Cumulative exposure to depressive symptoms and all-cause mortality among adults with HIV in Kenya, Nigeria, Tanzania, and Uganda

Objective: We estimated the effects of cumulative exposure to depressive symptoms on risk of all-cause mortality among people with HIV (PWH) in four African countries. Design: An analysis of prospective cohort data. Methods: The African Cohort Study (AFRICOS) is a prospective cohort of people receiving care at twelve clinics in Kenya, Nigeria, Tanzania, and Uganda. Every 6 months from January 2013 to May 2020, participants underwent laboratory monitoring, structured surveys, and assessment of depressive symptom severity using the Center for Epidemiologic Studies Depression Scale (CES-D). All-cause mortality was the outcome of interest. The predictor of interest was a time-updated measure of the percentage of days lived with depression (PDD). Marginal structural Cox proportional hazards regression models were used, adjusting for potential confounders including time-varying alcohol use, drug use, and viral load. Results: Among 2520 enrolled participants, 1479 (59%) were women and the median age was 38 (interquartile range [IQR]: 32–46). At enrollment, 1438 (57%) were virally suppressed (<200 copies/ml) and 457 (18%) had CES-D at least 16, indicating possible depression. Across 9093 observed person-years, the median PDD was 0.7% (IQR: 0–5.9%) with 0.8 deaths per 100 person-years. Leading causes of death included cancer (18% of deaths) and accidents (14%). Models suggested that each 25% absolute increase in PDD was associated with a 69% increase in the risk of all-cause mortality (hazard ratio: 1.69; 95% confidence interval: 1.18–2.43). Conclusion: Cumulative exposure to depressive symptoms was substantially associated with the risk of mortality in this cohort of PWH in Africa.

目的：我们评估了四个非洲国家的艾滋病病毒感染者（PWH）累积暴露于抑郁症状对全因死亡风险的影响。 设计：对前瞻性队列数据的分析。 方法：非洲队列研究（AFRICOS）是一个在肯尼亚、尼日利亚、坦桑尼亚和乌干达的12家诊所接受治疗的人群的前瞻性队列。从2013年1月到2020年5月，每6个月参与者接受实验室监测、结构化调查，并使用流行病学研究中心抑郁量表（CES - D）评估抑郁症状的严重程度。全因死亡是关注的结果。关注的预测因素是一个随时间更新的患有抑郁症天数百分比（PDD）的指标。使用边际结构考克斯比例风险回归模型，并对潜在的混杂因素进行调整，包括随时间变化的饮酒、吸毒和病毒载量。 结果：在2520名登记的参与者中，1479人（59%）为女性，中位年龄为38岁（四分位间距[IQR]：32 - 46岁）。在登记时，1438人（57%）病毒得到抑制（<200拷贝/毫升），457人（18%）的CES - D至少为16，表明可能患有抑郁症。在9093人年的观察中，PDD的中位数为0.7%（IQR：0 - 5.9%），每100人年有0.8人死亡。主要死亡原因包括癌症（占死亡人数的18%）和意外事故（占14%）。模型表明，PDD每绝对增加25%，全因死亡风险就会增加69%（风险比：1.69；95%置信区间：1.18 - 2.43）。 结论：在非洲的这一艾滋病病毒感染者队列中，累积暴露于抑郁症状与死亡风险显著相关。