080 298 0.038
Duration in current Domicile (Months) (112.4±112.9) (116.1±103.0) 0.254 298 0.8
Duration of HIV Disease (Months) (41.9±30.25) (46.7±34.6) 1.026 298 0.306
Duration of HAART Treatment (Months) (30.7±26.01) (35.9±28.9) 1.304 298 0.193
Logistic Regression of factors associated with Anxiety disorders
Table 9 shows the logistic regression analysis of factors associated with Anxiety disorders in HIV subjects. When the variables (family support, employment status and marital status) that were significantly associated statistically (p-value <0.05) with Anxiety disorders in HIV positive subjects were entered into the logistic regression analysis, only family support and employment status were still significantly predictive of Anxiety disorders in HIV patients (family support OR=0.396, 95% CI=0.223-0.705, p-value=.002 and employment status OR=0.469, 95% CI=0.256-0.858, p-value=0.014) (Table 9).
51 Table 9: Logistic regression of factors associated with anxiety disorders in HIV positive subjects
Variable ß Value Coefficient S.E df p-value Odds Ratio 95.0% C I
Marital status -0.099 0.115 1 0.390 0.906 0.723- 1.135
Employment -0.758 0.309 1 0.014 0.469 0.256- 0.858
Family support -0.925 0.293 1 0.002 0.396 0.223- 0.705
Constant 3.829 0.649 1 0.000 46.018 - -
S. E=Standard error, C I = Confidence interval
52 CHAPTER SIX
Discussion
Sociodemographic Variables of HIV subjects
A predominance of female gender (61.7%) among patients with HIV/AIDS was found in the study location. This is consistent with UNAIDS (2008) global report on HIV/AIDS which stated that women in sub-Saharan Africa account for about two third (60%) of HIV infections. In this study, possible explanations for the preponderance of female gender include the fact that women, especially of child bearing age are likely to have their HIV disease detected at antenatal routine screening or when their children develop HIV associated illnesses shortly after birth. Similar finding of female gender preponderance was reported by Olley et al., (2003) and Olisah (2007) in their studies among HIV positive adults in hospital settings in South Africa and Nigeria respectively. However, some other studies reported male gender preponderance among adults attending HIV clinic in a teaching hospital setting in Maiduguri located in northern Nigeria (Iliyasu et al., 2004 and Shehu, 2007). The observed male preponderance by Iliyasu et al., (2004) was explained by citing economic selection factor, because men have economic advantage over women thus more male received treatment compared to females. The observed sex distribution in favour of male compared to female in the aforementioned studies was also adjudged to be a reflection of the composition of patients attending HIV clinic in the study locations as well as the fact that religious practice of ‘pudah’ that restricts married women from public places like hospitals may allow more males to be seen.
The mean age of the study population was 36.95 (±8.73) years and the largest proportion of subjects was in the age range of 31 to 40 years (40%). The possible explanation for this is that people are most sexually active between the ages of 18 to 25 years (UNAIDS, 2008) and are more likely to be infected by HIV during this period. However, most patients will have symptoms about 10 to 12 years after initial infection, thus most patients will need medical attention around 30 years of age (Iliyasu, et al., 2004). Esan et al., (1999) and Shehu, (2007) also observed that the largest proportion of their subjects belonged to the age range of 31 to 40 years. Olley
53 et al., (2003) documented a mean age of 33.56 (±7.52) years among HIV positive adults.
Majority of the subjects were married (53.7%). This is similar to observations in previous studies by Olley et al., (2003), Boardman et al., (2005) and Olisah, (2007) who noted that, their study subjects were predominantly married. This observation may be due to the fact that the studies were carried out among adult HIV/AIDS patients who were more likely to be married.
The subjects were predominantly of the Christian faith (79.3%). The reason for this is because of the location of the study in south western part of Nigeria where Christian religion is popular (Matthews, 1999). Also, a large number of faith based non- governmental organisations with HIV focused programs are coordinated by several churches in Lagos. As such the presentation of HIV positive patients for treatment in HIV clinics in the study location may be enhanced among subjects practising Christian faith.
