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To the Editor: Rates of human immunodeficiency virus (HIV) infection in southern Africa are high, with up to 45% of pregnant women being HIV-positive.¹ Depression is associated with lowered adherence to antiretroviral medication² and poor use of antenatal care.³ It frequently persists into the postnatal period, raising the risk of adverse child outcomes.³ Because little is known about the rates of depression among women undergoing HIV testing in prevention of mother-to-child transmission programs (PMTCT), we undertook this prevalence study. A secondary aim was assessment of perceptions among these women about adverse consequences of an HIV diagnosis, and whether these perceptions were related to depression status.

Methods
This study was conducted in rural northern KwaZulu-Natal, South Africa, a region with a very high HIV prevalence.¹ A consecutive sample of women offered PMTCT during routine antenatal care at 3 representative clinics⁴ was invited to participate. Women were eligible if this was their first HIV test in the current pregnancy and they had not previously tested HIV-positive. Written informed consent was obtained and approval was granted by the Ethics Review Board of the University of KwaZulu-Natal and the Oxford Tropical Research Ethics Committee. Enrollment was obtained from 242 (82%) of the eligible women. Reasons for nonparticipation included insufficient time, nonreturn after requesting opportunity to discuss with family, and unwillingness to participate in research. Ethics boards did not permit collection of any other comparison data from nonparticipants.

Depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale (EPDS). It has specificity and sensitivity greater than 76%,⁵ has been validated antenatally and postnatally,⁶ and has been validated in a black South African population.⁷ Depression was defined by a score of 13 or above.⁶ Any patient reporting recent thoughts of self-harm was referred for intervention. A 9-item questionnaire scored in 3 domains (health care access, financial resources, and social support) was used to elicit women's perceptions of the consequences of an HIV diagnosis. Each item was scored 0 to 2 and an overall domain score calculated as the sum of item responses after appropriate score reversals. The questionnaire was developed from a validated construct⁸ shown to represent patient concerns elsewhere in Africa.⁹ The measures were translated into IsiZulu, back-translated, and administered during interviews. Participants subsequently were tested for HIV as part of the PMTCT.

Characteristics of women with and without depression were compared using ² tests for proportions or Mann-Whitney tests for medians. Stepwise logistic regression was used to assess independent associations. To balance type I and II errors, 2-sided P values <.025 were considered statistically significant. Power calculations determined that a sample size of 250 would provide 80% power to detect an odds ratio of 2.0 with 2-sided P <.05. Analyses were performed using SPSS version 11.5 (SPSS Inc, Chicago, Ill).

Results
Participant characteristics are shown in Table 1. Most pregnancies (84%) were unplanned. An EPDS score consistent with depression was found in 99 of 242 women (41%; 95% confidence interval [CI], 35%-47%), with 45 of 241 (19%; 95% CI, 14%-24%) reporting thoughts of self-harm within the last 2 weeks.

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table 1. Characteristics of the Participants (N = 242)*

The factors significantly and independently associated with increased depression scores are shown in Table 2. They include an unplanned current pregnancy and absence of a regular household income. In the perception questionnaire, the only domain significantly associated with increased depression scores was concerns about access to health care (P  = .02). Of the 9 specific items, only the perception of discrimination in access to health care and reduced access to household financial resources following an HIV diagnosis were significantly associated with depression at the .025 level (Table 2).

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table 2. Factors Associated With EPDS Score

Subsequent HIV testing was positive in 99 of 242 participants (41%; 95% CI, 35%-47%), not identical with the 99 with depression. Depression and HIV status were not significantly associated (P = 0.60). Participants did not know their HIV status when depression assessments were made.

Comment
Depression as measured by the EPDS was very prevalent (41%) in this sample. An antenatal study conducted in England using the same instrument found a prevalence of only 13%.⁶ High postnatal rates of depression have been shown in a black South African population.¹⁰

This study was limited in not using a clinical interview to diagnose depression, and by the possibility that the stress of the testing environment may have influenced responses. Nevertheless, given that maternal depression is associated with adverse effects on use of health services and child development,³ our results raise concern for both maternal and child health in HIV prevention and treatment.

Depression was associated with perceptions that a diagnosis of HIV would diminish the woman's access to health services because of discrimination. This could result in reluctance by HIV-positive women to access health care services and could affect adherence to antenatal interventions that are critical to the prevention of mother-to-child transmission.² There is evidence that depression can be effectively treated in comparable African populations.¹¹ Our results support the importance of screening for depression during pregnancy in areas with high HIV prevalence.

