Sexual relationship power and depression among HIV-infected women in Rural Uganda

Abigail M Hatcher, Alexander C Tsai, Elias Kumbakumba, Shari L Dworkin, Peter W Hunt, Jeffrey N Martin, Gina Clark, David R Bangsberg, Sheri D Weiser, Abigail M Hatcher, Alexander C Tsai, Elias Kumbakumba, Shari L Dworkin, Peter W Hunt, Jeffrey N Martin, Gina Clark, David R Bangsberg, Sheri D Weiser

Abstract

Background: Depression is associated with increased HIV transmission risk, increased morbidity, and higher risk of HIV-related death among HIV-infected women. Low sexual relationship power also contributes to HIV risk, but there is limited understanding of how it relates to mental health among HIV-infected women.

Methods: Participants were 270 HIV-infected women from the Uganda AIDS Rural Treatment Outcomes study, a prospective cohort of individuals initiating antiretroviral therapy (ART) in Mbarara, Uganda. Our primary predictor was baseline sexual relationship power as measured by the Sexual Relationship Power Scale (SRPS). The primary outcome was depression severity, measured with the Hopkins Symptom Checklist (HSCL), and a secondary outcome was a functional scale for mental health status (MHS). Adjusted models controlled for socio-demographic factors, CD4 count, alcohol and tobacco use, baseline WHO stage 4 disease, social support, and duration of ART.

Results: The mean HSCL score was 1.34 and 23.7% of participants had HSCL scores consistent with probable depression (HSCL>1.75). Compared to participants with low SRPS scores, individuals with both moderate (coefficient b = -0.21; 95%CI, -0.36 to -0.07) and high power (b = -0.21; 95%CI, -0.36 to -0.06) reported decreased depressive symptomology. High SRPS scores halved the likelihood of women meeting criteria for probable depression (adjusted odds ratio = 0.44; 95%CI, 0.20 to 0.93). In lagged models, low SRPS predicted subsequent depression severity, but depression did not predict subsequent changes in SPRS. Results were similar for MHS, with lagged models showing SRPS predicts subsequent mental health, but not visa versa. Both Decision-Making Dominance and Relationship Control subscales of SRPS were associated with depression symptom severity.

Conclusions: HIV-infected women with high sexual relationship power had lower depression and higher mental health status than women with low power. Interventions to improve equity in decision-making and control within dyadic partnerships are critical to prevent HIV transmission and to optimize mental health of HIV-infected women.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

