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ORIGINAL RESEARCH

Psychosocial Factors Associated with Suicidal

Ideation Among HIV/AIDS Patients on Follow-Up
at Dessie Referral Hospital, Northeast Ethiopia: A
Cross-Sectional Study
This article was published in the following Dove Press journal:
HIV/AIDS - Research and Palliative Care

Koku Sisay Tamirat Background: Psychosocial and mental health problems are common among HIV/AIDS
Getayeneh Antehunegn patients that affect sustained utilization of healthcare services. To date, information is scarce
Tesema regarding the perceived stigma, level of social support, and suicidal ideation among HIV/AIDS
Zemenu Tadesse Tessema patients in the study setting. Therefore, this study aimed to assess psychosocial factors associated
with suicidal ideation among HIV/AIDS patients on follow-up in the study setting.
Department of Epidemiology and
Methods: A hospital-based cross-sectional study was conducted among people living with
Biostatistics, Institute of Public Health,
College of Medicine and Health Sciences, HIV/AIDS (PLWH) on antiretroviral therapy follow-up for at least six months at a referral
University of Gondar, Gondar, Ethiopia hospital in northeastern Ethiopia from November to January 2019. A total of 395 study
participants of antiretroviral therapy clinic visitors were selected systematically. A binary logistic
regression model was fitted to identify factors associated with suicidal ideation among PLWH.
An adjusted odds ratio (AOR) with 95% confidence interval (CI) and variables having less than
or equal 0.05 p-value used to declare statistical significant association.
Results: This study revealed that 45.3%, 56.5%, and 20%, had perceived stigma, poor social
support, and depression, respectively. Moreover, the prevalence of suicidal ideation was
9.4% (95% CI: 6.7 to 12.7) of which, 3.3% had attempted to kill themselves. Low body mass
index (AOR=4.11, 95% CI: 1.70 9.91), stages three and above illnesses (AOR=6.63, 95% CI:
1.30 33.79), depression (AOR=4.67, 95% CI: 4.67, 95% CI: 1.75 3.93), poor social support
(AOR=4.18, 95% CI: 1.46 11.94), and fair and poor adherence (AOR=3.51, 95% CI: 1.14
10.85) were factors associated with suicidal ideation among PLWH.
Conclusion: This study showed that mental disorders and psychosocial problems were
common among PLWH. The poor social support, depression, low body mass index, and
poor adherence to ART medications were factors associated with suicidal ideation. This
finding underscores the importance of regular screening for common mental health disorders
and the strengthening of counseling services, nutritional, and psychosocial support programs.
Keywords: suicidal ideation, psychosocial factors, Ethiopia

Introduction
Correspondence: Koku Sisay Tamirat The world has made significant progress in the prevention and control of HIV/
Department of Epidemiology and AIDS in the last three decades, however, the disease remains a major global public
Biostatistics, Institute of Public Health,
College of Medicine and Health Sciences, health issue. According to the World Health Organization (WHO) 2019 report,
University of Gondar, P.O. Box 196, about 38 million peoples living with HIV/AIDS, of which 1.7 million were new
Gondar, Ethiopia
Email [email protected] cases, and about 690, 000 HIV/AIDS-related deaths occurred.1 The introduction of

