Correlates of perceived Stigma and Depression among the women with HIV / AIDS infection

Background: Depression, a universal problem for individuals with HIV/AIDS because the disease creates uncertainty and disruption in every aspect of their lives. Objectives: To assess the level of perceived stigma and depression among women with HIV/AIDS infection and to determine relationship between perceived stigma and depression. Methodology: A cross-sectional study was carried out in Bel – Air hospital located at Panchgani, state of Maharashtra, India during year 2013 among the women with HIV/AIDS infection. By purposive sampling technique, 50 women were enrolled and interviewed by utilizing Standardized data collection tool i.e. stigma perception scale by Sowell et al and CES-D by Radloff after institutional ethical clearance certificate. Statistics: Descriptive statistics, chi-square test and correlation coefficient was used to analyze the data. Results: The out of a total 50 HIV infected women maximum, 26(52%) were belonged to the age group of 28 – 36 years. All the women were married out of which majority were widows 28(56%). Among the study subjects, maximum, 25(50%) were having secondary education, followed by 46(92%) as housewives. 38(76%) women were aware of HIV status ranging from 1 month to 2.5 years. However, 43(86%) reported that they had acquired HIV infection from their husband. Almost all women perceived stigma at some or other time of which majority, 26(52%) perceived stigma frequently whereas 19(38%) and 5(10%) perceived stigma always and occasionally respectively. Similarly all the women have some sort of depression and majority, 37(74%) experienced depression most of the time whereas 13(26%) experienced depression occasionally. The perceived stigma and depression have a significant positive correlation as indicated by correlation coefficient. Conclusion: Moderate to severe degree of stigma and depression was perceived by women with a status of HIV/AIDS infection. A significant positive relationship is also existed between perceived stigma and depression among the women with HIV/AIDS infection.


Introduction:
Twenty six years into acquired immunodeficiency disease syndrome (AIDS) epidemic, revolutionary improvement in medical treatment of HIV/AIDS has converted the once life-threatening terminal illness into a manageable chronic disease 1 , but what changes these medical advances have brought when people still die because of isolation, stigma, discrimination, hatred and violence.More than medical support, we have reached into an era where psychological demands are to be met in advance.A person with AIDS experience serious psychological problems as a result of decreased self-esteem or rejection by the family and friends.AIDS has arouse a lot of emotions such as agony, frustration, shame, anger, guilt, fear, panic, loneliness, helplessness, anxiety, insecurity, uncertainty, and depression.AIDS often can result in stigma and fear for those living with the infection, as well as for those caring for them and may affect the entire family.AIDS often results in loss of socio-economic status, employment, housing, health care and mobility.For both individuals and their partners and families, psychosocial support can assist them in making informed decisions, coping better with illness and dealing more effectively with discrimination 2 .Depression is a universal problem for individuals with HIV/AIDS because the disease creates uncertainty and disruption in every aspect of their lives.HIV/ AIDS and depression are projected to be the two leading causes of disability by 2030 3 .Depression may have a negative impact on adherence, may affect quality of life, and is a predictor of poor treatment outcome.Depressions have a negative impact on HIV disease progression and the people living with HIV/AIDS (PLHAs) quality of life.HIV-related stigma and discrimination are major "road blocks" to universal access to HIV prevention, treatment care and support 4 .The present study designed to address the stigma and depression perceived by women with HIV/AIDS infection from western Maharashtra, India which is a most important public health and social issue which was yet not addressed.According to the National Aids Control Programme (NACP) released on World AIDS Day 2013, HIV/AIDS remains a major health problem in Maharashtra state as a rank 2 nd in India with an estimated 7.47 lakh persons infected with HIV.More than 14,500 people have died due to HIV/ AIDS in three-and-half years since April 2009 in India's second largest state of Maharashtra 5 .

