Background: Despite evidence that adults affected by HIV have increased risk of mental health disorders such as depression, and depression is associated with ART nonadherence, few studies have explored these relationships among adult caregivers of vulnerable children. The objective of this study was to examine depressive symptoms and explore their relationship with ART adherence among caregivers of vulnerable children living with HIV in Malawi.
Methods: In a cross-sectional study, we interviewed 820 caregivers of children aged 0-17 in vulnerable households in 24 randomly selected health facility catchment areas in five districts in southern Malawi. Vulnerable households were defined as having at least one of: 1) economic insecurity, 2) food insecurity, and/or 3) chronic illness. Responses from five depression screening questions (coded 0-2) adapted from the PHQ-9 were summed and standardized. We used multivariable logistic regression to explore the association between depressive symptoms and ART adherence, controlling for caregiver sex, age, wealth, marital status, and education. We also controlled for HIV-related stigma and social support, which were also associated with depression. Standard errors were clustered by enumeration area.
Results: Most caregivers were women (86.5%), caring for a median of three children, and about one third had no spouse or live-in partner. Depressive symptoms were high, with 62% of caregivers reporting three or more depressive symptoms sometimes or often. Among caregivers who knew of their HIV positive status (n=308), nearly all (98.4%) reported currently using ART medication. Of those on treatment, 90.8% reported never forgetting or missing a day of ART in the past 7 days. In a multivariable logistic regression of adherence on depressive symptoms, a 1-SD increase in depressive symptom score was significantly associated with 33.8% lower odds of ART adherence (OR=0.662, 95% CI=0.454-0.966). HIV-related stigma and social support, though associated with depression, and other socio-demographic characteristics were not associated with ART adherence.
Conclusions: Addressing mental health among caregivers of vulnerable children may be an important step toward achieving consistent ART use and viral suppression among adults living with HIV in Malawi. Integrating depression screening programs into HIV primary care could be a promising intervention modality that should be considered in medicalized interventions.