The overlapping shadows of depression and HIV/ AIDS on South Africa's young women

Adolescent girls and pregnant HIV-positive women in rural South Africa are particularly vulnerable to depression. Recent research suggests that depression is a risk factor for HIV infection among young girls and increases the risk for mother-to-child transmission among HIV-positive pregnant women. Providing mental-health services to these groups is a public-health and social-justice imperative and a critical step in reducing HIV infections. By Andrea Teagle.

In Mpumalanga, South Africa, one in five adolescent girls suffers from depression, recent research conducted by Prof Kathleen Kahn from Wits University together with scientists from the University of California, Berkeley (UC Berkeley) and Oxford University among others, shows. Among HIV-positive pregnant women in the same province, rates are even higher, with almost half of women in a 2019 HSRC study meeting the criteria for depression. In this study, which sought to investigate barriers to treatment faced by pregnant women, depression emerged as a major factor that contributes to mother-to-child HIV transmission and infant deaths.

In the collaborative Wits study involving 2 533 girls aged 13 to 21 years, those who experienced depression were at higher risk of contracting HIV, a finding that is particularly concerning given the already elevated risk faced by this population group. The correlation between HIV/AIDS and depression is well documented, although the direction of causation can be difficult to establish. A senior researcher of the study, Prof Jennifer Ahern of UC Berkeley, said the findings showed that, at least in this population, the arrow certainly goes one way, which is depression leads to HIV”.

Among girls who were diagnosed with depression, nearly 11% went on to contract HIV in the following six years, compared with 6.5% among those without depression. Poorer relationships with parents and intimate-partner violence were identified as avenues through which depression increases unsafe sexual behaviour and the risk for HIV infection.

The researchers emphasised the importance of treating depression among young girls and identified community-led healthcare interventions as a promising solution in resource-constrained settings.

Filling the cracks

Another way that depression increases HIV incidence is when it affects pregnant women living with HIV/AIDS who risk passing on the virus to their infants.

Those who are on treatment and virally suppressed have a negligible chance of transmitting HIV during birth or breastfeeding. However, in rural South Africa, women face many challenges such as poor access to healthcare, poverty, joblessness, unequal gender dynamics, stigma and depression that make remaining on treatment difficult.

One potential solution to some of these challenges is a pilot programme run by lay healthcare workers called Protect Your Family, which includes a mental-health component focused on the reduction of anxiety and perceived stigma for pregnant women.

In the 2019 HSRC study, Prof Karl Peltzer and Prof Sibusiso Sifunda set out with their colleagues to reach women who had fallen through the cracks of what had otherwise been an effective national prevention of mother-to-child-transmission (PMTCT) programme.

The researchers recruited a total of 1 370 HIV-positive women between 8 and 24 weeks pregnant in 12 randomly selected community healthcare centres in Mpumalanga, where HIV prevalence (37%) was almost 3 times the national average of 13%. Many of the participants had received their HIV diagnosis during their current pregnancy and 45% met the criteria for depression. Younger women were more likely to be depressed.

Because the researchers were interested in the possible impact of partner involvement, having a partner was a prerequisite for participation.

In the first phase, only women were recruited; in the second, the womens partners were also included. In both phases, participants were divided into two groups. Those in the control group received the standard PMTCT programme, while those in the treatment group received the Protect Your Family intervention.

In the second phase, Protect Your Family was delivered via a mix of separate group sessions for men and women, as well as individual and couples educational and psychological support sessions.

Social support and mental health

For many women, depression lifted as the study progressed. Six weeks after birth, the estimated depression rate was 30%. However, a year after birth, one in three (37%) still met the criteria for depression.

At the one-year mark, the only factor that significantly predicted whether the baby remained HIV negative was whether or not the mothers depression had worsened. Where depression had improved, the baby was also more likely to survive to the first birthday.

The study found that Protect Your Family, when delivered to women only, did not reduce depressive symptoms. But when women attended the intervention with their partners, they were significantly less likely to feel depressed over time, suggesting that the intervention increased meaningful male partner involvement and social support. Although the programme failed to achieve sustained maternal treatment adherence, it did lower the risk of infants contracting HIV in the first year.

One of the biggest shortfalls of [the standard PMTCT programme] is the exclusion of men,said Dr Shandir Ramlagan of the HSRC, who was involved in a different part of the study. A limitation of the study was that, in phase 2, the researchers could access only partners who would agree to participate in other words, partners who were already likely to be more supportive.

Any sort of behaviour change requires you to have some kind of vested interest,Ramlagan agreed. However, he added that many South African men wanted to be responsible fathers and involved through their partners pregnancy and childs early infancy.

The revealed role of social support echoed some of the findings of the Wits study in which adolescent girls with closer relationships with their parents were less likely to suffer depression and were less likely to engage in unsafe sexual behaviour that put them at greater risk of contracting HIV.

Identifying those most at risk for depression

Given the lack of mental-health professionals and facilities in South Africa, accurately identifying which women and young girls would benefit most from psychological support could help to improve targeted interventions.

In an ongoing, collaborative study, a team of local and international researchers noted that checklists that identify depression such as the 12-point Edinburgh Postnatal Depression Scale used in the HSRC study risk overstating prevalence. While many individuals will most likely be correctly identified, some whose distress does not constitute clinical depression also tend to be included.

The team, which comprises researchers from George Washington University, Yale University, the HSRC and the Transcultural Psychosocial Organization of Nepal, is exploring a different avenue for accurate diagnoses: cellphones and other wearable devices. Focusing on pregnant adolescents in Nepal, they are investigating whether phone data on, for example, physical exertion, sleep patterns and tone of speech, which is automatically collected as participants go about their daily lives, can raise red flags for depression.

Cellphones are already used in this way to monitor individuals at risk for conditions such as anaemia and Parkinsons disease. The intervention is arguably particularly suitable for young women and adolescents among whom cellphone usage is on the rise.

A digital-health approach to supporting these vulnerable groups clearly has huge potential in a climate where access to trained professionals is costly and scarce,says co-author Dr Alastair van Heerden from the HSRC. Cellphone games that teach principles of behavioural activation, passive cellphone data that is turned into behavioural insights anddigital peer-support groups are all promising approaches in South Africa.

The study findings are expected to be published in the next three to six months.

Ramlagan says that, in addition to expanded mental-health services and provision for greater male partner involvement, improving access to HIV-testing services in rural areas so that women do not learn of positive statuses only when they fall pregnant would help reduce instances of postpartum depression.


Andrea Teagle, science writer at the HSRC

Depression puts young women at risk of HIV infection but among HIV-positive pregnant women, it also increases the risk of mother-to-child HIV transmission.
Photo: Dexter Chatuluka, Unsplash