Background: With high HIV prevalence and numerous partners, reducing HIV transmission among female sex workers (FSWs) is an important component of Malawi''s epidemic control strategy. However, many HIV-positive FSWs report inconsistent HIV prevention behaviors, thus maintaining long-term adherence to anti-retroviral therapy (ART) is critical. Mental health is an important, yet overlooked element in influencing long-term adherence. Prior studies show that depression is associated with poor HIV treatment outcomes, and FSWs'' experience of violence may contribute to depressive episodes. We examined levels of depression among HIV-positive FSWs and associated factors to inform ART service delivery.
Methods: Data are from interviews with 190 HIV-positive FSWs residing in Blantyre and Mangochi. At recruitment, participants were either HIV-naïve, or were previously on ART but had defaulted on treatment for at least 90 days. Participants were recruited via community testing events, peer outreach, and referrals from HIV testing counselors. All were tested for HIV following national guidelines and referred to treatment services. The questionnaire included the PHQ-9 depression scale, on which a score of 10 or higher indicates moderate-to-severe depressive symptoms. We analyzed the data using descriptive and logistic regression methods to identify factors associated with depression: age, location, education level, prior treatment default, monthly income, and experience of physical and/or sexual violence.
Results: The median age of the sample was 25 years; 59% lived in Blantyre. Education was low: 6% had never attended school, and 68% had attended only primary school. Nearly 85% were new ART clients, while the remaining 15% were defaulters. Thirty-nine percent of participants had experienced violence in the past 12 months, and 22% reported moderate-to-severe depression. Depression was associated with prior treatment default (aOR: 6.8; 95%CI: 2.3-20.6), experience of violence (aOR: 4.8; 95%CI: 2.1-10.9), and lowest income quartile (aOR: 3.5; 95%CI: 1.3-9.4).
Conclusions: In developing countries, mental health services are difficult to access, particularly for marginalized populations. Our analysis suggests a link between depression, and treatment default, which may warrant targeted interventions for FSWs enrolling in ART. Focused depression screening and treatment, and enhancing referral to gender-based violence counseling and support services for FSWs are recommended.