Material and Methods:
A cross-sectional study was designed for a present study that includes descriptive epidemiological approach.The study setting was purposively selected Bel-Air hospital Panchgani, Maharashtra, a 240 bedded general hospital with all medical disciplines.Bel-Air hospital today is a home to a large number of HIV/AIDs patients from eleven blocks of Satara district, Maharashtra due to quality of HIV/AIDS services.The sample size used for present study was 50 women with HIV/AIDS status by utilizing purposive sampling technique and inclusion criteria of the study.Inclusion criteria: Women with positive HIV/AIDS status, in age group of 18 -45 years, attending HIV/AIDS and community care centre at Bel -Air Hospital, Panchgani during data collection period, resident of Maharashtra state and willing to participate in the study.The study was conducted in year 2013 after the institutional ethical clearance certificate.A standardized questionnaire was used to collect the information from study respondents that includes background information, stigma perception and depression scale.The perceived-stigma scale was developed by researchers of the Family Coping Project, a CDC funded study (1992-1995) in order to examine stressors and resistance factors of rural and urban women with HIV disease and their families residing in Georgia by Sowell et al 6 .The instrument was developed based on an exhaustive review of literature and data from multiple focus groups conducted with rural and urban women infected with HIV.The stigma-perceptions scale consisted of 12 items designed to assess respondents' frequency of experiencing various aspects of HIVrelated stigma within the previous six months.Fourpoint Likert type response options included never (1), rarely (2), sometimes (3), and always (4).A total stigma score (range = 12-48) was obtained by summing the responses of all 12 items.Higher scores indicated higher levels of HIV related stigma.A 20item self-report scale developed by the Centers for Epidemiological Studies of Depression (CES-D) by Radloff LS 7 was used to measure depression.The scale contained nine components; Sadness(Dysphoria), Loss of Interest(Anhedonia), Appetite, Sleep, Thinking / concentration, Guilt(Worthlessness), Tir ed(fatigue),Movement(Agitation), Suicidal ideation.Participants rated the extent to which they had experienced each item (depressive symptom) in the past week using a four-point response format ranging from "rarely or none of the time" (0) to "most or all of the time" (3).Four items in the scale (item # 4, 8, 12, and 16) were reverse-coded.Responses for each item were summed to obtain the total CES-D score ranging from 0 to 60. Higher scores indicated higher levels of depressive symptoms.As mentioned earlier, a score of 16 or higher has been shown to be significantly correlated with clinical depression.
Pilot study was conducted at Bel-Air Hospital Panchgani to test the feasibility and practicability and further modification of methodology.The data collection was collected by interview method utilizing structured questionnaire during the month of August to October, 2013 at Bel Air hospital Panchgani.

Statistical analysis:
The data was entered into a master data sheet and organized and analysed.Descriptive and inferential statistics was applied to describe background information, perceived stigma and depression.Chi-Square test was used to find out the association between perceived stigma, depression and demographic variables whereas correlation coefficient was used to determine the relationship between perceived stigma and depression.

Working definitions:
Perceived Stigma: Stigma refers to unfavorable attitudes and beliefs directed toward someone or something.In this study stigma refers to perceived or felt stigma refers to an individual's anticipated fear of societal attitudes and potential discrimination due to HIV infection 4 .Depression: Depression is a period of intense sad mood and other physical symptoms that exist nearly every day for at least 2 weeks 17 In this study depression refers to affective components: depressed mood, feelings of guilt and worthlessness, feelings of hopelessness and helplessness, psychomotor Among the total 50 HIV/AIDS infected women maximum, 26(52%) were belonged to the age group of 28 -36 years.All the women were married and of which 28(56%) were widows.Among the study subjects, maximum, 25(50%) were having secondary education, followed by 46(92%) as housewives.The 38(76%) women were aware of HIV status ranging from 1 month to 2.5 years however, 43(86%) reported that they had acquired HIV infection from their husband.The maximum, 24(48%) women were from low economic sector i.e. family income less than Rs.2000 per month.Majority of women, 42(84%) reported that their children are to be HIV negative (Table 1).Table 2 reveals that almost all women perceived stigma due to HIV/AIDS infection of which maximum, 26(52%) perceived stigma frequently, whereas 19(38%) and 5(10%) perceived always and occasionally.The participants experienced high level of perceived stigma as indicated by average score of 33.160 ± 6.322 ranging from 18 to 44.According to stigma perception scale, higher scores indicated higher levels of HIV/AIDS related stigma.All the women experienced some form of depression of which maximum, 37(74%) experienced depression most or all of the time whereas 13(26%) experienced depression occasionally or moderate amount of time.
The participants had high level of depression as indicated by average score of 42.480 ± 7. 993 ranged from 23 to 55.If CES-D score is ≥16, the depression is highly correlated with a clinical diagnosis of depression (Table 3).The level of perceived stigma among the women with HIV/AIDS infection is significantly associated with their occupational status (p<0.05)(Table 5).Statistical analysis using Chi-square test does not shows any significant association between experienced depression by women with HIV/AIDS infection and demographic variables as indicated by p value > 0.05 at 95% confidence interval (Table 6).