The largest proportion of the subjects (34%) in this study had semi-skilled jobs. The reason for this may not be unconnected with the attractiveness of the treatment centre (free antiretroviral drugs). About a quarter of the subjects (25.7%) were unemployed. This is in keeping with the findings of many studies (Olley et al., 2003 and Boardman et al., 2005) where significant number of HIV subjects was noted to be unemployed. Stigmatisation associated with HIV/AIDS as well as job loss due to incapacitation due to HIV illness have been reported as possible explanations for high rate of unemployment among HIV patients (Olley et al., 2003).
HIV/AIDS treatment related variables of HIV/AIDS subjects
Majority of the subjects had HIV test counselling (58%), and majority of them had both pre and post HIV test counselling. The reason for majority of the subjects undergoing HIV test counselling was due to the fact that HIV test counselling is a standard procedure before HIV infection screening. However, it was observed that it was not all the subjects that had HIV test counselling due to the fact that some of the
54 patients were diagnosed in peripheral health facilities where HIV test counselling was not done routinely before and after screening.
The mean duration of HIV disease and treatment was 45.7 (±33.7) and 34.7 (± 28.3) months respectively. The observed difference between the mean duration of HIV disease and HAART treatment can be explained by the fact that the commencement of HAART starts when the treatment initiation criteria are met and not just when HIV seropositive diagnosis is made. The observation in this study is different from the findings by Olisah, (2007) among subjects with HIV in a teaching hospital in Zaria where the mean durations of HIV disease and treatment were observed to be 26.53 and 17.67 months respectively. The aforementioned difference may be a reflection of the difference in rate of deaths of HIV patients between the two study locations as well as the difference in the time of inception of HIV clinic attendance between the study locations. Sebit et al., (2003) observed that 74% of their subjects had illness duration of less than 60 months and a longer duration of HIV illness compared to the observation in this study. The reason for the short duration of illness and treatment for majority of the patients in our study may be a reflection of the current effort at promoting public awareness about HIV/AIDS, voluntary test counselling and free antiretroviral treatment for people with HIV infection.
GHQ Score and Prevalence of Anxiety disorders in Subjects A proportion of the subjects (30%) had probable psychiatric morbidity defined by GHQ-12 score of 3 or greater. HIV/AIDS has been associated with significant psychological distress (Golub, et al., 2003) and reported to cause significant distress in HIV positive than in the general population (Israelski, et al., 2007). This study found a preponderance of females over males (41.6% to 36.5%) to be GHQ cases. This is in keeping with other studies where female gender was observed to be significantly associated with psychological disorders (Campos, 2006).
Sixty-five (21.7%) subjects had Anxiety disorders based on SCAN interview schedule. The observed prevalence of Anxiety disorders in the present study is in keeping with the given range of 2-40% noted by APA, (2006); Campos, et al., (2006) as well as Vitiello, et al., (2003) among HIV/AIDS patients. HIV/AIDS has been reported to be significantly associated with increased psychiatric morbidity compared to the general
55 population. The study observed 6% and 5.3% of the subjects to have anxiety disorders unspecified and mixed anxiety and depressive disorders respectively. Social phobia was also found in (4%) of HIV positive subjects. This is in keeping with other studies (Morrison et al., 2002, Pence et al., 2006 and Adewuya et al., 2007) where the occurrence of similar types of Anxiety disorders were documented to be common among HIV positive subjects. The possible reason for the presence of Anxiety disorders among HIV patients include the neurotropic nature of the virus (Semple et al., 2005) and the stress associated with living with an illness associated with stigma, unemployment (Yakassai, 2004), poor family support, death of partner (APA, 2002) and changed roles (Katalan, et al., 1989).
Patients in Africa have been reported to be at greater risk for developing psychopathology than patients living in developed countries (Eaton et al., 2003). Reasons given for the potential high psychiatric morbidity include potential stressful living conditions, poverty, inadequate housing, high rates of unemployment, poor housing, domestic violence and high crime rates (Eaton et al., 2003). The reason for the observed lower prevalence rate of Anxiety disorders in the study compared to some of the cited studies may be due to methodological issues like sampling, study design, diagnostic instrument used, time of assessment in relation to receiving HIV diagnosis (AIDS, 2006) and the fact that some cultures do not have words to describe anxious state.
The statistical accuracy, positive and negative predictive values of GHQ-12 in this study were 0.86, 0.6 and 0.9 respectively. This is in keeping with the observations of many studies that have reported its good psychometric property as a screening tool for detecting probable psychiatric morbidity in general practice (Gureje and Obikoya., 1999).
