The prevalence of perinatal anxiety symptoms and associated factors among HIV positive women: a cross-sectional study across 10 healthcare facilities in Tzaneen sub-district

¹Department of Public Health, Sefako Makgatho Health Sciences University, Tshwane, South Africa

^&Corresponding author
Khomotso Comfort Maaga, Department of Public Health, Sefako Makgatho Health Sciences University, Tshwane, South Africa

Introduction    

Perinatal anxiety is estimated to affect 1 in every 5 women from low- and middle-income countries, leading to poor maternal and infant outcomes [1]. Although perinatal anxiety is common among HIV positive and HIV negative women alike, literature has shown significantly higher prevalence rates of anxiety among those with a seropositive status [2,3]. Anxiety rates during the perinatal period range from 13% to 42% among HIV positive women on the African continent [3-7]. The perinatal period, which is supposed to be a wonderful experience filled with excitement and joy, inevitably turns into one full of fear, worry, doubt, and other anxiety-related symptoms due to the unique challenges faced by this population [8]. Issues such as stigma and disclosure [9,10], fear of vertical transmission [11], risk of comorbidities and complications during pregnancy due to compromised immunity [12], while trying to navigate the challenges of motherhood [10,11], are some of the key challenges faced by these women, which require closer monitoring during this period.

Anxiety affects the individual directly with physical and psycho-social problems that negatively affect academic, work, and interpersonal interactions. It has also been correlated with increased risk of suicide, reduced quality of life, disability, reduced productivity, as well as other non-communicable diseases [13-15]. Anxiety during the perinatal period also has long-lasting effects on the infant as it may impact the psychosocial and emotional development of children [16-18]. Specifically for HIV positive women, anxiety disorders have been significantly associated with non-adherence and poor retention during the prevention of mother-to-child transmission (PMTCT) program, increasing the risk of vertical transmission [18].

However, despite the numerous maternal and infant-related consequences associated with perinatal anxiety that make it a public health concern, routine screening remains limited in South Africa [19]. Historical data have demonstrated high rates of maternal mental health disorders in the country, with the highest burden experienced in rural and peri-urban areas [20]. For example, the Limpopo Province, characterized by socio-economic challenges, barriers to adequate healthcare services, and limited mental health resources, has reported rates of postnatal depression that are twice those documented for sub-Saharan Africa overall [21]. However, the true burden and prevalence of anxiety remain unknown, presenting a critical evidence gap. Thus, this study aimed to determine the prevalence of perinatal anxiety symptoms and associated factors among HIV positive women attending healthcare facilities in Tzaneen sub-district.

Methods     

Study design and setting: a cross-sectional quantitative survey was conducted between the 3^rd of May 2021 and 27^th of August 2021. The study was conducted across urban and rural areas in 4 community healthcare centers (CHC´s) and 6 clinics in Tzaneen local municipality, which is located in the Limpopo Province of South Africa. The healthcare facilities included in the sample offer PMTCT Option B+ services, thus having a high intake of the study target population.

Study population: HIV positive women who were pregnant (any gestational age) or postnatal (one year postpartum), who were enrolled in the PMTCT programme, older than the age of 18 years, and were able to provide informed consent were included in the study. The study excluded pregnant women with serious obstetric complications (emergency care) such as pre-eclampsia and vaginal bleeding requiring urgent attention. Using the Raosoft sample size calculator, and applying a 5% margin of error, a 95% confidence interval, and a 50% response distribution, a minimum sample size of 379 participants was derived based on a population of 2,184 HIV-positive women in Tzaneen local municipality. Initially, a purposive sampling strategy was employed to select healthcare facilities with a high intake of HIV-positive perinatal women. Subsequently, participants were randomly selected from within these facilities.

