The Ukrainian SORT IT Course Anxiety , depression , and quality of life among HIV positive injection drug users in Ukraine , 2017

Introduction: People who inject drugs (PWID) are one of the key populations most vulnerable to HIV infection, with 28 times higher prevalence compared to the rest of the population. PWID are known to have many physical, psychological and lifestyle challenges that can influence access to care. Depression is common among PWID living with HIV. It has major effect on health-related quality of life (HRQoL) and is influencing adherence to antiretroviral therapy. This study was conducted to explore how anxiety and depression affect HRQoL among HIVpositive PWID in Ukraine. It will provide knowledge for the further policy development. Methodology: A descriptive cross-sectional study using data from intervieweradministrated questionnaires was performed. The questionnaire was based on the Hospital Anxiety and Depression Scale. The questionnaire on HRQoL was based on the SF-36. Results: Among the 90 HIV positive PWID 74% (67) and 61% (55) had anxiety and depression scores higher than 7 respectively, indicating that most patients had mental health problems. Average scores for general health (40), role limitations due to physical (44) and emotional health (34), vitality (41) and mental health (45) had mean scores less than 50 along with total physical (43) and mental health scores (35). Having an HIV positive partner or partner with unknown HIV status increases anxiety in HIV positive PWID. Conclusion: There are increased depressive and anxiety symptoms and poorer QoL among HIV-positive PWID in Ukraine. Strategies focusing on psychosocial support addressing QoL as part of HIV care could improve health outcomes for these comorbid and debilitating conditions.


Introduction
The human immunodeficiency virus (HIV) epidemic is one of the major public health issues globally. In 2016, an estimated 36.7 million people were living with HIV, and around 30% are not aware of their HIV positive status [1]. Despite all HIV prevention and treatment activities, one million people died of acquired immune deficiency syndrome (AIDS) related illnesses [2]. Good health is essential for advancement on ending AIDS [2]. Ensuring healthy lives and promoting well-being for all, including people living with HIV or at risk of having it is part of the sustainable development goals (SDG) [3]. According to the World Health Organization (WHO) definition health is "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" [3]. Access to good health and wellbeing is a human right, and the SDG agenda states that everyone is entitled to the highest standards of health and health care [4]. The SDG target 3.8 on universal health coverage (UHC) aims to ensure that all people obtain preventive, curative and rehabilitative health services without financial hardship [4].
People who inject drugs (PWID) are one of the key populations most vulnerable to HIV infection. Globally, data show that HIV prevalence among people who inject drugs is 28 times higher than among the rest of the population [5]. The number of PWID worldwide is estimated to be 11.7 million, and 14% of them are living with HIV. PWIDs represent 0,8 up to 1,2% of Ukrainian 112S population, it makes more than 300 000 persons. There are approximately 80 000 PWID living with HIV in Ukraine.
In 2017, the prevalence of HIV among PWID was 22.6 % in Ukraine, accounting for the second highest rate in Eastern Europe [6] Ukraine ,with a population approximately 42 million, covers an area of 600000 km² making it the second largest country in Europe after the Russian Federation. [7].
There were 321382 HIV infections registered in Ukraine by April 2018, including 105166 AIDS cases and 46024 AIDS-related deaths. Infection through intravenous drugs remains the driving force of the epidemic [8,9]. It is estimated that there are approximately 80,000 PWID living with HIV in Ukraine. [9][10][11] In 2017 almost 25% of all new HIV cases accounted were observed in this group.
HIV testing and antiretroviral therapy (ART) were introduced through the national program in Ukraine in 2000. Despite harm reduction services widely implemented across the country, which includes rapid HIV testing, initiation of medical care among PWID is delayed. In 2016 nearly 60% of newly diagnosed PWID had a CD4 count less than 350 cells per mL. [11]. Moreover, PWID experience disparities in linking to medical care, initiating ART and achieving viral suppression. Only 10% (7472) of 80,000 HIV infected PWID received ART in 2017 [11] Loss to follow-up is the major challenge in improving HIV treatment for PWID.
Poltava, Sumy and Lviv are medium size cities with approximate populations of 318000, 293000 and 733000 respectively (according to the national census conducted in 2001), located in eastern and western regions of Ukraine. [9] From January 2018 until April 2018, the number of newly diagnosed HIV positive cases in these 3 cities were 133, 81 and 143. Estimated numbers of PWID in Poltava are 8200, in Sumy was 12200 and in Lviv was 11000. More than half of PWID are included in harm reduction programs. [11] Despite the latest developments in treatment and prevention techniques, PWID are known to have many physical, psychological challenges and lifestyle differences that can influence access to health care. Depression is one of the most prevalent mental health disorders and is known to have major effect on healthrelated quality of life (HRQoL). Symptoms are reported in approximately 60% of this group of patients influencing adherence to antiretroviral therapy (ART), with consequent decrease in immune function and acceleration of disease progression [12].
Available data suggest that PWID have a lower HRQoL compared to other populations, which is known to be associated with unemployment, mental health problems and frequent injecting practices [13].
To the best of our knowledge, none of the studies explored depression and HRQoL among HIV-positive PWIDS in Ukraine. In order to fill the gap, we conducted the study in three cities of Ukraine to a) describe anxiety and depression among HIV positive PWID interviewed with the hospital anxiety and depression scale (HADS), b) to describe HRQoL, interviewed with the short form health survey (SF-36) questionnaire, and c) to assess factors associated with anxiety, depression and HRQoL.