Socio-demographic attributes of Subjects with and without Anxiety disorders The study found a predominance of females (67.7%) compared to males (32.3%) to have Anxiety disorders with a sex ratio of 2:1. On the other hand, HIV subjects without anxiety disorders also had a female preponderance, however, with a sex ratio of 1.5:1. The relative proportion of females and males with anxiety disorders to those without anxiety disorders are 1.12:1 and 0.81:1 respectively.
56
The explanation for the observed female preponderance among HIV/AIDS patients with Anxiety disorders includes the fact that females may take health issues more seriously thus seek health care early and admit to emotional symptoms readily. It seems to reflect more of the sex distribution of the sample of subjects in the study with a female preponderance. This study observed the predominance of subjects with Anxiety disorders to be married (36.9%). Marriage is often said to be a protective factor for psychiatric morbidity (Semple et al., 2005). However, the psychosocial stress associated with living with HIV/AIDS due to stigmatisation, changed role, loss of close family members and frequently falling ill may overwhelm the protective cover of being married.
A significant proportion (40%) of subjects with Anxiety disorders was unemployed. This is in keeping with the observation in other studies where unemployment had been noted to be a common psychosocial complication of HIV/AIDS (Olley, et al., 2003). However, this study is at variance with the findings of Olisah, (2007), where majority of HIV subjects were highly skilled. The reason for this observation may be the reflection of the location of the study especially because Lagos is a cosmopolitan city where there is high turn over of labour force due to rural urban migration thus making replacement of expertise much easier. This may also be due to the fact that poor people and those with financial constraint are more likely to patronise treatment in this facility because it is free. Unemployment status was significantly associated with the diagnosis of Anxiety disorders (X2 = 8.543, df= 1, p-value =0.004).
A large proportion (55.4%) of the subjects with Anxiety disorders did not have family support. This is in keeping with the findings of Adewuya et al., (2007) who observed that psychiatric disorders in HIV positive population in Nigeria was associated with poor social support. This observation may be a reflection of the impact of stigmatisation against people living with HIV/AIDS from their family and the fact that HIV infected people may not readily disclose their HIV status to relatives in order to receive psychosocial support. Lack of family support was found to be associated significantly with the diagnosis of Anxiety disorders (X2 = 13.533, df =1, p- value =.000).
57
The logistic regression analysis showed that lack of family support and unemployment status were the significant predictors of anxiety disorders in subjects. This observation is not surprising because the absence of social support and loss of source of livelihood are significant life events that can lead to significant stress as well as constitute risk factors for developing anxiety disorders.
58 CHAPTER SEVEN
Conclusion
Based on the findings from this study, the following conclusions were noted: Anxiety disorders are commonly encountered in people living with HIV/AIDS and the prevalence rate is higher than the prevalence rate reported in studies done among the general population.
A larger proportion of subjects with Anxiety disorders were found to be female and married. Majority of HIV subjects with anxiety disorders had illness duration of less than 24months and had been on treatment for only 12months. There was significant difference in the mean age of HIV positive subjects with Anxiety disorders compare with those without Anxiety disorders.
Social problems like unemployment status and lack of family support were significantly associated with, and were significant predictors of Anxiety disorders in HIV/AIDS subjects.
59 CHAPTER EIGHT
Limitations of the Study
The study location was among people living with HIV/AIDS attending clinic at the Lagos University Teaching Hospital, Lagos. It is a hospital based study among literate patients, thus the observations may not depict the state of the entire people living with HIV/AIDS in the general population.
Also, the nature of patients attending the HIV clinic may have been determined by factors like: free clinical services and treatment, stigmatisation and the perception of the public that tertiary health institution is associated with lots of bottle necks in terms of the process of registration as well as high mortality.
Recommendations
Physicians involved in the care of people living with HIV/AIDS should always assess for the presence of psychiatric morbidity especially Anxiety disorders. Training and provision of screening instruments for psychiatric morbidity to enhance identification of cases should be provided in HIV clinics. The management of psychosocial problems in HIV subjects should be integrated into HIV interventions.
There is need to put in place ethical and educational mechanisms that would facilitate the practice of pre and post HIV test counselling in all health facilities.
The integration of mental health services as well as involvement of Psychiatrists in the management of HIV/AIDS at all levels of care, research and education are needed.
