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Mental health
Original research
Prevalence of common mental disorders and sleep disorder among adolescents and young adults with HIV: a systematic review and meta-analysis
  1. Yuting Tan1,
  2. Zhiyong Ma1,
  3. Qian Cao1,
  4. Shi-cheng Gao2,
  5. Yong Xiong2
  1. 1Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
  2. 2Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
  1. Correspondence to Dr Yong Xiong; yongxiong64{at}163.com

Abstract

Objective Adolescents and young adults (AYA) with HIV are a population at high risk of experiencing mental issues and sleep disorder. We aim to summarise the global prevalence and risks of depression, anxiety, post-traumatic stress disorder (PTSD) and sleep disorder among AYA with HIV.

Design Systematic review and meta-analysis.

Data sources PubMed, Web of Science, Embase and PsycINFO were searched from inception to 3 August 2024.

Eligibility criteria Observational studies reporting the prevalence of depression, anxiety, PTSD or sleep disorder among AYA with HIV and published in English were included. Reviews, case reports, conference papers, notes, editorials and non-observational research were excluded.

Data extraction and synthesis Titles, abstracts and full texts were reviewed and screened, and data were independently extracted. A modified Newcastle-Ottawa Quality Assessment Scale (NOS) was used to evaluate study quality. Heterogeneity was assessed by I2 statistics, and subgroup analysis was performed to identify the source of heterogeneity. The pooled prevalence and the risks of depression, anxiety, PTSD and sleep disorder by comparison with HIV-uninfected peers were measured with random-effects and fixed-effects models. Publication bias was examined using Egger’s correlation tests and funnel plot. The Grading of Recommendations Assessment, Development and Evaluation was used to assess the certainty of evidence.

Results 56 articles were included in the final analysis. According to the modified NOS, 13 (23.2%) studies were considered good, 38 (67.9%) were satisfactory and 5 (8.9%) were unsatisfactory. 51 studies including 21 735 AYA with HIV contributed data for the pooled prevalence of depression (28%, 95% CI 24% to 32%, I2=98.68%; low certainty evidence); 21 studies including 8021 cases contributed data for the pooled prevalence of anxiety (22%, 95% CI 17% to 27%, I2=98.35%; low certainty evidence); 9 studies including 3691 cases contributed data for the pooled prevalence of PTSD (12%, 95% CI 8% to 17%, I2=95.60%; low certainty evidence); and 4 studies including 1909 cases contributed data for the pooled prevalence of sleep disorder (51%, 95% CI 31% to 70%, I2=98.37%; low certainty evidence). Compared with AYA without HIV, those with HIV had a higher risk of depression (OR=2.67, 95% CI 1.63 to 5.90, I2=84.0%), anxiety (OR=1.89, 95% CI 1.32 to 2.69, I2=50.3%), PTSD (OR=1.58, 95% CI 1.23 to 2.04, I2=40.1%) and sleep disorder (OR=2.11, 95% CI 1.51 to 2.95, I2=0.0%). A subgroup analysis found that studies conducted in Asia had a lower prevalence of depression (21.7% vs 29.6%, p<0.001) and anxiety (14.7% vs 21.9%, p<0.001) than studies conducted in Africa. Egger’s test indicated that there was significant publication bias in the estimates of the prevalence of depression (p<0.001), anxiety (p<0.001) and PTSD (p=0.049), but not in the estimates of the prevalence of sleep disorder (p=0.861).

Conclusions AYA with HIV are a population at high risk of experiencing depression, anxiety, PTSD and sleep disorder. More sensitive screening strategies and more comprehensive intervention methods are needed. However, in view of the high heterogeneity, the differences between studies need to be considered and the pooled estimates interpreted with caution.

  • Adolescent
  • HIV & AIDS
  • MENTAL HEALTH

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2024-093320

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    Strengths and limitations of this study

    • This systematic review and meta-analysis provides a global systematic assessment of the prevalence of depression, anxiety, post-traumatic stress disorder and sleep disorder among adolescents and young adults with HIV, including a large sample size and covering different geographical areas.

    • The review included a comprehensive literature retrieval by searching across multiple databases without time limit.

    • Despite the subgroup analyses, it may not be possible to fully account for all sources of heterogeneity, which may affect the interpretation and generalisability of the results.

    • Significant publication bias indicated that there might be some unpublished studies, which may affect the estimation of pooled prevalence.

    Introduction

    Currently, more and more attention is being paid to the mental health problems of people living with HIV (PLHIV). Compared with the general population, PLHIV are at a higher risk of developing mental disorders and psychological health issues.1 They are more prone to a variety of mental health problems such as depression, anxiety, psychological stress and somatoform disorders.1 HIV itself, adverse drug reactions, social discrimination and stigmatisation may all contribute to mental health problems in individuals with HIV.2 3 A previous study has found that HIV can induce depression by triggering inflammatory responses in the central nervous system.4 Antiretroviral drugs, such as efavirenz, were also reported to be associated with depression, anxiety, mental confusion and suicidal behaviour.5 At the same time, mental health problems have brought a heavy burden to HIV treatment, thus leading to adverse outcomes.

    Adolescence is a critical developmental period that lays the foundation for mental health and well-being throughout the life-cycle. Previous studies have indicated that, compared with their peers, adolescents living with HIV are at a higher risk of experiencing adverse mental health due to the dual burden of living with a stigmatised infectious disease and a chronic illness that requires lifelong management.6 Mental health problems will lead to a decrease in treatment compliance, interruption of treatment, loss of follow-up and increase in mortality among PLHIV, as well as to rebound of viral load and virological failure.6 In adolescents and young adults (AYA), one of the special groups, it is crucial to understand the epidemiological data on psychological health issues, which are significant in improving medication adherence and prognosis. However, currently, the prevalence of mental problems among AYA with HIV in different studies varies due to differences in socioeconomic conditions, regional culture and screening tools. Different from previous systematic reviews and meta-analyses, this review and meta-analysis focused on the global prevalence of depression, anxiety, post-traumatic stress disorder (PTSD) and sleep disorder in AYA (age 10–40 years old) with HIV, expanding on research area and age range.

    Methods

    The systematic review and meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.7

    Data sources and search strategy

    Published studies from databases including PubMed, Web of Science, Embase and PsycINFO were searched from inception to 3 August 2024 by two authors (YT and ZM) independently. Detailed search strategies are provided in online supplemental table 1.

    Study selection

    Initial screening was conducted with duplicates removed. Subsequently, two independent authors (ZM and QC) evaluated eligible studies by reading their titles and abstracts, followed by a full-text review by the same two reviewers. Any divergences encountered were resolved through discussion until consensus was reached.

    Eligibility criteria

    Studies meeting the following criteria were included: (1) study population included AYA (age 10–40 years old) with HIV; (2) study results reported the prevalence rate among AYA with HIV of at least one of the following outcomes: depression, anxiety, PTSD and sleep disorder; and (3) observational studies including cross‐sectional, cohort and case–control studies published in English. Reviews, case reports, conference papers, notes, editorials and non-observational research were excluded.

    Data extraction

    Two authors (YT and QC) independently extracted the following data from the included studies using Microsoft Excel: first author surname, publication year, study location, sample size, study population (including HIV-negative participants), age, study design, type of mental issue, screening tools for depression, anxiety, PTSD and sleep disorder, and prevalence estimates of depression, anxiety, PTSD and sleep disorder. If there was inconsistency in data extraction between the two authors, the two authors first rechecked the data from the original text. If the inconsistency persisted, it was resolved through discussion until consensus was reached.

    Quality assessment

    A modified Newcastle-Ottawa Quality Assessment Scale (NOS) was used by two authors (ZM and QC) to independently evaluate the quality of the included studies.8 Five dimensions, namely sample size, representativeness, response rate, valid assessment of mental problems and strong statistical methods, were assessed. The quality of study was graded according to a star system, with a maximum score of 10. Studies with a score of 9–10 were rated as very good, studies with a score of 7–8 were rated as good, studies with a score of 5–6 were rated as satisfactory and those with a score of 0–4 were considered unsatisfactory. If there was inconsistency in quality assessment between the two authors, it was resolved through discussion until consensus was reached. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach (https://gdt.gradepro.org/).

    Data synthesis

    Statistical analyses were performed with Stata (V.14.0). The pooled prevalence and 95% CI of depression, anxiety, PTSD and sleep disorder were evaluated, and their risks (OR and 95% CI) of occurrence among AYA with HIV by comparison with those without HIV were calculated. The heterogeneity between studies was assessed by I2 statistics, and a value >75% indicated high heterogeneity. Fixed-effect models were performed when I2 <50%, and random-effects models were performed when I2 ≥50%. Subgroup analyses of the prevalence of depression, anxiety, PTSD and sleep disorder were performed to identify sources of heterogeneity according to study design, study location and measurement tools. Leave-one-out sensitivity analyses were conducted to evaluate how individual studies affected the overall analysis results. Sensitivity analyses excluding articles with unsatisfactory study quality were performed. Publication bias was examined using Egger’s correlation tests and funnel plot. Trim and fill analyses were further conducted. Statistical analyses were two‐sided with a significance level of 0.05.

    Patient and public involvement

    None.

    Results

    Study selection

    In total, 6676 records were screened from PubMed (n=1375), Web of Science (n=2570), Embase (n=1650) and PsycINFO (n=1081). After removing duplicate records, 3597 records were evaluated by reviewing the title and abstract according to the eligibility criteria. Further, 203 records were considered for full-text screening, of which 137 articles were excluded due to inconsistency with study population, study design and study outcomes, 6 articles excluded due to duplication of research data and 5 articles excluded as they were conference papers. Finally, 56 articles were included in the systematic review and meta-analysis (shown in figure 1).

    Figure 1
    Figure 1

    Flow chart of selection of studies for inclusion in the meta-analysis.

    Characteristics of studies

    Of the total 56 studies, 51 studies including 21 735 AYA with HIV reported the prevalence of depression,9–59 21 studies including 8021 AYA with HIV reported the prevalence of anxiety,10–14 20–23 27 28 36 41 42 47 50 53 56 57 59 60 9 studies including 3691 AYA with HIV reported the prevalence of PTSD12 23 36 39 41 42 50 57 61 and 4 studies including 1909 AYA with HIV reported the prevalence of sleep disorder.25 62–64 Most studies were conducted in Africa, and most were cross-sectional studies. The study characteristics are summarised in online supplemental table 2. According to the modified NOS, 13 (23.2%) studies were considered good, 38 (67.9%) were satisfactory and 5 (8.9%) were unsatisfactory. The quality assessment of the included studies is shown in online supplemental table 3.

    Prevalence of mental problems among AYA with HIV

    51 studies reported the prevalence of depression among AYA with HIV, ranging from 4% to 82%, with a pooled prevalence of 28% (95% CI 24% to 32%; low certainty evidence). 21 studies reported the prevalence of anxiety, ranging from 2% to 57%, among AYA with HIV, with a pooled prevalence of 22% (95% CI 17% to 27%; low certainty evidence). Nine studies reported the prevalence of PTSD, ranging from 3% to 28%, with a pooled prevalence of 12% (95% CI 8% to 17%; low certainty evidence). Four studies reported the prevalence of sleep disorder, ranging from 21% to 77%, with a pooled prevalence of 51% (95% CI 31% to 70%; low certainty evidence). Significant heterogeneity between studies existed, with I2 ranging from 95.60% to 98.64%. The pooled prevalence of depression, anxiety, PTSD and sleep disorder is shown in table 1, and the forest plots are shown in online supplemental figures 1–4. The evaluation of certainty of evidence is shown in online supplemental table 4.

    View this table:
    Table 1

    Pooled prevalence of depression, anxiety, PTSD and sleep disorder among AYA with HIV

    Risks of mental problems among AYA with HIV

    Five studies reported the prevalence of depression among AYA with HIV and those without HIV, four studies reported the prevalence of anxiety among AYA with HIV and those without HIV, two studies reported the prevalence of PTSD among AYA with HIV and those without HIV, and two studies reported the prevalence of sleep disorder among AYA with HIV and those without HIV. As shown in figure 2A–D, compared with AYA without HIV, those with HIV had a higher risk of occurrence of depression (OR=2.67, 95% CI 1.63 to 5.90), anxiety (OR=1.89, 95% CI 1.32 to 2.69), PTSD (OR=1.58, 95% CI 1.23 to 2.04) and sleep disorder (OR=2.11, 95% CI 1.51 to 2.95).

    Figure 2
    Figure 2

    (A) Forest plot of the risk of depression among AYA with HIV by comparison with those without HIV. (B) Forest plot of the risk of anxiety among AYA with HIV by comparison with those without HIV. (C) Forest plot of the risk of PTSD among AYA with HIV by comparison with those without HIV. (D) Forest plot of the risk of sleep disorder among AYA with HIV by comparison with those without HIV. AYA, adolescents and young adults; PTSD, post-traumatic stress disorder. DL: DerSimonian-Laird; MH: Mantel-Haenszel.

    Subgroup analysis

    Subgroup analyses of the prevalence of depression, anxiety and PTSD were performed according to study design, study location and measurement tools (shown in online supplemental figures 5–13). Study design (p=0.012), study location (p<0.001) and measurement tools (p<0.001) were the sources of heterogeneity in the prevalence of depression. Case–control studies (19.3%) had a lower pooled prevalence of depression. Studies that used measurement tools such as Beck Depression Inventory-Second Edition (BDI-II) (37.7%), Center for Epidemiologic Studies Depression Scale (CES-D) (36.3%) and Patient Health Questionnaire-9 (PHQ-9) (32%) indicated a higher prevalence of depression, while studies that used measurement tools such as Children's Depression Inventory (CDI) (24.1%), Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) (21.3%) and Patient Health Questionnaire - Adolescent (PHQ-A) (15.9%) indicated a lower prevalence of depression. Study design (p=0.014), study location (p<0.001) and measurement tools (p<0.001) were also sources of heterogeneity in the prevalence of anxiety. Studies conducted in Asia had a lower prevalence of depression (21.7% vs 29.6%, p<0.001) and anxiety (14.7% vs 21.9%, p<0.001) than studies conducted in Africa. Study design, study location and measurement tools (all p<0.001) were also sources of heterogeneity in the prevalence of PTSD. Studies performed in Africa showed a lower PTSD prevalence, while studies performed in North America showed a higher PTSD prevalence (7.7% vs 24.4%, p<0.001).

    Sensitivity analysis

    Leave-one-out sensitivity analyses were performed to assess the impact of individual studies on the pooled prevalence of depression, anxiety, PTSD and sleep disorder. As shown in online supplemental figures 14–17, there were no significant changes in the pooled prevalence of depression, anxiety, PTSD and sleep disorder after excluding individual studies, indicating that the results were stable. The results of the sensitivity analysis excluding articles with unsatisfactory study quality are shown in online supplemental figures 18–21. The pooled prevalence of depression, anxiety, PTSD and sleep disorder was 27% (95% CI 23% to 31%), 21% (95% CI 15% to 28%), 13% (95% CI 6% to 20%) and 42% (95% CI 21% to 63%), respectively. The results had no significant differences in comparison with the previous results.

    Publication bias

    Egger’s test indicated that there was significant publication bias in the prevalence of depression (p<0.001), anxiety (p<0.001) and PTSD (p=0.049), while there was no significant publication bias in the prevalence of sleep disorder (p=0.861). The publication bias funnel plots for depression, anxiety and PTSD are shown in online supplemental figures 22–24. Trim and fill analyses were further conducted. As shown in online supplemental figures 25 and 26, the results had no significant differences in comparison with the previous results.

    Discussion

    To date, few studies have summarised the global prevalence and risk of mental problems, including depression, anxiety, PTSD and sleep disorder, among AYA with HIV. Our study demonstrated a relatively high global prevalence and an increased risk of occurrence of depression, anxiety, PTSD and sleep disorder among AYA with HIV compared with those without HIV. Our data supported that depression, anxiety, PTSD and sleep disorder among AYA with HIV are important global public health issues that require enough attention for prevention and treatment.

    The pooled prevalence of depression and anxiety in our study was 28% and 22%, respectively. Previous reviews have reported a global prevalence of depression of as high as 44.0% and a global prevalence of anxiety of as high as 48.2% among young people with HIV,65–67 which are higher than our data. Consistent with our data, another study also showed higher risks of depression and anxiety among young people with HIV compared with their peers without HIV.68 The prevalence of depression and anxiety varied by study location. The subgroup analysis found that studies conducted in Asia had a lower prevalence of depression (21.7% vs 29.6%) and anxiety (14.7% vs 21.9%) than studies conducted in Africa. Differences in medical standards, social support, social and cultural awareness and educational level may account for the varying prevalence of depression and anxiety in these regions.