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Tamirat et al Dovepress

Highly Active Antiretroviral Therapy (HAART) saved substance use and treatment failure, and intractable social
millions of lives and significantly reduced the transmission support are determinants of depression and suicidal ideation
of the virus in the population. Thus, HAART reduced new among HIV/AIDS patients.10,12–16 The integration of HIV
HIV infection by 39%, HIV-related death by 51%, and care and treatment with counseling and psychosocial support
saved 15.3 million lives. However, only 68% of adults programs are helpful for the reduction of mental disorder and
living with HIV received lifelong antiretroviral therapy psychosocial concerns among PLWH. Besides, the involve­
(ART) in 2019 according to the WHO annual report.1,2 ment of HIV/AIDS patients in income-generating activities
More than two-third (25.7 million) of peoples living with showed a promising effect on the improvement of social net­
HIV/AIDS live in WHO Africa region and the diseases is more works and alleviating financial hardships.17 To date there is
prevalent in the general population and number of new infections a scarcity of information regarding the perceived stigma, level
are increasing among the most vulnerable groups.1 Different of social support, and suicidal ideation in the study setting.
interventions were made to realize the 90 90, 90 strategies of Therefore, this study aimed at the psychosocial factors asso­
2020 targets like by increasing the number of testing sites, ciated with suicidal ideation among HIV/AIDS patients on fol­
implantation of test and treat strategies, and point of care low-up in the study setting. The findings of this study could help
(POC) approach. Point of care strategies of HIV care treatment for the evaluation of psychosocial supports at HIV/AIDS pro­
is intended to provide accessible and affordable services like viral grams. In addition, the results of this study could help to integrate
load, CD4 count measurement, and staging of the disease.3 mental health services with HIV/AIDS treatment programs.
According to UNAIDS 2020 report, 81% of peoples living
with HIV/AIDS know their status, 67% were on ART and Methods
59% had achieved viral suppression.2,4 In Ethiopia, there are
Study Design, Setting, and Period
about 690, 000 peoples living with HIV/AIDS, with 23, 000
An institution-based cross-sectional study was undertaken at
are new infections, and 11,000 people died from an AIDS-related
Dessie referral hospital from November to January 2019. The
illness.1 Further interventions are needed to achieve the targets
hospital is the largest hospital serving millions of people in the
set; given that only 79% of peoples living with HIV/AIDS knew
region of Amhara and neighboring Afar, situated 401 kilo­
their status, of whom 65% were on HAART.4
meters away from Addis Ababa, the capital of Ethiopia. In
Mental health and psychosocial problems are common
addition to general care, the hospital has also offered more
among HIV/AIDS patients that affect sustained utilization of
than 6, 763 HIV/AIDS (6279 adults and 484 pediatric) patients
healthcare and adherence to the medications.5 Some of the
with antiretroviral therapy since the launch of the program.
mental health impairments are mood disorder, elevated
depressive symptoms, and suicidal ideations. The trends of
mental health problems are increasing worldwide and caused 1
Study Participants and Sampling
in 5 years lived with disability.6 In addition, there has been Procedures
a 13% rise in mental health conditions and substance use The study population consisted of adult HIV/AIDS patients
disorders in the last decade (to 2017).7 Around 20% of the who had been followed up on for at least six months. Patients
world’s children and adolescents have a mental health condi­ aged 18 and up who had been on ART for at least 6 months and
tion, with suicide the second leading cause of death among were available at the ART clinic during the data collection
15–29-year.7 Approximately one in five people in post-conflict period were also eligible. The sample size was estimated
settings have a mental health condition. About 79% of global using the single proportion formula with the assumptions of
suicides occur in low- and middle-income countries and close prevalence (P) suicidal ideation among HIV-positive adults
to 800, 000 people die due to suicide every year.8,9 Many (33.6%) obtained from a study conducted in Ethiopia, 95%
mental health conditions can be effectively treated at confidence level, a margin of error of 5%, and a 10% non-
a relatively low cost, yet the gap between people needing response rate, resulting in a sample size of 378.10 Finally, 395
care and those with access to care remains substantial. HIV/AIDS patients on follow-up were chosen from ART clinic
Effective treatment coverage remains extremely low. visitors using a systematic random sampling technique.
According to a study in low-income countries about 36.6%,
22.5%, 43.9% of HIV/AIDS patients had depression, suicidal Data Collection Procedure
ideation, and faced perceived stigma, respectively.10–12 After reviewing various literature, questionnaires were pre­
Moreover, advanced disease conditions, prior mental disorder, pared in English, then translated into the local Amharic