Author Contributions: Dr Stein and Ms Rochat had full access to all the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis.

Study concept and design: Stein, Richter, Rochat, Tomkins.

Acquisition of data: Buthelezi, Rochat.

Analysis and interpretation of data: Stein, Doll, Richter, Rochat, Tomkins.

Drafting of the manuscript: Rochat, Stein, Doll.

Critical revision of the manuscript: Stein, Rochat, Richter, Doll, Tomkins.

Statistical analysis: Doll.

Obtained funding: Stein.

Administrative, technical, or material support: Rochat, Tomkins.

Study supervision: Stein, Richter.

Financial Disclosures: None reported.

Funding/Support: This study was funded by grants from University of Oxford (HQ5035), the Tuixen Foundation (9940), and the Wellcome Trust (017571).

Role of the Sponsors: The funding organizations had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and the preparation, review, or approval of the manuscript.

Acknowledgement: We thank the women who participated in this study; and the KwaZulu-Natal Department of Health, Martin Dedicoat, PhD, Mark Tomlinson, PhD, Rosie Nicol-Harper, PhD, and Graham Lindegger, PhD, for their advice on design and comments.

Tamsen J. Rochat, MsocSc
Africa Centre for Health and Population Studies
University of KwaZulu-Natal
Mtubatuba, South Africa

Linda M. Richter, PhD
Child, Youth, Family, and Social Development Unit
Human Sciences Research Council
Durban, South Africa

Helen A. Doll, PhD
Department of Public Health
University of Oxford
Oxford, England

Nomphilo P. Buthelezi, NDip
Africa Centre for Health and Population Studies
University of KwaZulu-Natal
Mtubatuba, South Africa

Andrew Tomkins, FRCPCH
Centre for International Child Health
Institute of Child Health
University College London
London, England

Alan Stein, FRCPsych
alan.stein{at}psych.ox.ac.uk
Section of Child & Adolescent Psychiatry
University of Oxford
Oxford, England

1. National Department of Health. National HIV and Syphilis Antenatal Sero-prevalence Survey in South Africa 2004. Pretoria, South Africa: National Dept of Health; 2005;4:7-8. 2. Starace F, Ammassari A, Trotta MP, et al, AdICONA Study Group; NeuroICONA Study Group. Depression is a risk factor for suboptimal adherence to highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2002;31(suppl 3):S136-S139. ISI | PUBMED 3. Patel V, Rahman A, Jacob KS, Hughes M. Effect of maternal mental health on infant growth in low income countries. BMJ. 2004;328:820-823. FREE FULL TEXT 4. Rollins NC, Dedicoat M, Danaviah SD, et al. Prevalence, incidence, and mother to child transmission of HIV-1 in rural South Africa. Lancet. 2002;360:389-390. FULL TEXT | ISI | PUBMED 5. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ. 2001;323:257-260. FREE FULL TEXT 6. Heron J, O’Conner TG, Evans J, Golding J, Glover V, ALSPAC Study Team. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord. 2004;80:65-73. FULL TEXT | ISI | PUBMED 7. De Bruin GP, Swartz L, Tomlinson M, Cooper P, Molteno C. The factor structure of the Edinburgh Postnatal Depression Scale in South African peri-urban settlement. S Afr J Psychol. 2004;34:113-121. 8. Lester P, Partridge J, Chesney M, Cooke M. The consequences of a positive prenatal HIV antibody test for women. J Acquir Immune Defic Syndr Hum Retrovirol. 1995;10:341-349. ISI | PUBMED 9. Issiaka S, Cartoux M, Ky-Zerbo O, et al, Ditrame Study Group. Living with HIV: women's experiences in Burkina Faso, West Africa. AIDS Care. 2001;13:123-128. FULL TEXT | ISI | PUBMED 10. Cooper PJ, Tomlinson M, Swartz L, et al. Post-partum depression and the mother–infant relationship in a South Africa peri-urban settlement. Br J Psychiatry. 1999;175:554-558. et al. FREE FULL TEXT 11. Bolton P, Bass J, Neugebauer R, et al. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA. 2003;289:3117-3124. FREE FULL TEXT

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2006;295:1376-1378.

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