Study Design
A descriptive cross-sectional study using data from interviewer-administered questionnaires in three cities of Ukraine (Lviv, Sumy, Poltava) was performed.

Study population, sample size
The study included 90 PWID diagnosed with HIV aged 18 years and above who were registered at healthcare facilities (N = 49) or were not engaged in HIV medical care (N = 41). The convenience sampling was used. Study participants registered at healthcare facilities were enrolled by nurses and medical doctors, respondents not engaged in medical care were enrolled by non-government organization's social workers. Inclusion criteria: > 18 years of age, HIV+ status, former or current injective drug use, exclusion criteria: incomplete clinical profile, use of non-injectable drugs, pregnancy.

Variables
The questionnaire on anxiety and depression was based on the HADS. The HADS consists of 14 items, seven items each for the anxiety subscale and depression subscale. On a responsive scale, each item is scored with four alternatives ranging between 0 and 3. According to the scale; a total of 8 or above is used as a cut-off score for both HADS Anxiety and HADS Depression [14,15].
The questionnaire on HRQoL was based on the SF-36, which is a short-form health survey with only 36 questions. It gives an 8-scale outline of functional health and well-being gain as well as psychometrically allied physical and mental health summary measures. SF-36 scale is intended to evaluate eight health domains: (1) physical functioning, (2) social functioning, (3) physical-related role limitations, (4) 113S bodily pain, (5) general mental health, (6) emotionalrelated role limitations, (7) vitality (energy and fatigue), and (8) general health perception. All measures can have values from 1 to 100 where greater score indicates better quality of life related to the respective domain [16][17][18].
Other collected variables included social and demographic characteristics, such as age, gender, education, employment, personal monthly income, marital status, living conditions, history of incarceration, partner's HIV status, HIV status disclosure status, and receipt of harm reduction services. Behavioral variables were smoking status and frequency of drug use.
Clinical characteristics were linkage to HIV care (registration at AIDS center and receiving HIV-related check-up), receipt of opioid substitution treatment (OST), history of tuberculosis (TB), receipt of ART, and reaching undetectable viral load (<40 copies per mL).

Data collection
Data was collected in June and July 2017 through an interviewer-administered questionnaire.
A team of individuals reviewed the cohesiveness of the questionnaire before conducting the interviews; four interviewers who were trained conducted the interviews and collected the information in a standardized manner. The interviewer wrote the answers in the interview form in Ukrainian. This information was later translated into English. Data was entered into IBM ® SPSS ® Statistics database (version 22, IBM Corporation, Armonk, US).