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Dovepress Tamirat et al

language, and then translated back to ensure its consistency. Fair adherence: (85–94% or 4–8 doses missed per
There are socio-demographic, clinical, psychosocial, and men­ month).19
tal health elements of the questionnaire. Two data collectors Poor adherence: (less than 85% or ≥9 doses missed per
and one supervisor were hired before the initial data collection, month).
and they received one-day training on the target and how to Perceived stigma: Participants who scored above
interview participants and collect data from medical records. the median score ≥ 24 were perceived stigma and
The nine-item structured Patient Health Questionnaire those who scored below the median score (<24) were
(PHQ-9) and the suicide manual of the Composite not perceived stigma measured by using the HIV
International Diagnostic Interview were used to collect data stigma scale.20
on depression and suicidal ideation and attempt (CIDI). In Social support: The OSS-3 scores ranged from 3–14
addition, using the Oslo Social Support Scale (OSS) and with a score of 3–8 = poor support; 9–11 = moderate
HIV-stigma scale, the level of social support and perceived support; and 12–14 = strong support.21
stigma was measured. Suicidal ideation was the response Body Mass Index: based on Nutritional assessment classi­
variable, while socio-demographic (age, sex, education fication underweight <18.5 kg/m2, Normal=18.5–24.9 kg/m2,
level), clinical (ART routine, recent CD4 count, opportunistic over weight ≥25kg/m2.22
infection, WHO stage, and adherence to ART medication)
and psychosocial (depression, social support, and level of
stigma) variables were independent variables. Data Processing and Analysis
Initially, the completed questionnaire was reviewed manu­
Operational Definition ally for completeness and coding, entered in EpiData ver­
Depression: Participants who were interviewed and scored sion 3.1, and exported to STATA version 14 for further
five and above using patient health questioner 9 (PHQ-9) data management and analysis. Frequencies and percen­
were considered depressed.18 tages of socio-demographic, clinical, and psychosocial
Good adherence: If the average adherence level (95% or features are computed and displayed in charts, graphs,
more adherence = missing ≤ 2 doses of 30 doses or ≤3 doses of and texts. The binary logistic regression analysis was
60 doses).19 developed to classify factors associated with suicidal

Figure 1 Receiver Operative Curve (ROC) of model comparison after logistic regression model.

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ideation. Crude and adjusted odds ratio of 95% CI esti­ Result

mated to see the presence and severity of the correlation Socio-Demographic and Behavioral
between independent variables and depression.
In the multivariable logistic model, variables with
Characteristics
A total of 395 patients were included in the final analysis of the
a p-value of 0.05 or less were considered significantly
study. The median age was 38 years with an Interquartile range
correlated with suicidal ideation. Using the Hosmer and
(IQR) of 10 years, about 47.1% % of them aged between 35–44
Lemeshow goodness of fit test, the model adequacy was
years. Two hundred forty-two (61.3%) patients were females,
tested and revealed that the p-value of 0.222 is insignif­
icant suggested that the model matches the data better. 44.6% were single, and the majority (90.4%) of them were
Moreover, after running the null and full models, the urban dwellers. Regarding behavioral characteristics, about
area under the curve (AUC) was compared, and the full 94.7% disclosed their HIV Status, 30.9% ever consumed alco­
model had the highest AUC value of 0.8534, suggesting hol, 3% smoked a cigarette, and 10.1% chewed Khat. About
that it better explained the data over the null model 45.6% of respondent’s partners were HIV positive, of which
(Figure 1). 96.1% of them were on ART (Table 1).

Table 1 Socio-Demographic and Behavioral Characteristics HIV/AIDS Patients in Ethiopia

Characteristics Category Frequency, N (%) Suicidal Ideation P-value

Yes No

Age 18–24 13(3.3) 3(23.1) 10(76.9) 0.146

25–34 112(28.8) 13(11.6) 99(88.4)
35–44 186(46.1) 11(5.9) 175(94.1)
45–54 57(14.6) 7(12.3) 50(87.7)
≥55 27(7) 3(11.1) 24(88.9)

Sex Male 153(38.7) 10(6.5) 143(93.5) 0.125

Female 242(61.3) 27(11.2) 215(88.4)

Residence Urban 357(90.4) 34(9.5) 323(90.5) 0.743

Rural 38(9.6) 3(7.9) 35(92.1)

Marital status Married 74(18.7) 7(9.5) 67(90.5) 0.0001

Single 176(44.5) 7(4) 169(96)
Divorced 60(15.3) 5(8.3) 55(91.7)
Widowed 85(21.5) 18(21.2) 67(78.8)

Level of education No formal education 209(52.9) 19(9.1) 190(90.9) 0.010

Primary school 93(23.5) 5(5.4) 88(94.6)
Secondary school 60(15.2) 12(20) 48(80)
Diploma and above 33(8.3) 1(3) 32(97)