There is need for more research in the field of neuropsychiatric aspect of HIV/AIDS in order to promote evidence based clinical practice.
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42. Kaplan H., Sadock B., (2003) Synopsis of Psychiatry (Ninth edition) published by Lippincott Williams and Wilkins pg 371-379 43. Katalan J et al (1989) HIV disease and psychiatry practice Psychiatric Bulletin; 13: 316 – 322. 44. Kwong PD, Wyatt R, Robinson R, Sweet RW, Sodrosky J, Hendrickson WA., (1998) Structure of an HIV gp120 envelope glycoprotein: Complex with the CD4 receptor and a neutralizing human antibody. Nature; 393(6686):648-59 45. Leff, J. (1981) Psychiatry around the globe: a transcultural view. Dekker, New York 46. Martinson JJ, Chapman NH, Rees DC, Liu YT, Clegg JB, (1997) Global distribution of the CCR5 gene 32-basepair deletion. National Genetics; 16(1):100-3 47. McCarthy GM, Ssali CS, Bednarsh H, Jorge J, Wangrangsimakul K, Page- Shafer K (2002) Transmission of HIV in the dental clinic and elsewhere. Oral Diseases, (8)2: 126-135. 48. Meel BL (2003) Suicide and HIV/AIDS in Transkei, South Africa. South Africa Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology,2003;(4)1 http://www.geradts.com/anil/ij/vol_004_no_001/papers/paper001.html;
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66 Questionnaire
Hospital No: Date of Interview……………………
Section 1 Instruction: Please tick the appropriate response
1. Age …………………… 2. Sex (1) Male ( ) (2) Female ( )
3. Marital status :( 1) Single ( ) (2) Married ( ) (3) Separated ( ) (4) Divorced ( ) (5) Widowed ( )
4. Type of marriage: monogamy ( ) Polygamy ( )
5. What is your highest level of Education? (1) None ( ) (2) Primary ( )
(3) Secondary ( ) (4) Tertiary ( ) (5) Postgraduate ( )
6. Religion (1) Christianity ( ) (2) Islam ( ) (3) Others ( )
7. Tribe (1) Yoruba ( ) (2) Hausa ( ) (3) Igbo ( ) (4) Others ( )
Specify…………. 8. State of origin: Lagos ( ) others ( ) specify…….
9. Current domicile Duration (a) <1yrs ( )
b) 1-5 years ( ) c) 5-10yrs ( ) d) >10yrs ( )
10. Are you currently employed (1) Yes ( ) (2) No ( )
11. Occupation…………………..… Specify reason(s) for any change in job
Section 2
12. Any family history of mental illness? Yes ( ) No ( ) Type ……………..
13. Any history of psychoactive substance use? Yes ( ) No ( )
14. Any family support? Yes ( ) No ( ) what type? (1) Financial ( )
(2) Emotional ( ) (3) others …………………………………….
67 Section 3 15. When did you find out you are HIV positive? ……………………………….... 16. Any pre HIV test counselling? Yes ( ) No ( ), any post HIV test counselling? Yes ( ) No ( ) 17. Can you describe your feelings after the result of your test……………………. 18. What was your family reaction when they learnt about the illness? (1) Supportive ( ) (2) Unsupportive ( ) 19. Any change in role since the onset of the illness? Yes ( ) No ( ) Describe …………………………….. 20. When did you start antiretroviral treatment? …………………………………... 21. Which antiretroviral drugs are you using …………………………………… 22. Do you have any other chronic medical illness? (1) Hypertensive ( ) (2) Diabetes ( ) (2) Asthmatic ( ) (3) Others ( )
Section 4 23. Do you get regular supply of antiretroviral drugs? (1) Yes ( ) (2) No ( )
24. If response to no. 23 above is No, why? (1) No money ( ) (2) Drugs not available ( ) (3) Poor follow-up attendance ( )
25. How many times did you not use the medication in the past one week? (1) Once ( ) (2) Twice ( ) (3) Thrice ( ) (4) more than 3 times ( ) (5) Nil ( )
26. Why did you miss the dose/doses? (1) Forgot ( ) (2) drug not available ( )
(3) I got tired of them ( ) (4) Side effects ( ) (5) others specify ( )
27. How many pills did you not take on time as schedule in the past one week? (1) None ( ) (2) Few ( ) (3) Most ( ) (4) All of them ( )
68