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Catherine Anne Esposito, MPH, Zachary Steel, PhD, Tran Minh Gioi, MD, MPH, Tran Trieu Ngoa Huyen, MD and Daniel Tarantola, MD

At the time of the study Catherine Anne Esposito was a PhD candidate at the School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia. Daniel Tarantola was with the School of Public Health and Community Medicine, University of New South Wales, Sydney. Zachary Steel was with the Center for Population Mental Health Research, School of Psychiatry, University of New South Wales, Sydney. Tran Minh Gioi is with the Center for Community Health Promotion, Hanoi, Vietnam. Tran Trieu Ngoa Huyen is with the Quality of Life Promotion Center in Ho Chi Minh City, Vietnam.

Correspondence: Correspondence should be sent to Dr Zachary Steel, Center for Population Mental Health Research, level 4, Health Services Building, Liverpool Hospital NSW 2170, Australia (e-mail: z.steel{at}unsw.edu.au; esposito.catherine{at}gmail.com). Reprints can be ordered at http://www.ajph.org by clicking on the "Reprints/Eprints" link.

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION Human Participant Protection References

 

Objectives. We assessed the prevalence of depression among men living with HIV infection in Vietnam and compared the findings with those from a general population survey of Vietnamese men.

Methods. Between November 2007 and April 2008, 584 participants completed a structured questionnaire in Vietnamese that measured self-reported depression. We used the ² test to detect differences in prevalence rates within HIV populations and between our respondents and a general Vietnamese male population.

Results. Respondents had a depression rate of 18.7% over a 1-month period, which was substantially higher than that reported in the Vietnamese male population (0.9%). Rates were highest among men reporting higher levels of stress and more HIV symptoms. Men diagnosed with depression experienced significantly more difficulty than others in accessing medical care.

Conclusions. Our results provide the first empirical evidence of depression among men living with HIV in Vietnam and underscore the need to include mental health services in the response to HIV.

	INTRODUCTION

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Depression has emerged as a highly disabling and prevalent disorder among people with HIV.^1–4 High-income countries, where the majority of research has been undertaken, are increasingly focusing on the mental health needs of HIV populations.³ People with HIV in developing countries may be similarly at risk for mental health problems such as depression. This risk may be exacerbated by poverty, political instability, exposure to trauma, and limited access to services and treatment. Moreover, persons living with HIV may be affected by the criminalization and marginalization of populations at greatest risk for acquiring HIV.

A systematic review of 13 published studies on mental illness among HIV populations that were conducted in low- and middle-income countries and employed diagnostic interviews or psychiatric symptom scales concluded that depression was common.⁵ The largest of these, a controlled study in 4 sites in developing countries, found an average rate of depression of 6% among asymptomatic and 17.8% among symptomatic participants.⁶ That same study found a depression rate in Bangkok of 21% among symptomatic participants living with HIV, significantly higher than among control participants.⁶

Despite the emerging body of research from low- and middle-income countries, no data exist on the prevalence of depression among HIV populations in Vietnam, which has one of the fastest growing epidemics in Southeast Asia.⁷ The contribution of depression to the disease burden associated with HIV in Vietnam has not been reported.^8,9 This could reflect a general failure to consider the mental health of HIV-affected populations throughout much of Southeast Asia.

Vietnam's HIV infection rate in adults almost doubled between 2000 and 2007.¹⁰ An estimated 290 000 people were living with HIV, and 20 000 HIV-related deaths were reported in 2007.¹⁰ Although both men and women are vulnerable to HIV infection¹¹ and mental illness,¹² we focused exclusively on men in our study. Men were the first to experience high rates of HIV infection and now compose the larger pool of people living with HIV. Their membership in high-risk groups, such as injection drug users (IDUs) and men having sex with men, has been a major stimulus for government attention and response, creating a more visible and diverse male HIV network and making men more accessible for research than are affected female populations, such as sex workers on the streets.

It is widely recognized that injection drug use often coexists with mental disorders such as depression.¹³ In Vietnam, the level of mental disorders may be exacerbated by the lack of widespread community-based harm reduction or drug treatment programs. The Vietnamese government's program of compulsory detoxification for male drug users in Drug Treatment, Education, and Work Centers has an annual detainee population of 60 000 to 70 000.¹⁴ (Separate compulsory centers for women house mostly sex workers and some drug users.) High seroprevalence and drug-use relapse rates,^7,15 combined with crowded and violent conditions within these closed settings, contribute to reengagement with HIV risk behaviors¹⁶ and development of mental disorders.¹⁷ In Vietnam, stress associated with HIV infection compounds tensions caused by the stigmatization of male IDUs and men having sex with men and its consequent economic and social exclusion.¹⁸ Such marginalization has been associated with decreased visits to health care organizations¹⁹ and depression²⁰ in other populations.