Occupation Unemployed 18(4.5) 2(11.1) 16(88.9) 0.005

Employed 69(17.5) 4(5.8) 65(94.2)
Housewife 144(36.5) 8(5.6) 136(94.4)
Daily laborer 99(25.1) 19(19.2) 80(80.8)
Merchant 37(9.3) 1(2.7) 36(97.3)
Farmers 28(7.1) 3(10.7) 25(89.3)

Alcohol use Yes 143(36.2) 19(13.3) 124(86.7) 0.044

No 252(63.8) 18(7.1) 234(92.9)

Khat chewing Yes 38(9.6) 6(15.8) 32(84.2) 0.153

No 357(90.4) 31(8.7) 326(91.3)

Smoking Yes 13(3.3) 3(23.1) 10(76.9) 0.085

No 382(96.7) 34(8.9) 348(91.1)

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Clinical Conditions of the Participants Perceived Stigma, Social Support, and

The duration of illnesses for the majority (93.9%) of patients Suicidal Ideation
were above 12 months, 83.5% had stage one diseases, about Of the overall participants, 45.3%, 56.5%, and 20%
88.4% of patients were on first-line antiretroviral therapy (ART) were viewed as a stigma, low social support, and
of which, and 92.2% of patients took ART for more than 12 depression. Whilst, the prevalence of suicidal ideation
months and more than two-thirds of patients were on Efavirenz was between 9.4% (95% CI: 6.7 to 12.7) and 3.3%
(EFV) based regimen. Meanwhile, 5.8% had chronic illnesses, attempted suicide. More specifically, the prevalence of
of which Diabetes mellitus and Hypertension were common suicidal ideation among depressed, stigma-ridden, and
comorbid conditions, 7.8% had opportunistic infections in the inadequate social support was 29.1%, 10.6%, and
past six months, and 13.9% had Anemia (Hg<12gm/dl). The 12.6%, respectively (Figure 1). Of those who wanted
majority (81.3%) had a recent CD4 count above 200 cells/ to kill themselves, chemical substances such as
mm3, and 70.6% of undetected viral load on recent follow-up Berekina, Merz, and hanged were widely used materials
measurements (Table 2). (Figure 2).

Table 2 Clinical Characteristics of HIV/AIDS Patients in Ethiopia (N=395)

Characteristics Category Frequency, N(%) Suicidal Ideation P-value

Yes No

ART regimen First line 349(88.4) 33(9.5) 316(90.5) 0.868

Second line 46(11.6) 4(8.7) 42(91.3)

ART regimens TDF/3TC/EFV 137(34.7) 9(6.6) 128(93.4) 0.889

AZT/3TC/NVP 88(22.3) 11(12.5) 77(87.5)
TDF/3TC/NVP 68(17.2) 9(13.2) 59(86.8)
AZT/3TC/EFV 57(14.4) 5(8.7) 52(91.3)
ABC/3TC/ATV/r 17(4.3) 1(5.9) 16(94.1)
TDF/3TC/ATV/r 11(2.8) 1(9.1) 10(90.9)
AZT/3TC/ATV/r 7(1.8) 1(14.2) 6(85.8)
Other 10(2.5) 0(0) 10(100)

Duration since known to have HIV ≤12 months 24(6.1) 2(8.3) 22(91.7) 0.858
>12 months 371(93.6) 35(9.4) 336(90.6)

Recent CD4 count ≤200 cells/mm3 74(18.7) 13(17.6) 61(82.4) 0.007

>200cells/mm3 321(81.3) 24(7.5) 297(92.5)

Recent viral load Not detected 279(70.6) 33(11.8) 246(88.2) 0.027

Up to 999 31(7.9) 2(6.5) 29(93.5)
>1000 85(21.5) 2(2.4) 83(97.6)

Hgb level <12 mg/dl 55(13.9) 11(20) 44(80) 0.004

≥12 mg/dl 340(86.1) 26(7.6) 314(92.4)

WHO T stage Stage I 330(83.5) 22(6.7) 308(93.3) 0.0001

Stage II 37(9.4) 4(10.8) 33(89.2)
Stage III and above 28(7.1) 11(39.3) 17(60.7)

Recent adherence to HHART Good 365(92.4) 25(6.8) 340(93.2) 0.0001

Fair and poor 30(7.6) 12(40) 18(60)

Opportunistic infections Yes 31(7.8) 10(32.3) 21(67.7) 0.0001

No 364(92.2) 27(7.4) 337(92.6)

Recent hospitalization Yes 21(5.3) 10(47.6) 11(52.4) 0.0001

No 374(94.7) 27(7.2) 347(92.8)
Abbreviations: ABC, abacavir; ATV/r, atazanavir/ritonavir; AZT, zidovudine; EFV, efavirenz (EFV); NVP, nevirapine; TDF, tenofovir; 3TC, lamivudine.