References

    1. Kaharuza FM, Bunnell R, Moss S, Purcell DW, Bikaako-Kajura W, et al. (2006) Depression and CD4 cell count among persons with HIV infection in Uganda. AIDS Behav 10: S105–111.
    1. Lundberg P, Rukundo G, Ashaba S, Thorson A, Allebeck P, et al. (2011) Poor mental health and sexual risk behaviours in Uganda: A cross-sectional population-based study. BMC Public Health 11: 125.
    1. Ovuga E, Boardman J, Wasserman D (2005) The prevalence of depression in two districts of Uganda. Soc Psychiatry Psychiatr Epidemiol 40: 439–445.
    1. Kinyanda E, Woodburn P, Tugumisirize J, Kagugube J, Ndyanabangi S, et al. (2011) Poverty, life events and the risk for depression in Uganda. Soc Psychiatry Psychiatr Epidemiol 46: 35–44.
    1. Bolton P, Wilk CM, Ndogoni L (2004) Assessment of depression prevalence in rural Uganda using symptom and function criteria. Soc Psychiatry Psychiatr Epidemiol 39: 442–447.
    1. Gielen AC, McDonnell KA, Burke JG, O'Campo P (2000) Women's lives after an HIV-positive diagnosis: disclosure and violence. Matern Child Health J 4: 111–120.
    1. Prachakul W, Grant JS, Keltner NL (2007) Relationships among functional social support, HIV-related stigma, social problem solving, and depressive symptoms in people living with HIV: a pilot study. J Assoc Nurses AIDS Care 18: 67–76.
    1. Wu DY, Munoz M, Espiritu B, Zeladita J, Sanchez E, et al. (2008) Burden of depression among impoverished HIV-positive women in Peru. J Acquir Immune Defic Syndr 48: 500–504.
    1. Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, et al. (2007) Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med 64: 1823–1831.
    1. Tsai AC, Bangsberg DR, Frongillo EA, Hunt PW, Muzoora C, et al. (2012) Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Soc Sci Med 74: 2012–2019.
    1. Ciesla JA, Roberts JE (2001) Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry 158: 725–730.
    1. Mello VA, Segurado AA, Malbergier A (2010) Depression in women living with HIV: clinical and psychosocial correlates. Arch Womens Ment Health 13: 193–199.
    1. Millikin CP, Rourke SB, Halman MH, Power C (2003) Fatigue in HIV/AIDS is associated with depression and subjective neurocognitive complaints but not neuropsychological functioning. J Clin Exp Neuropsychol 25: 201–215.
    1. Eller LS (2001) Quality of life in persons living with HIV. Clin Nurs Res 10: 401–423.
    1. Valente SM (2003) Depression and HIV disease. J Assoc Nurses AIDS Care 14: 41–51.
    1. Tsai AC, Weiser SD, Petersen ML, Ragland K, Kushel MB, et al. (2010) A marginal structural model to estimate the causal effect of antidepressant medication treatment on viral suppression among homeless and marginally housed persons with HIV. Arch Gen Psychiatry 67: 1282–1290.
    1. Cook JA, Cohen MH, Burke J, Grey D, Anastos K, et al. (2002) Effects of depressive symptoms and mental health quality of life on use of highly active antiretroviral therapy among HIV-seropositive women. J Acquir Immune Defic Syndr 30: 401–409.
    1. Burack JH, Barrett DC, Stall RD, Chesney MA, Ekstrand ML, et al. (1993) Depressive symptoms and CD4 lymphocyte decline among HIV-infected men. JAMA 270: 2568–2573.
    1. Evans DL, Ten Have TR, Douglas SD, Gettes DR, Morrison M, et al. (2002) Association of depression with viral load, CD8 T lymphocytes, and natural killer cells in women with HIV infection. Am J Psychiatry 159: 1752–1759.
    1. Ickovics JR, Hamburger ME, Vlahov D, Schoenbaum EE, Schuman P, et al. (2001) Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study. JAMA 285: 1466–1474.
    1. Antelman G, Kaaya S, Wei R, Mbwambo J, Msamanga GI, et al. (2007) Depressive symptoms increase risk of HIV disease progression and mortality among women in Tanzania. J Acquir Immune Defic Syndr 44: 470–477.
    1. Cook JA, Grey D, Burke J, Cohen MH, Gurtman AC, et al. (2004) Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. Am J Public Health 94: 1133–1140.
    1. James JS (2004) Chronically depressed women with HIV almost twice as likely as others to die from AIDS-related causes; those with mental-health services had half the death rate of those without. AIDS Treat News: 2–3.
    1. Cohen MH, Fabri M, Cai X, Shi Q, Hoover DR, et al. (2009) Prevalence and predictors of posttraumatic stress disorder and depression in HIV-infected and at-risk Rwandan women. J Womens Health (Larchmt) 18: 1783–1791.
    1. Stein MD, Hanna L (1997) Use of mental health services by HIV-infected women. J Womens Health 6: 569–574.
    1. Valverde EE, Purcell DW, Waldrop-Valverde D, Malow R, Knowlton AR, et al. (2007) Correlates of depression among HIV-positive women and men who inject drugs. J Acquir Immune Defic Syndr 46 Suppl 2: S96–100.
    1. Nduna M, Jewkes RK, Dunkle KL, Shai NP, Colman I (2010) Associations between depressive symptoms, sexual behaviour and relationship characteristics: a prospective cohort study of young women and men in the Eastern Cape, South Africa. J Int AIDS Soc 13: 44.
    1. Smit J, Myer L, Middelkoop K, Seedat S, Wood R, et al. (2006) Mental health and sexual risk behaviours in a South African township: a community-based cross-sectional study. Public Health 120: 534–542.
