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East Asian Arch Psychiatry 2022;32:39-42 | https://doi.org/10.12809/eaap20104

ORIGINAL ARTICLE

Prevalence and Determinants of Suicidal Ideation and Suicide Attempt in People With Human Immunodeficiency Virus in Africa: a Systematic Review
WM Metekiya, AT Gebreselassie, TA Amare, DZ Wondafrash

WM Metekiya, Department of Psychiatry, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
AT Gebreselassie, Department of Psychiatry, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
TA Amare, Department of Psychiatry, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
DZ Wondafrash, Department of Pharmacology, Saint Pauls Hospital Millennium Medical College, Addis Ababa, Ethiopia

Address for correspondence: WM Metekiya, Department of Psychiatry, College of Health Sciences, Mekelle University, Mekelle, Ethiopia. Email: workua.mekonen@mu.edu.et

Submitted: 31 October 2020; Accepted: 27 May 2022

pdf Full Paper in PDF

Abstract

Background: People with human immunodeficiency virus (HIV) are at higher risk of suicidal ideation and suicide attempts. We reviewed the literature for the prevalence and determinants of suicidal ideation and suicide attempt in people with HIV in Africa.

Methods: The PubMed, Scopus, and Google scholar were searched for original studies published in peer- reviewed journals in English language between January 2015 to July 2020, using the key words: ‘suicidal behavior’, ‘suicidal attempt’, ‘suicidal ideation’, ‘HIV/AIDS’, and/or ‘Africa’. The quality of included studies was assessed using the Newcastle-Ottawa scale.

Results: 12 cross-sectional studies published in the past 5 years in African countries were included. The quality of studies was high, with score ranging from 6 to 9. The prevalence of suicidal ideation ranged from 8.8% to 39%. The prevalence of suicide attempt ranged from 2.8% to 20.1%. The most common risk factors for suicidal behaviour were mental health-related problems. Other factors included high clinical stage of HIV, being unmarried, poor medication adherence, poorer quality of life, not taking highly active antiretroviral therapy, female sex, no education, substance use, low CD4 level, and opportunistic infection.

Conclusion: Patients with HIV/AIDS have an increased risk of suicidal ideation and suicide attempts. Early screening, treatment, and referral of suicidal patients are necessary for HIV clinics.

Key words: Acquired Immunodeficiency Syndrome; Africa; HIV; Suicidal ideation; Suicide; Suicide, attempted

Introduction

Suicidal behaviour and human immunodeficiency virus (HIV) / acquired immune deficiency syndrome (AIDS) are major public health issues, particularly in low- and middle-income countries.1 Patients with HIV/AIDS are at higher risk for suicidal behaviour.2,3 Such patients have 6.55 times higher risk of suicidal ideation, compared with the general population, and have higher risks of suicide and accidental or violent death.4 In Brazil, the suicide risk was 56% among patients with a chronic illness and was 5.24 times higher in patients with HIV than in those without a medical condition.5

People with chronic illnesses, particularly HIV/AIDS are at increased risk of suicide.6 In South Africa, 83.1% of patients with HIV/AIDS had a significantly elevated risk of suicidal ideation, and most of them were young men aged <30 years.7 Two time points are peak for suicide incidence: 72 hours and 6 weeks after the diagnosis of HIV/AIDS, in addition to immediately after the diagnosis.7 In Uganda, the rate of suicidal ideation was 8.8% and the rate of suicide attempt was 3.1% in patients with HIV/AIDS, and thus assessment and management of suicide risk is an integral part of HIV care.8 In people with HIV, the prevalence of suicidal ideation has been reported to vary from 13.6% to 31.0%, and the prevalence of attempted suicides has been reported to vary from 3.9% to 32.7%.9 In Ethiopia, the respective prevalence was 22.5% and 13.9%; people with HIV/AIDS face various day-to-day and long-term personal, interpersonal, social, physical, and psychological challenges in addition to health conditions.9 We aimed to review the literature for the prevalence and determinants of suicidal ideation and suicide attempt in people with HIV in Africa.