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Figure 2 A graph showing common psychosocial problems of HIV/AIDS patients in Ethiopia.

Factors Associated with Suicidal Ideation major health problems among HIV/AIDS patients.
In those patients who had poor social support, the odds of Especially stigma and poor social support for HIV/AIDS
suicidal thought was 3.64 times higher compared to those patients, which can impede care and good clinical predic­
who had moderate and strong social support (AOR=4.18, tion. The completion of this research was consistent with
95% CI: 1.46 11.94). Similarly, those patients who had studies in Ethiopia and Nigeria.10,23
a low body mass index (BMI<18.5 kg/m2) associated with In addition, this research also found that poor social
4.46 times higher than those who had normal BMI support, low BMI, depression, disease stage, ART regi­
(AOR=4.11, 95% CI: 1.70 9.91). Moreover, in patients men, and poor adherence to ART drugs were variables
who had depression, the odds of suicidal ideation were associated with suicidal ideation. In contrast to other
4.28 times than higher those who had not depression Ethiopian studies, the magnitude of suicidal ideation in
(AOR=4.67, 95% CI: 1.75 12.39). For those patients this sample was relatively poor. This may be because the
who had poor adherence the odds of suicidal ideation research participants took ART for at least six months,
was 4.11 times than those who had good adherence to resulting in clinical recovery and emotional relaxation for
ART medications (AOR=3.51, 95% CI: 1.14 10.85). the majority of the patients.
Those patients on the first-line ART regimen had 4.69 Thus, those patients who had insufficient social support
times higher odds of suicidal ideation than those on were associated with increased self-murder thoughts. This
the second-line regimen (AOR=4.69, 95% CI: 1.05 result was in line with results from Ethiopian studies.10,11,24
2085). Patients who had the second stage of diseases This may be because social support plays a critical role in
were associated with 6.13 times higher odds of suicidal the psychosocial adaptation to the living conditions of
ideation than those asymptomatic individuals (AOR=6.13, patients. In addition, social support is the social health
95% CI: 1.30 33.79) (Table 3). determinant (SDH) that affects the quality of life of the
patient and the use of health care networks.
Discussion Depression was similarly associated with higher suicidal
This research found that common mental illnesses were ideation odds. This result was consistent with prior results
more common, with around 56.5%, 45.3%, 20%, 9.4%, from the report.11 This may be because extreme depressive
and 3.3% having inadequate social support, perceived symptoms are related to suicidal risk and thoughts. Depression
stigma, depression, suicidal thoughts, and attempts, affects everyday activities, social interactions, and low self-
respectively. Common mental health issues such as depres­ esteem can cause increased suicidal thoughts. Similarly, rela­
sion, suicidal ideation, stigma, and discrimination are tive to asymptomatic people, patients with stage two HIV/

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Dovepress Tamirat et al

Table 3 Binary Logistic Regression Analysis to Identify Factors Associated with Suicidal Ideation Among PLWH
Characteristics Suicidal Ideation Crude OR Adjusted OR P-value

Yes No

Sex of patient
Male 10 143 1 1
Female 27 215 1.79(0.84 3.82) 1.48(0.59 3.70) 0.392

Age of patient
Below 35 16 109 1 1
Above 35 21 250 0.57(0.28 1.14) 0.95(0.40 2.26) 0.922

ART regimen
First line 33 317 1.09(0.36 3.24) 4.69(1.05 20.85) 0.042*
Second line 4 42 1

Recent T stating
1 24 308 1 1
2 4 33 1.69(0.55 5.22) 2.13(0.60 7.58) 0.241
3 and above 11 18 9.05(3.78 21.68) 6.63(1.30 33.79) 0.023*

Adherence to ART
Fair and Poor 12 18 9.06(3.93 20.91) 3.51(1.14 10.85) 0.029*
Good 25 341 1 1