    1. Filson J, Ulloa E, Runfola C, Hokoda A (2010) Does powerlessness explain the relationship between intimate partner violence and depression? J Interpers Violence 25: 400–415.
    1. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C, et al. (2008) Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: an observational study. Lancet 371: 1165–1172.
    1. Campbell R, Sullivan CM, Davidson I, William S (1995) Women who use domestic violence shelters: Changes in depression over time. Psychology of Women Quarterly 19: 237–255.
    1. Weiser SD, Tsai A, Senkungu J, Emenyonu N, Kawuma A, et al... (2010) Effect of Low Sexual-Relationship Power on Viral Load Suppression among Women Receiving ART in Mbarara, Uganda. 17th Conference on Retroviruses and Opportunistic Infections. San Francisco, CA.
    1. Siedner MJ, Tsai AC, Dworkin S, Mukiibi NF, Emenyonu NI, et al. (2012) Sexual Relationship Power and Malnutrition Among HIV-Positive Women in Rural Uganda. Behav 2012 Mar 2 [Epub ahead of print].
    1. Gove WR, Hughes M, Style CB (1983) Does marriage have positive effects on the psychological well-being of the individual? J Health Soc Behav 24: 122–131.
    1. Ross CE, Mirowsky J, Goldsteen K (1990) The impact of the family on health: The decade in review. Journal of Marriage and the Family: 1059–1078.
    1. Kawachi I, Berkman LF (2001) Social ties and mental health. J Urban Health 78: 458–467.
    1. Kim HK, McKenry PC (2002) The relationship between marriage and psychological well-being. Journal of Family Issues 23: 885–911.
    1. Kiecolt-Glaser JK, Fisher LD, Ogrocki P, Stout JC, Speicher CE, et al. (1987) Marital quality, marital disruption, and immune function. Psychosom Med 49: 13–34.
    1. Farmer P, Connors M, Simmons J (1996) Women, poverty, and AIDS: sex, drugs, and structural violence: Common Courage Pr.
    1. Geng EH, Bwana MB, Kabakyenga J, Muyindike W, Emenyonu NI, et al. (2010) Diminishing availability of publicly funded slots for antiretroviral initiation among HIV-infected ART-eligible patients in Uganda. PLoS One 5: e14098.
    1. Pulerwitz J, Gortmaker SL, DeJong W (2000) Measuring sexual relationship power in HIV/STD research. Sex Roles 42: 637–660.
    1. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, et al. (2004) Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 363: 1415–1421.
    1. Ketchen B, Armistead L, Cook SL (2009) HIV infection, stressful life events, and intimate relationship power: The moderating role of community resources for black South African women. Women & health 49: 197.
    1. Connell RW (1985) Theorising gender. Sociology 19: 260.
    1. Bolton P, Ndogoni L (2001) Cross-cultural assessment of trauma-related mental illness (Phase II): a report of research conducted by World Vision Uganda and The Johns Hopkins University.
    1. Martinez P, Andia I, Emenyonu N, Hahn JA, Hauff E, et al. (2008) Alcohol use, depressive symptoms and the receipt of antiretroviral therapy in southwest Uganda. AIDS Behav 12: 605–612.
    1. Bolton P (2001) Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. J Nerv Ment Dis 189: 238–242.
    1. Epino HM, Rich ML, Kaigamba F, Hakizamungu M, Socci AR, et al. (2012) Reliability and construct validity of three health-related self-report scales in HIV-positive adults in rural Rwanda. AIDS Care
    1. Wu AW, Revicki DA, Jacobson D, Malitz FE (1997) Evidence for reliability, validity and usefulness of the Medical Outcomes Study HIV Health Survey (MOS-HIV). Qual Life Res 6: 481–493.
    1. Wu AW, Rubin HR, Mathews WC, Ware JE Jr, Brysk LT, et al. (1991) A health status questionnaire using 30 items from the Medical Outcomes Study. Preliminary validation in persons with early HIV infection. Med Care 29: 786–798.
    1. Shahriar J, Delate T, Hays RD, Coons SJ (2003) Commentary on using the SF-36 or MOS-HIV in studies of persons with HIV disease. Health Qual Life Outcomes 1: 25.
    1. Revicki DA, Sorensen S, Wu AW (1998) Reliability and validity of physical and mental health summary scores from the Medical Outcomes Study HIV Health Survey. Med Care 36: 126–137.
    1. Babikako HM, Neuhauser D, Katamba A, Mupere E (2010) Feasibility, reliability and validity of health-related quality of life questionnaire among adult pulmonary tuberculosis patients in urban Uganda: cross-sectional study. Health Qual Life Outcomes 8: 93.
    1. Bradley KA, Bush KR, Epler AJ, Dobie DJ, Davis TM, et al. (2003) Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med 163: 821–829.
    1. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 158: 1789–1795.
    1. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L (1974) The Hopkins Symptom Checklist (HSCL). A measure of primary symptom dimensions. Mod Probl Pharmacopsychiatry 7: 79–110.
    1. Low-Beer S, Chan K, Yip B, Wood E, Montaner JS, et al. (2000) Depressive symptoms decline among persons on HIV protease inhibitors. J Acquir Immune Defic Syndr 23: 295–301.
    1. Rabkin JG, Ferrando SJ, Lin SH, Sewell M, McElhiney M (2000) Psychological effects of HAART: a 2-year study. Psychosom Med 62: 413–422.