An increasing variety of risk behaviors among at-risk populations and rising heterosexual transmission beyond these populations could lead to a second wave of the HIV epidemic in Vietnam.²¹ Data about how depression affects the lives of men living with HIV and who is affected will be important to the shaping of a more effective HIV response.

To address the paucity of evidence about mental illness and HIV in Vietnam, we investigated (1) the prevalence of depression among men living with HIV in Vietnam and (2) whether rates of depression among men affected by HIV are higher than in a sample of the general Vietnamese male population.

	METHODS

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Hanoi and Ho Chi Minh City are the major cities in northern and southern Vietnam, respectively. Hanoi, the political capital of Vietnam, has a population of 3 million, with HIV prevalence rates highest among IDUs (23.9%) and female sex workers (23%); 0.7% of the adults in the city are infected.²² With a population of more than 6 million people, Ho Chi Minh City is the largest city in Vietnam. It has a generalized HIV epidemic, with 1.2% of the adult population infected with HIV and high rates among IDUs (34%) and female sex workers (11.1%).²¹

Participants
Men living with HIV were recruited from clinic and community settings and represented 2 different pools of men living with HIV. Members of the first group were part of support networks of people living with HIV, were aware of their positive serostatus, and lived in the community. In Hanoi participants were affiliated with and recruited through Bright Futures, coordinator of the Northern Network People Living With HIV. In Ho Chi Minh City we recruited through the Southern Network of People Living With HIV. A complete survey of every member of these networks was conducted between August and October 2007; 532 men completed the self-administered survey questionnaire.

We also recruited a consecutive sample of 52 men with Living With HIV who were not part of a network but who sought treatment from the outpatient clinic in Yen Phu Health Center, Tay Ho District, Hanoi, between April and May 2008; this HIV population was likely to have HIV-related symptoms. The response rate was high: 97% of eligible participants from the networks and 95% from the outpatient clinic agreed to participate in the study, and all of them completed the survey. Network leaders and clinic staff described the research procedures and obtained participants' written consent.

Measures
Data for baseline prevalence of depression among men in Vietnam was drawn from the Can Tho City and Hau Giang Province Mental Health Survey in the Mekong Delta. A detailed description of this survey has been provided elsewhere.²³ Can Tho City, 1 of the survey sites, has an HIV epidemic similar to Ho Chi Minh City's and Hanoi's, with high prevalence rates detected among IDUs (84%) and female sex workers (29%).²² The Can Tho Provincial Health Department, in cooperation with Can Tho University and the University of New South Wales, conducted the survey between November 2004 and March 2005 to determine mental health needs and resultant policy and service requirements. Local health workers used a multistage probabilistic sampling frame and random sampling²³ to survey 3039 people, of whom 1431 were male. This survey, although conducted in a different location, provided the best available comparative data on depression, because of the broad similarities of HIV infection rates between our sites and the survey's and the scarcity of population-level data on depression in the Vietnamese population and in Vietnamese people affected by HIV.

The Phan Vietnamese Psychiatric Scale (PVPS), a Vietnamese-language questionnaire of mental disorders, was used to measure the prevalence of depression in both the Mekong Delta survey and our study. Development of the PVPS is described in detail elsewhere.^24,25 In brief, the PVPS was developed sequentially through a review of emotional states found in Vietnamese literature, ethnographic interviews with Vietnamese speakers, and psychometric testing. From these analyses, 3 symptom constellations emerged, broadly recognizable as the domains of anxiety, somatization, and depression. We used the depression subscale, which describes 26 symptoms and asks respondents to indicate how often within the past month (never, occasionally, or frequently) they experienced each one. PVPS depression scores were calculated by summing the number of responses that indicated either occasional or frequent experience of each symptom and dividing by 26, the total number of items. Scores higher than 1.85²⁴ defined the depressive disorder range.

The depression subscale has been found to have acceptable levels of internal consistency (0.93), test–retest reliability (0.89), and convergent and discriminate validity against other measures of depression.²⁴ The subscale has yielded moderate to strong indices of diagnostic concordance with depressive diagnoses made independently by psychiatrists ( = 0.62), structured diagnostic measures ( = 0.61), and roughly equivalent categories diagnosed by naturalist healers ( = 0.71). The subscale was rated by respondents as being superior to comparable Western-derived measures of depression on ease of comprehension, familiarity of idioms, meaningfulness of items, and perceived usefulness to a doctor.²⁴ We selected the PVPS for its validity, cultural sensitivity, ease of administration, and comparability with the general population survey data.