Discussion:
The present study have been shown that out of 50 women with HIV/AIDS infection maximum, 52% of women belonged to the age group of 28-36 years.A study conducted by Phaladze 9 reported that 61.2% women were in age group of 27 -36 years and difference could be due to study is conducted in rural area of India, a developing country however, Phaladze 9 findings were from developed would.Socio-cultural factors in Rural India could be responsible for poor health seeking behavior among women.
All the women in this study were married and almost similar findings have been also noted by Jebessa S from Ethiopia 10 where more than 92% were married women.The 56% women were widows and study conducted by Bimal 11 also observed similar findings.The 50% of the women in our study have been educated upto secondary level and a similar finding has also been reported by Lasiele Y 12 among Nigerian women.Majority of women, 92% were housewives however, study conducted by Jebessa, in Ethiopia 10 observed that 70.1% women were housewives and the difference could be due to rural culture of study subjects.The 48% respondents were from poor economic background observed in the study and similar findings also have been noted by Bimal 11 among South India women.It indicates that poverty, illiteracy and lack of knowledge could be responsible for HIV/AIDS transmission in Indian community.
In present study maximum, 76% women knew their HIV/AIDS status which was ranging from 1 month to 2.5 years before the time of interview.Almost a similar finding has also been reported by Thom 13 .The 86% women reported that they had acquired HIV infection from their husband.A study conducted by Gangakhedar 14 among India women also observed almost similar findings i.e. 85% women were infected due to HIV/AIDS through generally their spouse.Similarly Thom  18 .Mothers' levels of depression were also significantly higher when their levels of stigma were higher.The high levels of stigma have been linked with lower self-concept, poorer emotional outcomes, and greater psychological distress in mothers with HIV.A study conducted by Sandelowski 19 found that both perceived and enacted stigma was pervasive in the lives of HIV-positive women.HIV-related stigma was intensified in women because they were women.Stigma management largely involved efforts to control information in the service of preserving social relations and maintaining moral identity.The perceived stigma and depression have a significant correlation as shown by p value <0.0001 which is moderate positive indicated by an r value of 0.7027.It shows that perceived stigma influences depression in women with HIV disease.Similar finding was also noted by Endeshawl 20 from Ethiopia indicating that higher levels of HIV-related stigma were significantly associated with higher levels of depressive symptoms ( p< 0.001).A study conducted by Emlet 21 also reported that stigma was positively and significantly correlated with depression (r = 0.627, p = 0.001).

Conclusion:
Based on the present study, it is concluded that high level of stigma and depression was perceived by women with HIV/AIDS infection residing in rural area of western Maharashtra, India.Further, housevies were commonly affected by the stigma and depression in the community.

Ethical consideration:
Institutional ethical clearance certificate and permission from Bel-Air Hospital Panchgani, Maharashtra was obtained.Informed consent was also obtained from study respondents and confidentiality was maintained.Source of funding: Nil Conflict of interest: None declared

Table 1 : Frequency and percentage distribution of sample characteristics n=50
8etardation, loss of appetite and sleep retardation8.HIV positive status: HIV positive status in this study refers to HIV seropositive status by means of serological tests, polymerase chain reaction test or virological tests.Results: The data was obtained from 50 women presented in terms of age, marital status, educational status, occupational status, economic status, time since diagnosis, number of children, HIV status of children and route of transmission.

Table 4
and Fig 1 reveals that the perceived stigma and depression have a significant positive correlation as indicated by value of correlation coefficient (r) of 0.702 and p value of <0.0001.It shows that perceived stigma influences depression in women with HIV/ AIDS infection.

Table 5 : Association between perceived stigma and demographic variables
* = significant p value 95% confidence interval

,
17also has been reported in his study that 91.06% women had become infected with HIV through a regular partner.In present study 52% participants experienced high level of perceived stigma as indicated by average score of 33.160 ± 6.322.A study conducted byBimal 11from South India also observed severe personalized stigma as indicated by average score of 28.8% (24.3-33.2).A similar finding has been also noted by Murphy D 15 .Bennetts et al17and Shanthi AG