Data collection: a self-administered questionnaire consisting of a socio-demographic section as well as the Brief Symptoms Index (BSI-18) to screen for anxiety symptoms and the HIV and abuse-related shame inventory (HARSI) tool to determine scores of HIV shame. The BSI-18 scale is a valid and reliable [22] scale used globally to assess psychological distress. It has a good internal consistency [23] and has been used globally to assess anxiety [24,25]. Thus, the study used the 6-item anxiety sub-scale of the BSI-18 to determine the symptoms of anxiety in the current study. Using a Likert scale with options ranging from 0 (not at all) to 4 (extremely), the questions assess anxiety-related symptoms over the past week. As informed by previous research [26], a cut-off point of 1.1 was used to determine symptoms of anxiety. Similarly, to determine HIV-related shame, a subscale of the HARSI tool was used. This tool consists of nine statements, and participants have to indicate to what extent they agree with the statement on a Likert scale ranging from 0 (not at all) to 4 (very much). Higher scores indicate higher levels of shame, with a minimum of 0 and a maximum of 27. The scale has good psychometric properties and has been used in a variety of settings to determine HIV-related shame [13,26,27]. Eligible participants were recruited through the assistance of staff members. While awaiting healthcare services, the researcher was provided the platform to explain the objectives of the study, and participants who were willing and able to provide consent were taken to a separate room for participation. Participants were provided with ample time to ask questions, and ethical principles were explained prior to participation.

Definitions: Brief Symptom Inventory (BSI-18): An anxiety scale used to screen for anxiety symptoms. HIV and Abuse Related Shame Inventory (HARSI): a scale used to determine HIV-related shame. Perinatal anxiety: a clinical disorder characterized by frequent, persistent, and uncountable worrying that may also manifest somatically as shaking, tension, restlessness, or easy irritability that lasts longer than two weeks during the perinatal period. Perinatal period: the perinatal period in this paper specifically refers to the antenatal period (any gestation age) and up to one year postpartum.

Statistical analysis: data were captured and cleaned in Excel and imported to Stata-18 (Stata Corporation, College Station, TX, USA) for analysis. Questionnaires with more than 15% of missing data were discarded; additionally, questionnaires with incomplete anxiety scores were also not included. To test the distribution of the data, the skewness and kurtosis normality tests were used, and it was found that the data were normally distributed. Descriptive analysis was conducted and expressed as means, standard deviations, and range for continuous variables as well as proportions and percentages for categorical variables. The scores from BSI scale were used to determine the prevalence of anxiety using a cut-off score of 1.1. Univariate analysis was conducted using binary logistic regression to determine the factors that were significantly associated with anxiety (p ≤ 0.05). A forward stepwise regression method was used to build a logistic regression model. All factors that were found significant at a bivariate level were converted into numeric codes to perform multivariate logistic regression to see which factors would remain significant (p ≤ 0.05).

Ethical considerations: ethical principles and COVID-19 regulations were upheld at all times. Confidentiality, privacy, and informed consent were observed for all participants, and counselling services were available for participants who were in distress or expressed the need for further mental health support. Ethical clearance was provided by the Sefako Makgtaho Health Science University Research Ethics Committee (SMUREC/H/293/2020) and permission was sought from the Limpopo Department of Health, district office as well as the facility managers of the healthcare centers.

Results     

General characteristics of the study population: the total sample consisted of 395 participants, with the largest proportion of prenatal women (n=238; 60.25%) and only 39.75% (n=157) of postnatal women. There was an average age was 27, with the youngest participant at 19 years old and the eldest at 37. A small percentage (n=46; 11.65%) of participants planned their current pregnancy, while half (n=198; 50.13%) were experiencing pregnancy for the first time. The majority of the women found out about their HIV status due to an illness (n=112; 35%); however, only a few had a detectable viral load (n=97; 24.56%). Table 1 and Table 1.1 below provides further insights into the sample characteristics.

Prevalence of anxiety symptoms: overall, 47.09% (n=186) of the participants exhibited anxiety symptoms, with a mean score of 6.43. The prevalence of antenatal anxiety was 28.35% (n=112), whereas the prevalence of postnatal anxiety symptoms was 18.73% (n=74).

Bivariate and multivariate analysis for factors associated with anxiety: during univariate analysis, several factors were significantly associated with anxiety, including period of relationship, partner´s employment status, gravidity, mode of delivery, HIV status of other children, viral load, disclosure to family members, HIV shame, and CD-4 count. After controlling for confounders at a multivariate level, relationship duration remained significantly associated with anxiety, with women in longer relationships showing lower odds (aOR = 0.19, 95% CI: 0.05-0.80; p = 0.023). Partner employment strongly lowered the odds of anxiety (aOR = 0.08, 95% CI: 0.01-0.40; p = 0.002), as did vaginal delivery (aOR = 0.04, 95% CI: 0.01-0.26; p = 0.001) and disclosure to family members (aOR = 0.02, 95% CI: 0.00-0.14; p < 0.001). On the other hand, detectable viral load increased the odds of anxiety symptoms by 4 (aOR = 4.08, 95% CI: 1.76-9.45; p = 0.001) (Table 2).

Discussion     

This study aimed to determine the prevalence of perinatal anxiety symptoms and associated factors among HIV positive women attending healthcare facilities in Tzaneen sub-district. The present study documented a 47.09% prevalence of perinatal anxiety, with rates of 25.35% and 18.73% during the antenatal and postnatal period, respectively. This perinatal prevalence of 47.09% is much higher than the 20% global estimate among perinatal women in the general population living in low- and middle-income countries [1]. The current study´s perinatal anxiety rate is also much higher than the 28.9% anxiety rate reported among HIV positive women [28]. These results indicate that although a positive HIV diagnosis and the perinatal period are risk factors for anxiety separately, the risk is heightened when they occur simultaneously. Moreover, the antenatal prevalence of 28.35% is higher than previous reports in Uganda and Tanzania, which reported rates of 13% and 24.6%, respectively [7,26], which is synonymous with a systematic review rating South Africa as having the highest prevalence of maternal mental health disorders. South Africa is one of the worst HIV affected countries; thus, these prevalence rates illustrate the extent of this burden.

Although some studies found significant associations between socio-demographic factors such as age, marital status and level of education [6,13,26,28], these results were not replicated in the current study. Instead, factors linked to the participants´ romantic partners played a more significant role. For example, it was found that partners´ employment status was significantly associated with greater rates of anxiety symptoms among those whose partners were employed. The majority of the women were unemployed, and one-third (n = 130; 32.91%) depended on their partners as their primary source of financial support. These dire socio-economic conditions may help explain the high levels of anxiety symptoms observed in the study, a pattern that has also been reported in previous literature [7,21,23]. Moreover, it was also demonstrated that women who had been with their current partner for more than 5 years were less likely to be anxious than those who had a relatively shorter relationship duration. It is explained that a good relationship offers a great support structure that may aid in alleviating adverse mental health outcomes [29]. Support and good quality relationships are protective factors during the perinatal period [10,13,30], hence strengthening support during the perinatal period may yield better maternal outcomes.

HIV-related factors such as HIV shame, CD4 count, viral load, and HIV status of other children were positively correlated with anxiety symptoms. Though this did not remain significant at a multivariate level, it was found that women who had high levels of internalized HIV stigma were more likely to exhibit symptoms of anxiety, which is similar to other sources on this topic [4,26]. HIV-related stigma remains a major contributor towards poor mental health among women living with HIV, as they often face rejection, isolation, and lack of support arising from misconceptions, stereotypes, and negative beliefs about the virus and those affected by it. Thus, when such beliefs are internalized by those living with the virus, it becomes a source of distress that takes a toll on their mental health [9,31]. Stigma also has implications for disclosure as it may discourage individuals from sharing their seropositive status with their loved ones due to fear of rejection or being mistreated [4,32,33]. The current study found that the participants who had disclosed their HIV status to their family members were significantly more likely to be anxious than those who had not. It may be reasoned that the disclosure may not have been well received by family members due to stigma and thus heightening levels of anxiety.