Participants self-administered a structured questionnaire in Vietnamese that covered demographic data, HIV serostatus, and medical treatments. A list of 10 HIV symptoms was derived from the World Health Organization HIV/AIDS staging system.²⁶ Questions concerning sexual and injection risk behavior were taken from the HIV/STI Integrated Biological and Behavioral Surveillance in Vietnam, 2005 to 2006.²² Stressful life events were measured by the HIV Stressor Scale.²⁷ We used results from focus group discussions convened to pretest this scale to select 8 items across 5 main sources of stress for people with HIV: general, medical care, grief and illness, finances, and employment. Respondents indicated the degree to which stressors had been problematic over the previous year (no, moderate, or serious). We calculated a cumulative index of HIV stress by summing the total number of stressors that were moderate or serious problems over the previous 12 months.

Data Analysis
We used SPSS version 15 for statistical analyses.²⁸ Random checks were conducted by bilingual researchers not involved in the data entry process to ensure data quality. We performed the ² test to detect differences in prevalence rates by demographic strata and by demographic characteristics of the HIV and Mekong Delta samples. We used the same method as that of the Mekong Delta survey to weight male population prevalence estimates to reflect household composition and the age structure of the Can Tho–Hau Giang 1999 census.

Unweighted prevalence estimates were computed for the 2 HIV populations, reflecting the sampling approach. We performed the ² test to detect differences in diagnosis of depression among men living with HIV by HIV symptoms, stressful life events, and drug use in the past 6 months.

	RESULTS

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Table 1 presents demographic information for the HIV and Mekong Delta survey populations. Within the HIV population, the median age of the men was 30 years (interquartile range = 27–34 years); most respondents completed primary (45%) or secondary school (50%). Forty-five percent were employed, and 55% reported being unemployed or not in the workforce. There were no significant differences in demographic characteristics among men with HIV by location or recruitment site.

Significantly more participants from the Ho Tay District Outpatient clinic than from the HIV networks reported receiving treatment of an opportunistic infection (² = 26.4; P < .001) and experiencing more than 3 HIV symptoms (² = 26.9; P < .001). A significantly higher proportion of men from the networks (67.8%) than from the clinic (44.2%) reported knowing about their serostatus for more than 1 year (² = 25.9; P < .001). We found no differences between respondents from the Ho Tay District Outpatient clinic and the 2 HIV networks in demographic variables, risk behaviors, HIV stressors, or levels of depression. For this reason, we collapsed the HIV samples into a single HIV-affected population for analysis.

Participants in the Mekong Delta survey were more likely to be older than 35 years (²₂ = 262.7; P < .001), to have lower levels of education (²₂ = 127.4; P < .001), and to have formal employment (²₁ = 28.9; P < .001) than were men living with HIV.

Table 2 presents prevalence rates of depression derived from the PVPS for the HIV and Mekong Delta samples, stratified by age and education. The prevalence rate of depression within the past month for men living with HIV was 18.7%. For each age and educational stratum, depression rates were significantly higher in the HIV sample than in the Mekong Delta sample.

Table 3 presents stressful life events experienced by men living with HIV in the past year. Respondents reported an average of 4.3 life events that caused moderate to serious difficulties during the previous year. Concern about the future of family was the most frequently reported (81%) stressful life event, followed by having no income (72%) or work (60%). Trouble accessing medical care within the past month was reported by 45% of the men.

	DISCUSSION

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We found that 18.7% of men living with HIV in Vietnam experienced depression over the previous month. We were able to directly compare this prevalence rate with an index of depression from a general population survey in the Mekong Delta that used an identical instrument. The rate of depression in the sample of men living with HIV was substantially higher than the 12-month prevalence rate identified in the Mekong Delta survey (0.9%). The rate of depression among HIV-affected respondents was higher in each age and educational stratum, indicating that this finding was not attributable to demographic differences between the HIV and general population samples. This adds to the growing body of evidence documenting elevated rates of depression among people with HIV in low- and middle-income countries and specifically in Southeast Asia.^29–31

Our findings are consistent with earlier studies that showed that men with a greater number of HIV symptoms have higher rates of depression than do HIV-infected but asymptomatic men^6,32 and with studies that reported elevated rates of depression among people with substance abuse disorders.^33,34 The relationship between HIV and depression is complex and likely to be circuitous.^4,35 Although our cross-sectional design made it impossible to clarify the nature of this relationship, our findings have important implications for HIV programs in Vietnam.

Evidence that men living with HIV in Vietnam suffer disproportionately from depression should spur the provision of an extended and integrated array of services to ensure that physical and mental health needs are met. This is a formidable challenge because people with HIV in Vietnam do not have a history of seeking or receiving mental health care: they are deterred by the scarcity of such services³⁶ and by the compounding stigmas carried by HIV and associated risk-taking behaviors. This pattern is revealed by the proportion of men with depression reporting difficulties accessing medical care.