Data analysis
Data on anxiety, depression, and HRQoL was calculated according to the instructions of respective questionnaires manual. First, HADS and SF36 scores were summarized with descriptive statistics. HADS scores on anxiety and depression were categorized as borderline or abnormal level if the score was ≥8 cutpoint level. Then, differences in proportions of individuals with borderline or abnormal levels of anxiety and depression were calculated by Fisher exact tests with respect to selected covariates. As for HRQoL scores, we calculated mean differences and their 95% confidence intervals. The level of significance was set at P ≤ 0.05.

Ethics
The study was approved by the institutional Ethics Review board of Lviv Regional Public Health Center, Ukraine. All participants gave their informed consent.

Results
The average age of the study participants was 38.9 (SD = 7.19). The majority of the study participants were males (73%) and unemployed (64%). Most of the study participants (67%) had vocational (technical) education. Table 1 summarizes descriptive statistics for anxiety and depression measures as well as for domains of SF-36. HADS determine the levels of anxiety and depression that a person is experiencing. The mental composite score (MCS) of SF-36 includes mental health, emotional role, social function and vitality.

Anxiety and depression
Among the HIV positive PWID, average Anxiety and Depression scores were the same (9 out of 18 points, with a standard deviation (SD) of 4). Seventyfour percent and 61% had anxiety and depression scores higher than cutoff level 7 respectively, which indicates that the majority of patients had mental health problems.

Health-related Quality of life
With regards to the quality of life among HIV positive PWID, mean physical health score was 43 points out of 100 (SD = 11) and mean mental health score was 35 out of 100 (SD = 9). Physical health score and mental health score were lower than 50 in 67% and 92% of patients respectively. Several HRQoL domains had mean scores less than 50, which are considered lower than the general population. These included scores for general health (mean = 40, SD = 19), role limitations due to physical health (mean = 44, SD = 46) and emotional health (mean = 34, SD = 43), vitality (mean = 41, SD = 18) and mental health (mean = 45, SD = 17).

Factors associated with anxiety, depression and HRQoL
More anxiety symptoms were reported by PWID who had an HIV positive partner or a partner with unknown HIV status (p = 0.012) ( Table 2). None of selected variables were significantly associated with borderline/abnormal depressive symptoms.

Discussion
This is one of the first studies in Ukraine that is exploring anxiety, depression, and HRQoL among HIV positive PWID. Anxiety and depression are prevalent in the study population. Seven out of every ten HIV positive PWID, had anxiety and six out of ten had depression. Moreover, assessment of HRQoL disclosed that 90% people have low total mental health scores. Scores of total physical health as well as five out of 116S eight domains on HRQoL were lower than the average in general population. Studies conducted in countries such as China and South Africa revealed that mental health is a critical factor in the adherence of ART regimen [19][20][21]. Many PWID come from a background of high-risk behavior, stigmatization, legal constraints, and discrimination when positive HIV status disclosed [22].Therefore, the findings in this study highlight the importance of targeted psychosocial work in this key population to ensure adequate level of care.
The study strengths are that we assessed HIV positive PWID using a validated questionnaire to assess QoL, depressive and anxiety symptoms. The major limitation of the study is the small sample size which did not allow adjusted analysis of the data. Another limitation of the study is that participants were individuals only from the three cities/urban areas in Ukraine, so results are not generalizable to overall population.
Nonetheless, the study has policy and practice implications. With the advent of effective treatment, HIV survival is similar to that of the general population. Although our study did not quantify the impact of HIV infection compared with other factors on anxiety, depression and QoL, it does highlight that HIV positive PWID have mental health and QoL needs greater than the general population. Thus, health services will need to focus on mental health and QoL issues present in PWID.
Finally having a HIV positive partner or partner with unknown HIV status increases anxiety rates in HIV positive PWID. Other factors are yet to be explored in larger scale studies.

Conclusion
In conclusion, we have highlighted that there are increased depressive and anxiety symptoms and poorer QoL among HIV-positive PWID in three cities of Ukraine. Thus, strategies focusing on psychosocial support are urgently needed. Ultimately, addressing QoL as part of HIV care could improve health outcomes for these comorbid and debilitating conditions. Further research using reliable methods to identify causes of depressive and anxiety symptoms in key populations as well as effective approaches to reduce those symptoms and to improve QoL and subsequently HIV care is necessary.