The paper sought to investigate the prevalence and the psychological, social and biological correlates of ‘moderate to high risk for suicidality’ (MHS) in HIV/AIDS in the African socio-cultural context. The principal finding of this study is that among ambulatory HIV/AIDS patients in the sub-Saharan African environment of Uganda, an increasing number of negative life events, past psychiatric history, and major depressive disorder were independent determinants of MHS. These results are in agreement with the stress-vulnerability model where social and psychological stressors acting on an underlying diathesis (including previous and current psychiatric morbidities) leads to suicidality [19
The prevalence of a ‘moderate to high risk for suicidality’ (MHS) in this study was 7.8 %, a figure similar to that reported for suicidal ideation of 12.4 % by Kinyanda (1998) in urban Pre-ART Uganda, 13 % by Petruskin et al., (2005) in urban Post-ART Uganda and more recently of 8.8 % by Rukundo (personal communication)
in semi-urban south-western Uganda. A life-time attempted suicide rate of 3.9 % reported in this study is similar to that of 3.1 % reported by Rukundo (personal communication)
in semi-urban south-western Uganda but much lower than the rates reported in western studies [7
]. Some of this difference with western studies can be attributed to differences in the risk for suicidality inherent to the sub-population being investigated [7
]. The sub-populations at risk for HIV in the west (‘men who have sex with men’ and IV drug users) have an inherently increased risk for suicidality independent of there HIV serostatus, this contrasts with the lower risk for suicidality associated with the general population derived heterosexually married sub-population (in this study sample, 48.5 %) who now constitute the biggest risk category for new HIV infections in sub-Saharan Africa [20
The majority of suicide attempters in this study (77.3 %) had done so once, similar results were reported by Kinyanda et al. (2005b) [22
] among a general hospital sample of suicide attempters in urban Uganda where the rate for first time suicide attempters was 75 %. The main method of suicide attempt reported in this study was the use of medications (both HIV medications and others, 52.4 %), this contrasts with the findings of Kinyanda et al., (2004) [23
] who among a general hospital sample reported that the main method of attempted suicide was by poisons (mainly organophosphates, 65 %). In this study female gender conferred a three fold increased risk for suicidality relative to the male gender, a similar female predominance has been reported in South Africa [24
] and France [9
] but has not been observed in other western countries [2
Social factors associated with an increased risk for suicidality in this study included an increasing number of negative life events and the associated stress and food insecurity. Previous research has reported the following negative life events to be correlated with suicidality in HIV/AIDS: physical and sexual abuse, multiple HIV-related losses, loss of employment or insurance cover, financial difficulties, and partner relational problems [2
]. Food insecurity has previously been correlated with major depressive disorder in HIV/AIDS [25
The psychological factors of a past psychiatric history and a diagnosis of major depressive disorder were independent correlates of MHS in this study. Bellini and Bruschi (1996) [7
] in a review of studies on HIV infection and suicidality pointed out that, ‘suicide attempts occur mainly in persons with a psychiatric history, previous attempted suicides or drug dependence’. More recent studies have also reported an association between suicidality in HIV/AIDS and psychological distress [2
] and major depressive disorder [12
Other psychological factors reported to be correlated with NHS in this study were a negative coping style and psychosocial impairment. Previous studies have reported that the positive coping style/adjustment of ‘spirituality’ and ‘a fighting spirit’ to be protective against suicidality [11
]. Pugh and colleagues (1993) studying a case series of HIV positive suicide in London observed that worsening physical health was a risk factor for suicide in HIV/AIDS [26
]. In this study there was no evidence for the role of the neurotoxic effect of the HIV virus and for HIV associated neurocognitive impairment as correlates of NHS.
Limitations of this study include firstly, that the cross sectional nature of this study made it difficult to determine the direction of causality of the investigated factors and MHS. Therefore, there is need for longitudinal studies to establish the exact causal direction between the investigated variables and MHS. Secondly, the number of individuals with some of the diagnosed psychiatric disorders was too small to enable us to satisfactorily explore independent associations with MHS. Thirdly, the threshold used as a cut off point for ‘moderate to high risk for suicidality’ (MHS) was derived from the authors of the M.I.N.I. neuropsychiatric assessment and has never been locally validated in the African socio-cultural environment. However the items used to assess for risk for suicidality i.e. previous suicide attempt, suicidal ideation, hopelessness and degree of planning have previously been shown to be associated with suicidality in the African environment by the first author [20
Fourthly, the use of the surrogate measure “risk for suicidality” instead of “suicidality” as the dependent variable may have reduced the importance of the correlates identified in this study.
Lastly, a number of the tools used to assess various psychosocial constructs have not been locally validated. These tools were however locally adapted through a forward and backward translation process and to minimise bias, only those tools with a minimum α Cronbach of 0.50 were used in the analysis for this paper.