    1. Palar K, Wagner G, Ghosh-Dastidar B, Mugyenyi P (2012) Role of antiretroviral therapy in improving food security among patients initiating HIV treatment and care in Uganda. AIDS
    1. Seligman ME (1974) Depression and learned helplessness.
    1. Abramson LY, Seligman ME, Teasdale JD (1978) Learned helplessness in humans: critique and reformulation. J Abnorm Psychol 87: 49–74.
    1. Mirowsky J, Ross CE (1989) Social causes of psychological distress: Aldine de Gruyter.
    1. Grant RL (1978) The value of “learned helplessness” in understanding depression. Am J Psychiatry 135: 625.
    1. Buchwald AM, Coyne JC, Cole CS (1978) A critical evaluation of the learned helplessness model of depression. J Abnorm Psychol 87: 180–193.
    1. Miller WR, Seligman ME (1975) Depression and learned helplessness in man. J Abnorm Psychol 84: 228–238.
    1. Li B, Piriz J, Mirrione M, Chung C, Proulx CD, et al. (2011) Synaptic potentiation onto habenula neurons in the learned helplessness model of depression. Nature 470: 535–539.
    1. Bougarel L, Guitton J, Zimmer L, Vaugeois JM, El Yacoubi M (2011) Behaviour of a genetic mouse model of depression in the learned helplessness paradigm. Psychopharmacology (Berl) 215: 595–605.
    1. Maier SF (2001) Exposure to the stressor environment prevents the temporal dissipation of behavioral depression/learned helplessness. Biol Psychiatry 49: 763–773.
    1. Petty F, Kramer GL, Wu J, Davis LL (1997) Posttraumatic stress and depression. A neurochemical anatomy of the learned helplessness animal model. Ann N Y Acad Sci 821: 529–532.
    1. Hajszan T, Dow A, Warner-Schmidt JL, Szigeti-Buck K, Sallam NL, et al. (2009) Remodeling of hippocampal spine synapses in the rat learned helplessness model of depression. Biol Psychiatry 65: 392–400.
    1. Amaro H, Raj A (2000) On the margin: Power and women's HIV risk reduction strategies. Sex Roles 42: 723–749.
    1. Wingood GM, DiClemente RJ (2000) Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Educ Behav 27: 539–565.
    1. Bermudez MP, Castro A, Gude F, Buela-Casal G (2010) Relationship power in the couple and sexual double standard as predictors of the risk of sexually transmitted infections and HIV: multicultural and gender differences. Curr HIV Res 8: 172–178.
    1. Hahm HC, Lee J, Rough K, Strathdee SA (2012) Gender power control, sexual experiences, safer sex practices, and potential HIV risk behaviors among young Asian-American women. AIDS Behav 16: 179–188.
    1. Wingood GM, Scd, DiClemente RJ (2000) Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Educ Behav 27: 539–565.
    1. Landstedt E, Asplund K, Gillander Gadin K (2009) Understanding adolescent mental health: the influence of social processes, doing gender and gendered power relations. Sociol Health Illn 31: 962–978.
    1. Chonody JM, Siebert DC (2008) Gender Differences in Depression. Affilia 23: 338–348.
    1. Hahm HC, Lee J, Rough K, Strathdee SA (2011) Gender Power Control, Sexual Experiences, Safer Sex Practices, and Potential HIV Risk Behaviors Among Young Asian-American Women. AIDS Behav
    1. Pettifor AE, Measham DM, Rees HV, Padian NS (2004) Sexual power and HIV risk, South Africa. Emerg Infect Dis 10: 1996–2004.
    1. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, et al. (2007) Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 370: 1164–1174.
    1. Chisholm D, Flisher AJ, Lund C, Patel V, Saxena S, et al. (2007) Scale up services for mental disorders: a call for action. Lancet 370: 1241–1252.
    1. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, et al. (2011) Scale up of services for mental health in low-income and middle-income countries. Lancet 378: 1592–1603.
    1. Tomlinson M, Rudan I, Saxena S, Swartz L, Tsai AC, et al. (2009) Setting priorities for global mental health research. Bull World Health Organ 87: 438–446.
    1. Piccinelli M, Wilkinson G (2000) Gender differences in depression. Critical review. Br J Psychiatry 177: 486–492.
    1. Sherr L, Clucas C, Harding R, Sibley E, Catalan J (2011) HIV and depression–a systematic review of interventions. Psychol Health Med 16: 493–527.
    1. Yang X (2011) Prevalence and correlates of HIV unsafe sex and STIs among women working in China's entertainment industry. AIDS Care 23 Suppl 1: 75–82.
    1. Shannon K, Leiter K, Phaladze N, Hlanze Z, Tsai AC, et al. (2012) Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland. PLoS One 7: e28739.
    1. Pulerwitz J, Amaro H, De Jong W, Gortmaker SL, Rudd R (2002) Relationship power, condom use and HIV risk among women in the USA. AIDS Care 14: 789–800.
    1. Weeks MR, Hilario H, Li J, Coman E, Abbott M, et al. (2010) Multilevel social influences on female condom use and adoption among women in the urban United States. AIDS Patient Care STDS 24: 297–309.
    1. Gagnon AJ, Merry L, Bocking J, Rosenberg E, Oxman-Martinez J (2010) South Asian migrant women and HIV/STIs: knowledge, attitudes and practices and the role of sexual power. Health Place 16: 10–15.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera