Young girls in South Africa face an extraordinary threat of HIV: One in four will have contracted the virus by adulthood, and most are first infected during adolescence.
Now a new study, published online in the American Journal of Epidemiology, finds that adolescent girls with depression face an even greater risk of contracting HIV.
The research suggests that interventions targeted at improving mental health among teen girls may help control the spread of HIV in South Africa and throughout the rest of sub-Saharan Africa.
“We’ve known that depression and HIV go together for decades, but no one has known which way the arrow goes: Does depression lead to HIV or does HIV lead to depression?” said Dr. Jennifer Ahern, professor of epidemiology at the University of California, Berkeley and senior author on the study.
“Probably it goes both ways, but we were able to show that, at least in this population, the arrow certainly goes one way, which is depression leads to HIV. This could have important implications for where interventions might lie.”
As part of the study, the researchers examined which aspects of teens’ social lives and behaviors might explain the link between depression and HIV incidence.
They found that teen girls who experienced symptoms of depression were later more likely to report not having close relationships with their parents, and having a partner who would hit her if she asked him to wear a condom. These factors appeared to be part of the pathway to contracting HIV.
“Partner violence in response to condom negotiations, and a lack of parental monitoring, had the strongest association with both depression and HIV, which indicates that the majority of the relationship between depression and HIV may be influenced through those factors,” said Dana Goin, a postdoctoral scholar in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, and lead author of the study.
“The results illustrate how so much of infection among this population has to do with structural factors,” said Goin, who completed the work as a PhD candidate in epidemiology at UC Berkeley.
The researchers analyzed data from 2,533 young women, ages 13 to 21, living in rural Mpumalanga Province, South Africa. Each participant was screened for symptoms of depression at the beginning of the study and then tested for HIV annually for six years.
A little more than 18% of the young women had depression at the beginning of the study — about twice the national average of South Africa. Of those with depression, nearly 11 percent went on to contract HIV, while only 6.5% of those without depression eventually became infected.
While previous research has shown that depression can lead to higher incidence of HIV in men who have sex with men in the U.S., this study is the first to look at the association among girls and young women in sub-Saharan Africa.
Although residents in rural South Africa have limited access to mental health services, Ahern and Goin’s collaborators at Oxford University in the U.K. and at the University of the Witwatersrand in South Africa are currently working to develop community-based interventions that can help identify and support girls who are struggling with depression.
“There is increasing evidence that proven psychological treatments for depression, such as behavioral activation, can be delivered by lay counsellors and community healthcare workers, which provides a feasible way of delivering treatment for depression in the community,” said Alan Stein, a professor of child and adolescent psychiatry at the University of Oxford.
“There is also the possibility of delivering these kinds of treatments using the internet or mobile phones, with the support of phone calls from peer mentors, and this is something we are working on.”