Depression and coping strategies among Vietnamese women living with HIV: A qualitative study

Women living with HIV (WLWH) are more likely to suffer from depression than seronegative women and are also more likely to suffer from depression than men living with HIV. There is limited depression research with WLWH in Vietnam. Twenty in-depth interviews with WLWH were conducted to identify pathways leading to depression and coping strategies for depression. Participants were recruited from an antiretroviral treatment clinic in northern Vietnam. Audio-recorded interviews were transcribed, translated, and analysed to identify key themes. All participants reported sudden loss of social support, debilitating depression, and suicidal ideation in the first six months after HIV diagnosis. While some were able to cope with their status after several months, others continued to struggle due to HIV-related stigma that was perceived as more isolating for WLWH than for men. Women who were able to effectively cope with depression found ways to re-establish connections to family and community. Interventions to improve mental wellbeing should link WLWH to mental health services immediately after diagnosis and address loss of support and stigma, as they contributed to the onset and persistence of depression after HIV diagnosis. Community-level HIV stigma reduction interventions may also help repair broken social bonds and foster new ones

Validation of screening tools for common mental health disorders in the methadone maintenance population in Hanoi, Vietnam

Background: Common mental health disorders (CMDs), including depression, anxiety and post-traumatic stress disorder (PTSD) may worsen both HIV and drug use outcomes, yet feasible tools to accurately identify CMDs have received limited study in this population. We aimed to validate the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder screen (GAD-7) and Primary Care PTSD screen for DSM-5 (PC-PTSD-5) in a methadone maintenance therapy (MMT) patient population in Hanoi, Vietnam. Methods: We conducted a cross-sectional survey. The PHQ-9, GAD-7, and PC-PTSD-5 were administered to MMT patients. A blinded interviewer administered the Mini-International Neuropsychiatric Interview (MINI) as the reference gold standard. Total scores of each tool were compared with the MINI diagnoses using a receiver operating characteristic curves, and we identified the optimal respective cut-off scores using the Youden’s Index. Results: We enrolled 400 MMT patients. Approximately 99.3% were male (n = 397) and 21.8% (n = 87) were HIV positive. The prevalence of major depressive disorder, generalized anxiety disorder and PTSD, respectively, was 10.5, 4 and 2%. Optimal cut-off scores for the PHQ-9, GAD-7 and PC-PTSD were ≥ 5, ≥3, and ≥ 4 with a sensitivity/specificity of 95.2%/91.9, 93.8%/87.5, and 62.5%/95.2%. Conclusions: The prevalence of CMDs in the MMT population was lower than expected. A lower cut-off score may be considered when screening for CMDs in this population. Further research should investigate the validity of somatic symptom-based screening tools among other drug-using or MMT populations

Examining common mental health disorders in people living with HIV on methadone maintenance therapy in Hanoi, Vietnam

Background: Injection drug use drives HIV transmission in Southeast Asia, where around a quarter of users are living with HIV. Vietnam developed Methadone Maintenance Therapy (MMT) programs to reduce unsafe drug abuse. Common mental health disorders (CMD), including depression, anxiety and post-traumatic stress disorder (PTSD), can worsen MMT outcomes and are highly prevalent among people living with HIV (PLH). We aimed to characterize HIV and CMD among MMT patients and assess the impact of HIV and CMD on MMT engagement outcomes in Hanoi, Vietnam. Methods: This cross-sectional study was conducted at an urban MMT clinic in Hanoi. Participants were screened for CMD with the relevant sections of the Mini International Neuropsychiatric Interview (MINI). Tabular comparisons and regression models were used to understand the association of HIV and CMD with substance use and methadone compliance. Results: Of the 400 MMT participants, 22% were living with HIV, 11% a CMD, 27% reported injection drug use, and 27% reported methadone noncompliance. Around 17% of those with HIV also had a CMD. Reporting non injection and injection drug use were each higher among those with CMD regardless of HIV status. In addition, reporting any drug use was much higher among those with both HIV and CMD than among those with neither (73% vs 31%, p value 0.001). While methadone noncompliance was lower among PLH than among those without HIV (16.3% vs 30.1%, p value 0.010), noncompliance was higher among those with CMD than among those without (40.5% vs 25.6%, p value 0.045). Among those without HIV, noncompliance was higher among those with CMD than among those without, but among those with HIV, the opposite relationship was observed. Conclusion: There is complex overlap between substance use and methadone noncompliance among MMT patients living with HIV, CMD or both. In this population, we found a high prevalence of CMD and substance use among PLH, and a high prevalence of substance use and methadone noncompliance among those with CMD. Prioritizing provision of mental health care services to MMT patients living with HIV can help improve engagement with substance use disorder treatment and reduce the risk of HIV transmission

The relationship between health-related variables and increases in smoking among recently diagnosed HIV+ people who inject drugs in Vietnam

Background: In Vietnam tobacco smoking is prevalent among people living with HIV (PLHIV) and causes excess mortality in this population. Injection drug use is a driver of HIV infections in Vietnam. Changes in HIV disease state may correlate to changes in smoking among PLHIV. This study investigates the relationship between increases in smoking and health-related variables among recently diagnosed HIV+ people who inject drugs (PWID) in Vietnam. Methods: We analyzed longitudinal data from 323 recently diagnosed HIV+ PWID in a randomized controlled trial from 2009 to 2013 in Thai Nguyen province, Vietnam. The outcome was an increase of >one cigarette/day from baseline visit cigarette smoking. A generalized estimating equation for repeated measures was used to estimate bivariable and multivariable associations between participant characteristics and smoking increases. We collected qualitative data to enhance our understanding of quantitative results, from 16 HIV+ PWID who smoke. Results: Ninety three point 5% of participants reported some smoking at baseline. Smoking fewer cigarettes, higher health related quality of life (QOL), and higher CD4 counts were predictive of increases in smoking at future visits in a multivariable model. Qualitative data showed smoking increases were tied to improved perceived health, and counseling during respiratory illnesses may increase intention to quit. Conclusion: HIV+ PWID in Vietnam smoke at a very high rate. Increases in their smoking are correlated to increases in heath-related QOL, and increases in perceptions of health. Any tobacco-use intervention should account for internal tobacco use triggers faced by HIV+ PWID

The role of depression in secondary HIV transmission among people who inject drugs in Vietnam: A mathematical modeling analysis

Background Among people who inject drugs (PWID), depression burden is high and may interfere with HIV prevention efforts. Although depression is known to affect injecting behaviors and HIV treatment, its overall impact on HIV transmission has not been quantified. Using mathematical modeling, we sought to estimate secondary HIV transmissions and identify differences by depression among PWID. Methods We analyzed longitudinal data from 455 PWID living with HIV in Vietnam during 2009–2013. Using a Bernoulli process model with individual-level viral load and behavioral data from baseline and 6-month follow-up visits, we estimated secondary HIV transmission events from participants to their potentially susceptible injecting partners. To evaluate differences by depression, we compared modeled transmissions per 1,000 PWID across depressive symptom categories (severe, mild, or no symptoms) in the three months before each visit. Results We estimated a median of 41.2 (2.5th, 97.5th percentiles: 33.2–49.2) secondary transmissions from all reported acts of sharing injection equipment with 833 injecting partners in the three months before baseline. Nearly half (41%) of modeled transmissions arose from fewer than 5% of participants in that period. Modeled transmissions per 1,000 PWID in that period were highest for severe depressive symptoms (100.4, 80.6–120.2) vs. mild (87.0, 68.2–109.4) or no symptoms (78.9, 63.4–94.1). Transmission estimates fell to near-zero at the 6-month visit. Conclusions Secondary transmissions were predicted to increase with depression severity, although most arose from a small number of participants. Our findings suggest that effective depression interventions could have the important added benefit of reducing HIV transmission among PWID. This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose

Estimating the Effect of Depression on HIV Transmission Risk Behaviors Among People Who Inject Drugs in Vietnam: A Causal Approach

The burden of depression and HIV is high among people who inject drugs (PWID), yet the effect of depression on transmission risk behaviors is not well understood in this population. Using causal inference methods, we analyzed data from 455 PWID living with HIV in Vietnam 2009–2013. Study visits every 6 months over 2 years measured depressive symptoms in the past week and injecting and sexual behaviors in the prior 3 months. Severe depressive symptoms (vs. mild/no symptoms) increased injection equipment sharing (risk difference [RD] = 3.9 percentage points, 95% CI −1.7, 9.6) but not condomless sex (RD = −1.8, 95% CI −6.4, 2.8) as reported 6 months later. The cross-sectional association with injection equipment sharing at the same visit (RD = 6.2, 95% CI 1.4, 11.0) was stronger than the longitudinal effect. Interventions on depression among PWID may decrease sharing of injection equipment and the corresponding risk of HIV transmission. Clinical trial registration ClinicalTrials.gov NCT01689545

Depression, antiretroviral therapy initiation, and HIV viral suppression among people who inject drugs in Vietnam

Background: The burden of depression is high among people who inject drugs (PWID) and may contribute to the spread of HIV through poor treatment engagement and persistent viremia. We estimated the effects of depression on antiretroviral therapy (ART) initiation and viral suppression among PWID living with HIV. Methods: Longitudinal data were collected from 455 PWID living with HIV in Vietnam during 2009–2013. We estimated the 6- and 12-month cumulative incidence of ART initiation and viral suppression, accounting for time-varying confounding, competing events, and missing data. The cumulative incidence difference (CID) contrasted the incidence of each outcome had participants always vs. never experienced severe depressive symptoms across study visits to date. Results: Severe depressive symptoms decreased the cumulative incidence of ART initiation, with CID values comparing always vs. never having severe depressive symptoms of -7.5 percentage points (95% CI: -17.2, 2.2) at 6 months and -7.1 (95% CI: -17.9, 3.7) at 12 months. There was no appreciable difference in the cumulative incidence of viral suppression at 6 months (CID = 0.3, 95% CI: -11.3, 11.9) or 12 months (CID = 2.0, 95% CI: -21.8, 25.8). Limitations: Discrepancies between the ART initiation and viral suppression outcomes could be due to under-reporting of ART use and missing data on viral load. Conclusions: Future work probing the seemingly antagonistic effect of depression on treatment uptake – but not viral suppression – will inform the design of interventions promoting HIV clinical outcomes and reducing onward transmission among PWID

Depressive Symptoms at HIV Testing and Two-Year All-Cause Mortality Among Men Who Inject Drugs in Vietnam

People who inject drugs (PWID) with HIV experience an elevated risk of death. A potentially important determinant of survival is the high burden of depression. This study examined the relationship of depressive symptoms at HIV testing with 2-year all-cause mortality among newly diagnosed HIV-positive PWID in Vietnam. At HIV testing, 141 PWID (42%) experienced severe depressive symptoms, and over the 2 years following diagnosis, 82 PWID (24%) died. Controlling for potential confounders, the 2-year risk of death among those with depressive symptoms was 9.7% (95% CI − 1.2, 20.6%) higher than the risk among those without depressive symptoms. This increased risk of mortality for PWID with depressive symptoms was relatively consistent throughout the 2-year period: at 6, 12, and 18 months, the risk difference was 12.6% (5.5–19.7%), 13.9% (4.6–23.2%), and 11.0% (0.9–21.1%), respectively. HIV diagnosis may provide an important opportunity for depression screening and treatment, subsequently improving survival in this key population. Trial registry: ClinicalTrials.gov NCT01689545

Longitudinal Analysis of Depressive Symptoms, Perceived Social Support, and Alcohol Use among HIV-Infected Men Who Inject Drugs in Northern Vietnam

