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Most people feel depressed at times. Losing a loved one, getting fired from a job, going through a divorce and other difficult situations can lead a person to feel sad, lonely, scared, nervous or anxious. The term depression often characterizes feelings of being sad, discouraged, hopeless, irritable, unmotivated as well as a general lack of interest or pleasure in life. When these feelings last for a short period of time, it may be called a passing case of the blues. But its likely to be a depressive disorder when they last for more than two weeks and interfere with regular daily activities (Marina Marcus, 2012). Persons living with HIV/AIDS are at increased risk for developing affective disorders, particularly depression (Atkinson, 2006). Recent studies have also shown that depression impacts the course of HIV disease in Botswana and other sub-Saharan African countries (L. N. Makoae, 2005).
HIV associated depression has multiple causes, some of which may be components of the neurotropic disease process itself. The virus can cause damage to subcortical regions of the brain that are directly involved in the regulation of affect and mood (L. Simbayl, 2007). Early in the disease, people often see themselves as being persecuted by the virus. At later stages, physical and psychological anxieties and fears about death are common (B. O. Olley, 2004). As the disease progresses, control (or power) issues emerge as patients face increasing loss of physical control. Self-efficacy and active involvement in their health can increase peoples sense of being in control and reduce their risk of feeling helpless. But hope may alternate with despair as initial bewilderment turns to fear as the disease becomes more severe. Denial is most typical in the early stages of infection (G. Andrews, 2010). Control issues are more salient in the asymptomatic or mild symptomatic stages, and helplessness along with hopelessness are most concentrated in the severe symptomatic and terminal phases of AIDS. Thus, one can characterize HIV disease as producing four major psychological concerns such as the existential and spiritual issues, a perception of HIV as a threat or persecutor, feelings of vulnerability and loss of control as well as the death-related concerns associated with the infection (American-Psychiatric-Association, 1994).
Such an issue is heightened by the socio-cultural fact that mental disorders such as depression do not exist in the culture of Batswana which may increase the prevalence rate when individual choose to engage in destructive behavior (Kathy Lawler, 2011). Women are disproportionately affected by the HIV epidemic. In 2016, there was an HIV prevalence rate of 26.3% among adult women (aged 15-49), compared to 17.6% for men of the same age. Around 200,000 women were estimated to be living with HIV in 2016, compared to 150,000 in 2005. This means more than half (56%) of those living with HIV are women (Utility of a new procedure for diagnosing mental disorders in primary care., 2014). Gender inequality in Botswana is fueling the epidemic among females. Factors such as early sexual debut, forced marriage and gender-based violence have increased their vulnerability to HIV. According to a national study into gender-based violence in 2012 (the most recent of its kind) 29% of women in Botswana reported experiencing some form of intimate partner violence during the past 12 months. 67% reported experiencing intimate partner violence in their lifetime (UNAIDS, 2017). This issue is common across Sub-Saharan Africa and there have been various campaigns to curb the issue through educating individuals from an early age as well as providing aid for those affected (Mahabeer, 2000).
HIV/AIDS is associated with stigma and discrimination, an individuals HIV status is seen as a lens to judge the morality of the individual. Majority of those with HIV/AIDs do not voluntarily disclose their HIV status to the health care provider or approach a health facility with the fear of rejection (Z. Steel, 2014). It is important to identify depression because it can lead to poor adherence to highly active antiretroviral treatment (HAART) regimens. Inadequate levels of antiretroviral (ARV) medications contribute to the development of resistance, which compromises control of HIV disease. However, this destructive cycle can be averted in that poor adherence due to depression may be amenable to therapy, such as anti-depressant medications (M. Dalessandro, 2007).
Diagnosis is further complicated because some HIV+ individuals develop neurocognitive impairment including slowed thinking, poor concentration, forgetfulness, and executive dysfunction (V. Patel, 2010). HIV+ individuals with executive dysfunction may develop a flat affect and apathy due to damage to the frontal-striatal regions of the brain, thus they are often misdiagnosed as depressed and treated with anti-depressants (R Desjarlais, 1995). This may seem a minor problem, since anti-depressants are usually not harmful from a medical perspective; however, from a resource perspective this can be wasteful, and can translate into a large number of HIV+ individuals being prescribed expensive medications, with no benefit. Differentiation of affective changes due to executive dysfunction from depression is of great importance, not only clinically, but also to ensure judicious allocation of scarce medical resources in the regions worst affected by the HIV epidemic (R. Araya, 2006).
In conclusion there are a range of issues that people with HIV have to contend with prime among which being depression. Depression not only complicates the lives of people living with HIV in Botswana as it is affected by psychological, social, cultural and economic factors but also if left untreated can ultimately lead to self-destructive behavior like suicide as well as individuals transmitting the infection whilst knowing their HIV status (HIV+). However, if properly diagnosed depression is very treatable and preventable highlighting the necessity of adequate education on the matter especially when dealing with issues like HIV.
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