    PTSD was also common in PLHIV. One meta-analysis including 19 studies with 9094 participants and another meta-analysis including 38 articles with 11 743 participants estimated that the pooled prevalence of PTSD among people with HIV/AIDS was 28%–32.67%,69 70 which significantly exceeded the PTSD prevalence of 3.9% in the general population.71 Our data on AYA with HIV indicated that the pooled prevalence of PTSD was 12%, which was lower than the prevalence of PTSD in the previous meta-analysis performed in all PLHIV regardless of age. Our subgroup analysis by study location showed a higher prevalence of PTSD in North America than in Africa. On the one hand, in North America, young people with HIV are more likely to belong to LGBTQ, who are at heightened risk for violence, bullying, victimisation and homelessness,72 while in Africa there is a higher incidence of vertically acquired HIV. On the other hand, most of the studies (two out of three studies) from North America were conducted 10 years ago, while most of the studies (four out of six studies) from Africa were conducted after 2020 (including 2020). The incidence of PTSD may be influenced by different socioeconomic conditions and educational backgrounds when comparing the situation 10 years ago and recently.

    Sleep disorder is a common issue among PLHIV. One meta-analysis including 27 articles with a total of 9246 HIV-positive participants found that the overall prevalence of self-reported sleep disturbances in HIV-infected people was 58.0% (95% CI 49.6 to 66.1), which was higher than that reported in the normal population (13%–30%).73 These data are similar to our results showing a pooled prevalence of sleep disorder of 51% among AYA with HIV, with the risk of sleep disorder among AYA with HIV higher than that among AYA without HIV. The prevalence of sleep disorder varied between different locations, with the prevalence estimated at 70.7% in North America, 34.5% in Africa, 66.8% in South America and 40.7% in Europe.73 Since few studies on sleep disorder among AYA with HIV were included in our meta-analysis, subgroup analysis by study location and screening tools could not be further assessed. More research is needed to explore the risk of sleep disorder among AYA with HIV in the future.

    Strengths and limitations

    This review and meta-analysis provided a global systematic assessment of the prevalence of depression, anxiety, PTSD and sleep disorder among AYA with HIV, expanding the age range and covering different geographical areas. In addition, the subgroup analyses in this study further provided the prevalence of depression, anxiety, PTSD and sleep disorder in different countries and regions and the prevalence measured by different screening tools. The meta-analysis has several limitations. First, high heterogeneity in the pooled prevalence existed between studies. Study design, study location and measurement tools for mental problems were all sources of heterogeneity. Cross-sectional and longitudinal designs might have led to discrepant prevalence estimates. Study location also plays a crucial role, as different geographical areas may have unique cultural, social and environmental factors that influence the occurrence of mental problems. Additionally, some studies might have relied on self-report questionnaires, which are subject to response bias, while others might have used clinical interviews administered by trained professionals. The high heterogeneity might limit the general applicability of systematic estimation. Second, there was significant publication bias, indicating that some studies might be unpublished. This may affect the estimation of the pooled prevalence. Third, more than half of the measures of certainty of evidence were low, mainly due to limitations in study design and publication bias.

    Conclusions

    AYA with HIV are a population at high risk of experiencing depression, anxiety, PTSD and sleep disorder. More sensitive screening strategies and more comprehensive intervention methods are needed. However, in view of the high heterogeneity, the differences between studies need to be considered and the pooled estimates interpreted with caution.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Following the Helsinki Declaration, no human or animal species were involved in this review of existing scientific literature; hence, this work did not require ethical approval.

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    Footnotes

    • YT, ZM and QC are joint first authors.

    • YT, ZM and QC contributed equally.

    • Contributors YT: data curation, formal analysis, investigation, methodology, software, writing—original draft. ZM: data curation, formal analysis, methodology, writing—original draft. QC: data curation, formal analysis, methodology. S-cG: conceptualisation, supervision, writing—review and editing. YX: guarantor, conceptualisation, project administration, supervision, writing—review and editing.

    • Funding This study was funded by ‘Comprehensive reform of medical education quality, first-class undergraduate professional construction project’, Wuhan University (grant number: 202102). The funder has any role or influence on the paper.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.