Background: Limited research examines depressive symptoms, alcohol use, and social support among HIV-infected people who inject drugs. Objectives: Using longitudinal data, we investigated whether perceived social support moderates the relationship between depressive symptoms and alcohol use among HIV-infected men who inject drugs in Vietnam. Methods: Data were collected from participants (N = 455; mean age 35 years) in a four-arm randomized controlled trial in Thai Nguyen, Vietnam. Data were collected at baseline, 6, 12, 18, and 24 months with 94% retention excluding dead (N = 103) or incarcerated (N = 37) participants. Multilevel growth models were used to assess whether: (1) depressive symptoms predict when risk of alcohol use is elevated (within-person effects); (2) depressive symptoms predict who is at risk for alcohol use (between-person effects); and (3) within- and between-person perceived social support moderates the depressive symptoms-alcohol relationship. Results: Participants reported high but declining levels of depressive symptoms and alcohol use. Participants with higher depressive symptoms drank less on average (B = −0.0819, 95% CI −0.133, −0.0307), but within-person, a given individual was more likely to drink when they were feeling more depressed than usual (B = 0.136, 95% CI 0.0880, 0.185). The positive relationship between within-person depressive symptoms and alcohol use grew stronger at higher levels of within-person perceived social support. Conclusions: HIV-infected men who inject drugs have increased alcohol use when they are experiencing higher depressive symptoms than usual, while those with higher average depressive symptoms over time report less alcohol use. Social support strengthens the positive relationship between within-person depressive symptoms and alcohol use

Characteristics of persons who inject drugs and who witness opioid overdoses in Vietnam: a cross-sectional analysis to inform future overdose prevention programs

Abstract Background Persons who use opioids have a high risk of overdose and associated mortality. In Vietnam, little is known about the characteristics of this population and the persons who are witness to those overdoses. One approach to combatting fatal overdose has been the use of peer interventions in which a friend or injecting partner administers overdose reversal medication, but availability in Vietnam of these medications is limited to pilot programs with aims to expand in the future (Le Minh and V.F. Go, Personal Communication, 2016). The primary objective of this paper is to explore the characteristics associated with witnessing three or more overdoses in a lifetime. Methods This cross-sectional analysis used baseline data from a four-arm randomized control trial conducted in Thai Nguyen, Vietnam, known as the Prevention for Positives project. One thousand six hundred seventy-three PWID were included in the analysis. We conducted bivariable and multivariable logistic regression to identify characteristics associated with witnessing three or more overdoses in a lifetime. Characteristics explored included education, employment, marital status, risky drug use behaviors, locations for accessing syringes, recent overdose, history of incarceration, drug treatment, and having slept outside in the past 3 months. Results Seventy-two percent (n = 1203) of participants had witnessed at least one overdose in their lifetime, and 46% had witnessed three or more overdoses (n = 765). In the multivariable model, having less than secondary education (AOR 0.70; 95% CI 0.57, 0.86), having slept outside in the past 3 months (AOR 1.77; 95% CI 1.31, 2.40), having a history of incarceration (AOR 1.33; 95% CI 1.07, 1.65), having a history of drug treatment (AOR 1.41; 95% CI 1.12, 1.77), experiencing a recent non-fatal overdose (AOR 3.84; 95% CI 2.36, 6.25), injecting drugs daily (AOR 1.79; 95% CI 1.45, 2.20), receptive needle sharing (AOR 1.30; 95% CI 1.04, 1.63), and number of years injecting (AOR 1.04; 95% CI 1.02, 1.07) were significantly associated with witnessing three or more overdoses. Conclusions Targeted interventions are needed to train persons witnessing an overdose to administer overdose-reversal medication. This includes targeting persons prior to release from prisons, drug treatment centers, and those accessing syringe exchange programs. Additional research should assess the burden of witnessing an overdose as well as locations for medication distribution. Assessments of the training capacity and needs for implementing these programs among drug using peers in Vietnam are of the utmost importance