Psychiatric illnesses, in particular mood disorders
, commonly co-occur with the human immunodeficiency virus (HIV).1–4
Numerous studies report high rates of depression and depressive symptoms in HIV-infected individuals compared to uninfected individuals in the general population, and the rates have been reported to be significantly higher in women than in men.5
The relationship between depression and HIV infection is clinically important because the co-occurrence of the two conditions provides an additional health burden and can contribute to poor treatment adherence in women6,7
and thereby affect disease progression, viral suppression, and survival.8–11
For example, the Women's Interagency HIV Study (WIHS), a large multicenter investigation of 3766 women, found that in analyses adjusting for possible confounding factors, HIV-infected women with high levels of depressive symptoms were significantly less likely to be on highly active antiretroviral therapy (HAART) regimens.6
Depressive symptoms in HIV-infected women are associated with substance use, including the use of crack, cocaine, heroin, and amphetamines,7
and injected drugs.12
Depression in HIV-infected women has also been shown to be related to AIDS-related mortality,13
social and economic adverse events, and risk-taking behaviors, such as an increased number of sexual partners.12
Other predictors of depressive symptoms in HIV-infected women include low income, less than a high school education, and Hispanic ethnicity.12
Taken together, these findings suggest that reducing depressive symptoms in HIV-infected women may contribute to increased medication adherence, improved health, and a reduction in drug use and other maladaptive behaviors.
Despite a wealth of knowledge about factors related to depression and depressive symptoms in HIV-infected women, little is known about the prevalence of and risk factors for perinatal depression symptoms in this high-risk population. Perinatal depression encompasses major and minor depressive episodes that occur during pregnancy or within 1 year after childbirth. Prevalence estimates of perinatal depression in the general population range from 8.5% to 11% during pregnancy and from 6.5% to 12.9% during the first year postpartum depending on the assessment method (i.e., self-report measures, clinical interview), timing of the assessment (i.e., first, second, or third trimester of pregnancy or number of weeks after delivery), and population characteristics.14
Depressive symptoms that occur during this specific reproductive time are a serious mental health problem in the general population, and the consequences have critical implications for the mother; mother-infant relationship15
; the emotional, behavioral, and cognitive development of the child16,17
; and marital and family relationships.18
Early diagnosis and treatment interventions are critical to ensure the welfare of the mother, child, and family.
Only a few studies have examined the prevalence and risk factors of perinatal depression in high-risk populations, such as HIV-infected women and at-risk HIV-uninfected women. To our knowledge, only one study has examined the rate of perinatal depression among HIV-infected women. That study was a retrospective cohort design and involved 273 predominantly minority HIV-infected women from Los Angeles between 1997 and 2006.19
Perinatal depression was based on medical records or multidisciplinary chart notes indicating an onset of depression during pregnancy and/or within 4 weeks after delivery. The overall prevalence of perinatal depression was 30.8%, of depression during pregnancy was 22%, and of depression within 4 weeks postpartum was 18.3%. Estimates of the rate of perinatal depressive symptoms in HIV-infected women were not presented in the study.
There is also limited research on potential risk factors for perinatal depression in HIV-infected women. Only one study in HIV-infected women specifically examined correlates of depression in both the pregnancy and postpartum periods. Kapetanovic et al.19
reported that past history of a psychiatric illness, substance use during pregnancy, social stress during pregnancy, and lower CD4+ pregnancy nadir were associated with an increased risk of perinatal depression as defined by medical records and multidisciplinary notes in their sample of HIV-infected women (n
=273). Other studies have attempted to elucidate the predictors of depressive symptoms in HIV-infected women during either pregnancy or postpartum but not both time periods. One study (n
=307) examined correlates of depression during pregnancy as defined by the Center of Epidemiological Studies—Depression scale (CES-D) (interval measure with somatic items removed) in a sample of young, pregnant (≥24 weeks), HIV-infected women who were predominantly low-income, low-education (<12 years), and minority women (71% African American, 20% Hispanic).20
Depression during pregnancy was significantly associated with ineffective coping styles, stress, social isolation, and drug and alcohol use. Another study (n
=245) examined postpartum depressive symptoms operationally defined by the CES-D (median split of ≥15 was used to define depression) in a sample of young, low-income, low-education (<12 years), unmedicated, asymptomatic HIV-infected patients who had recently given birth (18–24 months postpartum) in Thailand.21
Postpartum depression was related to broken relationships, ineffective coping strategies, having an HIV-infected infant, and nondisclosure of HIV status to others. Taken together, these studies help to elucidate some of the determinants of depression during pregnancy and the postpartum period in HIV-infected women.
The primary objective of the present investigation was to assess the prevalence of elevated perinatal depressive symptoms in a sample of HIV-infected vs. at-risk HIV-uninfected women. The study design involved prospective evaluations of depressive symptoms as measured by the CES-D scale during preconception, pregnancy, and postpartum. Based on previous findings, we hypothesized that perinatal depressive symptoms would be increased in HIV-infected compared to at-risk HIV-uninfected women. The secondary objective was to examine risk factors for elevated perinatal depressive symptoms in HIV-infected and at-risk HIV-uninfected women. Given demonstrations that risky health behaviors7,12
(e.g., drug use, multiple sexual partners), sociodemographic factors12
(e.g., ethnicity, education, income), and service features6
(e.g., insurance status, use of mental health services) related to depressive symptoms in past studies of HIV-infected women, we examined these factors as risk factors of elevated perinatal depressive symptoms. We also examined unintended pregnancy as an additional risk factor, given that unintended pregnancy is associated with an increase in smoking, illicit drug use, and alcohol use compared with intended pregnancy.22