BMI
Low BMI 19 54 5.94(2.93 12.04) 4.11(1.70 9.91) 0.002*
Normal 18 305 1 1

Recent CD4 count

Below 200 13 62 1 1
Above 200 24 297 0.37(0.18 0.78) 1.37(0.48 3.93) 0.551

Depression
Yes 24 56 10.17(4.88 21.17) 4.67(1.75 12.39) 0.002*
No 13 303 1 1

Social support
Poor 29 195 3.06(1.36 6.88) 4.18(1.46 11.94) 0.008*
Moderate and strong 8 164 1 1

HIV related stigma

Yes 19 160 1.30(0.66 2.57) 1.36(0.58 3.21) 0.473
No 18 199 1 1

Recent OI
Yes 10 21 5.94(2.54 13.89) 0.97(0.21 4.52) 0.977
No 27 338 1 1
Notes: *Significant at p-value ≤0.05.
Abbreviations: OI, opportunistic infections; OR, odds ratio; BMI, body mass index.

AIDS following treatment had a higher risk of suicidal idea­ The Efavirenz-containing first-line antiretroviral therapy
tion. This result was in line with previous research.11,12,16 This (ART) has been linked to an increased risk of psychiatric
may be because the progression of the disease leads to complications.25 This research also found that higher chances
a compromised quality of life of a patient who has progressed. of suicidal thoughts were correlated with the low body mass
This research also showed that patients on a first-line ART index of HV/AIDS patients. This may be attributable to the
regimen were associated with increased suicidal ideation odds. fact that unexplained weight loss is a symptom of advanced
This result was in line with previous results from the report. disease that affects patients’ physical, mental, and

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Tamirat et al Dovepress

psychological well-being. This result was in line with the Declaration of Helsinki. An additional official permission
results of a systematic review and meta-analysis.26 letter was also obtained from the chief clinical director of
Poor adherence to ART drugs has been related to a rise the hospital. Verbal informed consent was taken from after
in suicidal thoughts. This result was in line with previous briefing about the objective of the study each of the study
research findings. This may be due to inadequate adher­ participants. Moreover, all the study participants were
ence to ART drugs, which leads to rapid disease develop­ assured to leave the study at any time of the study.
ment and treatment failures. Furthermore, psychiatric Moreover, filled questionnaires keep in locked cabinets
conditions such as depression, suicidal ideation, and for the attainment of confidentiality of patients’ informa­
attempts can affect their medication adherence. tion. Patients who had depression, suicidal ideation, and
This study indicates that mental health concerns have attempts during data collection time were linked to the
been prevalent in patients with HIV/AIDS that can impact psychiatry clinic for further treatment and follow-ups.
the quality of life and clinical results of the patient. In
addition, frequent screening and therapy for mental well­ Consent for Publication
being and strengthening psychosocial care for HIV/AIDS Not applicable as there is no image or other confidential­
patients is of vital importance. ity-related issues.

Strength and Limitation of the Acknowledgment

Study We would like to acknowledge data collectors, hospital
This research has the power to evaluate common psycho­ administrators, and Microbiology department staff for their
social and mental illnesses in patients with HIV/AIDS. support.
This research could help improve mental and psychosocial
support interventions and be used as an entry point for Author Contributions
further screening of mental health status. However, due to All authors made a significant contribution to the work
the cross-sectional study design and the fact that study reported, whether that is in the conception, study design,
participants are clinically healthy, the frequency of suicidal execution, acquisition of data, analysis and interpretation,
ideation could be underestimated. or in all these areas; took part in drafting, revising or
critically reviewing the article; gave final approval of the
Conclusion version to be published; have agreed on the journal to
This study showed that among HIV/AIDS patients, psychiatric which the article has been submitted; and agree to be
illnesses and psychosocial issues were widespread. Suicide accountable for all aspects of the work.
ideation was related to a lack of social support, depression,
a low BMI, and a lack of adherence to ART medications. This Funding
result highlights the importance of frequent screening for We didn’t receive external funds for this research.
common mental illnesses as well as the improvement of
therapy, nutritional, and psychosocial support services. Disclosure
The authors declared that they have no competing
Data Sharing Statement interests.
The datasets used during the current study are available
from the corresponding author up on request. References
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