Cumulative exposure to depressive symptoms and all-cause mortality among adults living with HIV in Kenya, Nigeria, Tanzania, and Uganda.

OBJECTIVE::We estimated the effects of cumulative exposure to depressive symptoms on risk of all-cause mortality among people living with HIV in four African countries. DESIGN::Analysis of prospective cohort data. METHODS::The African Cohort Study (AFRICOS) is a prospective cohort of people receiving care at twelve clinics in Kenya, Nigeria, Tanzania, and Uganda. Every six months from January 2013 to May 2020, participants underwent laboratory monitoring, structured surveys, and assessment of depressive symptom severity using the Center for Epidemiologic Studies Depression Scale (CES-D). All-cause mortality was the outcome of interest. The predictor of interest was a time-updated measure of the percentage of days lived with depression (PDD). Marginal structural Cox proportional hazards regression models were used, adjusting for potential confounders including time-varying alcohol use, drug use, and viral load. RESULTS::Among 2520 enrolled participants, 1479 (59%) were women and the median age was 38 (interquartile range [IQR]: 32-46). At enrollment, 1438 (57%) were virally suppressed (<200 copies/mL) and 457 (18%) had CES-D ≥ 16, indicating possible depression. Across 9093 observed person-years, the median PDD was 0.7% (IQR: 0-5.9%) with 0.8 deaths per 100 person-years. Leading causes of death included cancer (18% of deaths) and accidents (14%). Models suggested that each 25% absolute increase in PDD was associated with a 69% increase in the risk of all-cause mortality (HR: 1.69; 95% CI: 1.18-2.43). CONCLUSIONS::Cumulative exposure to depressive symptoms was substantially associated with the risk of mortality in this cohort of PLWH in Africa.