Methods

The databases of PubMed, Scopus, and Google scholar were searched for original studies published in peer-reviewed journals in English language between January 2015 to July 2020, using the key words: ‘suicidal behavior’, ‘suicidal attempt’, ‘suicidal ideation’, ‘HIV/AIDS’, and/or ‘Africa’. Studies on non-suicidal deliberate self-harm were excluded, as were studies with only the abstract available. The title and abstract of each study were screened by two authors independently for eligibility. Disagreements between the two authors were resolved by consensus of the remaining authors. Full text of eligible studies was then screened, and studies that did not fulfil the inclusion criteria were excluded.

Variables of included studies were extracted: citation of the study, country where the study was performed, year of data collection, study design, study population, age of participants, selection criteria of participants, prevalence of suicidal ideation, prevalence of attempted suicide, prevalence of completed suicide, method of data analysis, and sampling criteria for participants.

The quality of included studies was assessed by two authors independently using the Newcastle-Ottawa scale.10

The scale takes into account the representativeness of the sample, sample size, non-respondents, ascertainment of the exposure, and assessment of outcome.

Results

Of 868 studies identified, 13 were duplicates. Of 855 studies screened, 830 were excluded because of irrelevancy to the topic. Full text of 25 studies was screened for eligibility; 13 did not fulfil the inclusion criteria and were excluded. The remaining 12 were included in analysis.8,9,11-20 All 12 studies were cross-sectional studies published in the past 5 years in African countries. The quality of studies was high, with score ranging from 6 to 9 (Table 1). The prevalence of suicidal ideation ranged from 8.8% to 39%, whereas the prevalence of suicide attempt ranged from 2.8% to 20.1% (Table 2). The most common risk factors for suicidal behaviour were mental health-related problems. Other risk factors included high clinical stage of HIV, being unmarried, poor medication adherence, poorer quality of life, not taking highly active antiretroviral therapy, female sex, no education, substance use, low CD4 level, and opportunistic infection.

 

Discussion

People with HIV/AIDS have higher prevalence of suicidal behaviour (suicidal ideation and suicide attempt), compared with those HIV-negative. Suicidal ideation is a predictor for attempted and completed suicide in adolescents with HIV.8 Suicidal behaviour occurs in all stages of HIV infection. In the present review, the prevalence of suicidal ideation was 8.8% to 39%, whereas the prevalence of suicide attempt was 2.8% to 20.1.8,9,11-20 In a review in the United Kingdom, the prevalence was 26.9% for suicidal ideation, 30.2% for suicidal thoughts, and 22.2% for a suicide plan.21 In Italy, the prevalence of suicidal ideation was 13.6% to 31.0%, whereas the prevalence of attempted suicide was 3.9% to 32.7%.22 In women with HIV during pregnancy and postpartum, the prevalence of suicidal ideation was 39% prenatally and 7% at 12 months postpartum; 13% experienced incident suicidal ideation.23

One risk factor for suicidal behaviour is being women. Women tend to internalise stressful events, whereas men tend to act them out.7 In addition, the high World Health Organization clinical stage of AIDS is a risk factor for suicide attempts. This may be because patients with advanced immunosuppression may have opportunistic infections that may lead to suicide attempts.9 In addition, patients who do not take highly active antiretroviral therapy may have concerns on lifelong drug adverse effects and the burden of lifelong treatment.9 Substance use may disturb the normal function of the brain and result in attempted suicide, particularly when patients are unable to buy the substance.18 Social stigmatisation regards HIV/AIDS as a terminal illness, which imposes an enormous emotional and psychological burden on the patient and family.17 Intimate partner violence and depression are predictors for sustained suicidal ideation, whereas increased income, younger age, disclosure of HIV status to partner, and greater stigma are predictors for incident suicidal ideation.21

Healthcare providers should be aware of suicidal behaviour in patients with HIV. They should routinely assess the patients’ suicidal behaviour, depressive symptoms, and common mental illness, and refer to mental health services if needed. Treating depression can improve the suicidality and the CD4 count. Further studies are warranted to determine the cause-effect relationships between suicidal behaviour and HIV viral load, CD4 count, treatment outcome, and quality of life among people with HIV.

Conclusion

Patients with HIV/AIDS have an increased risk of suicidal ideation and suicide attempts. Early screening, treatment, and referral of suicidal patients are necessary for HIV clinics.

Contributors

All authors designed the study, acquired the data, analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

Funding/support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data Availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

References

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