Despite an escalation of resources committed to a response to HIV in Vietnam over the past 5 years,¹⁶ little policy attention has been directed to the mental health needs of men living with HIV. One exception is the establishment of several small-scale psychosocial support programs aimed at improving quality of life for those affected, particularly in the context of palliative care.³⁷ Although no formal evaluation of these programs has been undertaken, they may provide a model and precedent for establishing a more comprehensive service delivery model. One of the challenges facing this resource-constrained nation is to establish structures, skilled personnel, and resources to enhance mental health services generally and in particular to meet the specific needs of people living with HIV.

Our data confirm the need for further research on the psychological manifestations of HIV throughout the course of the infection in Vietnam, to identify those most at risk and to design interventions to reduce individual and societal factors that exacerbate vulnerability to depression and other mental disorders.³⁸ Access to antiretroviral therapy is increasing in Vietnam; consideration should be given to how high rates of depression might affect access to and compliance with HIV treatment.

Limitations
Our study had several limitations. Despite a high response rate from the HIV populations surveyed, the findings may not be generalizable to all seropositive male populations in Vietnam. Our sample included only men living with HIV who resided in the community and functioned within organized networks or outpatient settings and not hospitalized people with AIDS, men in drug reeducation camps or prisons, or persons living with HIV who were not receiving treatment or services. Caution is therefore required for interpretation of our finding of elevated rates of depression among men who used opiates in the past 6 months. Further studies are needed to examine the degree and effect of comorbidity of substance abuse and psychiatric disorders among a wider sample of drug users. Our findings will be more pertinent as a wider sample of drug users becomes accessible in response to an improved national program that expands prevention, care, and treatment services to at-risk populations such as IDUs.

We assessed the prevalence of depression with threshold scores derived from the PVPS. This approach to psychiatric case identification has been associated with overestimation in comparison with structured diagnostic interviews in other populations.³⁹ However, this bias probably did not exert an undue influence in our study. The overall prevalence of PVPS-defined depressive disorder in the general population survey was low, suggesting that the survey did not yield an inflated rate of depressive disorder. Levels of disability stemming from both mental and physical health among persons identified as depressed in the Mekong Delta survey were similar to those measured by the World Health Organization's Composite International Diagnostic Interview,²³ suggesting that the thresholds applied by the PVPS do not result in the detection of less severe cases than are found by standard psychiatric case-finding instruments.

The difference in the length of time used to assess PVPS depressive symptoms in the HIV surveys (1 month) and the general population survey (12 months) may have attenuated differences; possibly the 12-month prevalence rate for depression in the HIV sample was higher than reported. Although depression rates increased with reported HIV symptomatology, we did not distinguish stage of HIV illness; further effort is required to differentiate somatic symptoms of depression (weight loss, fatigue) from symptoms of HIV illness.

Conclusions
Our findings suggest that up to 1 in 5 men living with HIV in Vietnam experiences clinically significant depressive symptoms. Although there are important differences in population settings, this rate is many times higher than in the general adult male population surveyed in the Mekong Delta. High stress scores among those with high rates of depression suggest that the prevalence of depression may increase as a function of HIV-related life stressors. This finding supports contemporary research that documents a correlation between HIV and stressful life events.^20,40,41

Our findings highlight a compelling need to reduce the dual burden of HIV and psychiatric morbidity among men in Vietnam. Our methods could be used to explore the prevalence of depression in other populations affected by HIV in Vietnam and in other cultural settings.

In Vietnam, the emergence of HIV has been a catalyst for greater attention to other important policy and program issues, such as civil society¹⁶ and the application of human rights norms and standards.⁴² Integrating mental health with HIV efforts on a national scale will help reduce dual morbidity among disenfranchised populations and raise awareness of the importance of mental health in the broader context of Vietnam.

	Human Participant Protection

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The study was approved by the human research ethics committee of the University of New South Wales and the ethics review board of the Ho Chi Minh City Provincial AIDS Committee. All participants gave written consent.

	Footnotes

 
Peer Reviewed

Contributors

C. A. Esposito designed the study, developed the structured questionnaire, modified the case-finding instrument, assisted with data collection and analysis, and wrote the article. Z. Steel assisted with study design, instrument development, data analysis, and writing and revising the article. T. M. Gioi assisted with data collection in Vietnam. T. T. N. Huyen contributed to data entry and descriptive analysis. D. Tarantola assisted with study and instrument design and writing and revising the article. All authors approved the final version of the article.

Accepted for publication April 21, 2009.

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This Article Abstract Full Text (PDF) Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Google Scholar Articles by Esposito, C. A. Articles by Tarantola, D. PubMed PubMed Citation Articles by Esposito, C. A. Articles by Tarantola, D. Related Collections Access to Care HIV/AIDS Mental Health Asians Men's Health