Interestingly, participants with a detectable viral load had 1.8 greater odds of displaying anxiety symptoms. This finding is similar to a study that found elevated levels of anxiety among those with higher viral loads [34] and contrary to another which found no association [35]. It is explained that the fear of vertical transmission is intensified during the perinatal period due to the increased risk of HIV transmission through pregnancy, delivery, and breastfeeding [11,32]. This also offers an explanation as to why the current study found that among the 22 women who had an HIV positive child in previous pregnancies, a higher proportion (n=16; 8.89%) of these exhibited symptoms of anxiety. Anxious symptoms were also higher among women who had a CD4 count below 499, though this did not remain significant at a multivariate level. In their study among Ethiopian women living with HIV, Yousuf and colleagues [28] also reported higher levels of anxiety among women with lower CD4 count, who were at advanced clinical stages of the virus and had opportunistic infections. Immunocompromised individuals are at an increased risk of poor physical health [36,37], which poses a problem during pregnancy due to the potential for adverse outcomes. Thus necessitating the need to better understand the challenges faced by HIV positive women during the perinatal period for early detection and probable prevention and treatment.

Adverse pregnancy and delivery outcomes and other clinical factors have been linked with increased risk of anxiety [6,7,30,38,39], which were similarly replicated in the current study. Higher levels of anxiety were more frequent among nulligravida women. The journey of motherhood is complex and filled with many challenges; trying to navigate these challenges can be quite distressing, leading to worry, fear, and doubt, especially for those experiencing it for the first time [11]. This experience is worsened for women living with HIV due to the unique challenges that they face [10,40], especially for those without a good support system [6,13]. Some authors describe receiving a positive HIV diagnosis as a life-altering event, and learning to live, accept, and manage it requires a lot of adjustment [8,41,42]. Despite improvements in management, prevention, and treatment, HIV/AIDS remains a significant contributor to disease burden in developing nations [43]. It is therefore important to improve mental health screening during the perinatal period for women living with HIV for better maternal and infant outcomes.

Conclusion     

There was a high prevalence of perinatal anxiety symptoms among the HIV positive women in this sample, with the highest symptoms experienced during the antenatal period. This is indicative of probable undiagnosed perinatal anxiety in the sample, with implications for maternal and neonatal health. The study further demonstrated that anxiety among perinatal women living with HIV is influenced by a combination of social, relational, obstetric and HIV-related factors. The observed association between undetectable viral load and HIV non-disclosure displays the complex interplay between psychological distress and HIV-related factors within this population. Additionally, the relationship between mode of delivery and perinatal anxiety emphasizes the psychological dimension of obstetric experiences among women living with HIV. Similarly, the significant role of relationship and disclosure factors further indicates that both social support dynamics play a significant role in maternal mental health. Overall, the study underlines the multifactorial factors that play a significant role in shaping mental health outcomes for perinatal women living with HIV.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conception and study design: Tebogo Shivuri and Kebogile Elizabeth Mokwena; data collection: Tebogo Shivuri; data analysis and interpretation: Khomotso Comfort Maaga; manuscript drafting: Khomotso Comfort Maaga and Tebogo Shivuri; manuscript revision: Tebogo Shivuri, Kebogile Elizabeth Mokwena, and Khomotso Comfort Maaga; guarantor of the study: Khomotso Comfort Maaga. All the authors read and approved the final version of this manuscript.

Acknowledgments     

The authors would like to acknowledge the operational managers of the facilities where the study was conducted, as well as all women who participated in this study for their commitment and patience.

Tables     

Table 1: general characteristics of HIV positive perinatal women recruited from the prevention of mother-to-child transmission program across 10 healthcare facilities in Tzaneen sub-district

Table 1.1: general characteristics of HIV positive perinatal women recruited from the prevention of mother-to-child transmission program across 10 healthcare facilities in Tzaneen sub-district

Table 2: bivariate and multivariate analysis for factors associated with anxiety among HIV perinatal women recruited from the prevention of mother-to-child transmission program across 10 healthcare facilities

References