Social Support Household Structure and Depressive Symptoms among

Social Support, Household Structure, and Depressive Symptoms among Women Living with HIV in Almaty Nugmanova Z. , MD, Ph. D, Asfendiyarov Kazakh National Medical University; Urbaeva Z. , Ph. D UAlbany SPH

HIV in Kazakhstan (National AIDS Cr Data) • HIV is growing in Eastern Europe and Central Asia, including Kazakhstan • As of June 30, 2019, the total number of HIV cases was 37 616 people, of which 34 836 were citizens of the Kyrgyz Republic; PLWHA - 23, 799 • For 12 months of 2018, the proportion of women was 38% • A decrease in the parenteral mode of transmission with intravenous drug use was 2. 4 times (from 72% to 30%), the sexual mode of transmission increased 3 times (from 20% to 62%)

3 HIV in KZ (2006 -2016): Modes of Transmission (AIDS Cr Data) 72 66, 7 56 65, 4 60, 3 60, 5 57, 7 55, 7 61 58, 5 50 46, 2 35 28, 4 39, 7 40, 4 33, 8 24, 5 32, 5 33 30 18 0, 45 0, 57 0, 79 0, 93 1, 25 0, 8 1, 4 1, 7 2006 2007 2008 2009 2010 2011 2012 2013 2014 парентеральный половой гетеросесуальный 2, 9 3, 9 2015 2016 половой гомосексуальный

4 HIV in KZ (2006 -2016): Gender Distribution (AIDS Cr Data) 25 75 2006 30 70 2007 29 71 2008 33 67 2009 35 37 40 42 44 43 42 63 60 58 56 57 58 2010 2011 2012 2013 2014 2015 мужчины женщины 65 2016

«Engaging in ART services » • Myer and Phillips, who studied ART adherence among women postpartum, proposed the term “Engaging in ART Services” to reflect related phenomena: ART adherence and retention in care services (Myer & Phillips, 2017). • To a certain extent, this approach can be extended to all women living with HIV in general.

Conceptual model: determinants of engagement in ART services for women (Myer & Phillips, 2017). 1. Structural, social and economic conditions in regions where HIV is prevalent. 2. Health systems and services: the availability and accessibility of health services, as well as the quality of service and service delivery models. 3. Factors at the individual level, including partnerships and social relationships, disclosure of HIV status, social support and / or mental health. 4. Biomedical factors: problems associated with HIV and / or ART (for example, side effects of ARVs).

Factors at the Individual Level • Factors affecting women's participation in ART services on an individual level (interpersonal relationships or psychosocial problems) are important, although these factors are often strongly influenced by structural and / or biomedical conditions. • Depression or other mental health problems, for example, can affect women's ability to adhere to ART, and the determinants of mental health can include both social conditions and biological processes.

Psychosocial Determinants of Mental Health • Psychosocial determinants are an important risk factor and protective factor for mental health. • Many studies have found an inverse relationship between social support and symptoms of depression among people living with HIV, • There are few such studies in Kazakhstan • At the same time, in our region, the family is an important social institution based on collectivist values, which determine both the socialization systems and the support systems available to women through relatives • Understanding the relationship between social support, household structure, and mental health issues can help design interventions.

General Information: Depression Mental health is a key factor in the quality of life of people in general, PLHIV in particular The relationship between depression / anxiety and HIV is probably bi-directional PLHIV have a higher risk of developing mental illness Increased psychological stress due to HIV diagnosis and stress of living with HIV Social side effects of HIV associated with mental illness, including low levels of social support, feelings of isolation, and discrimination • People living with mental illness are more likely to engage in risky behaviors for HIV infection: • Unprotected sex, use of surfactants and the presence of several sexual partners • • •

General Information: Depression and PLWH • • Depression is a risk factor for the progression of HIV infection. Depression is associated with A decrease in the number of CD 4; Slow virologic suppression; HIV mortality; Faster progression to AIDS; Mortality from all causes among PLHIV. • Depression is a risk factor for poor ART adherence • Estimates of the prevalence of depression among PLHIV vary widely depending on the measure, sample, and country.

General Information: The Role of Social Support • Social support can be defined as the presence of people on whose care and love you can rely Social support is a supporting factor for: - commitment to ART - changes in risk behavior - general health Social support is a protective factor for mental health because it is associated with a reduction in depressive symptoms among women living with HIV.

Methods: Inclusion Criteria Patients who were registered at the Almaty City AIDS Cr were invited from April to October 2018 to participate in the study. Inclusion Criteria: - Women - age ≥ 18 years - Laboratory-confirmed HIV infection, - Knowledge of Kazakh or Russian - Not intoxicated while visiting the Center

Methods. Depression: Patient Health Questionnaire-8 (PHQ-8) • The eight items in PHQ-8 directly correspond to the criteria for the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) for depressive disorders, excluding suicidality. • A score of 10 or more is used to measure current depression in population studies.

Measure: Depression Patient Health Questionnaire (PHQ - 8) Symptoms over the last 2 weeks Major depressive disorder Other depressive disorder Necessary symptoms: 1. Little interest of pleasure in doing things 2. Feeling down, depressed or hopeless At least 1 Other Symptoms: 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself – or that you are failing or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or opposite – being so fidgety or restless that you have been moving around a lot more then usual More that half of the days OR nearly every day At least 4 1 to 3 symptoms More that half of the days OR nearly every day

Methods. Social Support: A Multi-dimensional Scale of Perceived Social Support (MSPSS) • Perceived social support was measured using an approved multi-dimensional 12 point scale that measures women's perceptions of available social support in three dimensions: (a) family; (b) friends; (c) significant others. • In addition, a household structure was defined (female-headed households, maleheaded households, and kinship-based households). • Logistic regression was used to measure the relationship between social support and the household structure with depression, taking into account demographic characteristics. • The study was approved by the research ethics committee of Kaz. NMU. Surveys were conducted after obtaining informed consent from women who decided to participate.

Measure: Multidimensional Scale of Perceived Social Support (MSPSS) Family sub-scale My family really tries to help me I get the emotional help and support I need from my family. I can talk about my problems with my family. My family is willing to help me make decisions. Significant other sub-scale There is a special person who is around when I am in need There is a special person with whom I can share joys and sorrows I have a special person who is a real source of comfort to me There is a special person in my life who cares about my feelings Friends sub-scale My friends really try to help me I can count on my friends when things go wrong I have friends with whom I can share my joys and sorrows. I can talk about my problems with my friends

Demographics (n=410) AGE Percent 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 18 -29 30 -39 Language Percent 70 40 -49 50+ Russian Kazakh Rus/Kaz Other

General health and livelihoods (n=410) General Health Self Assessment # of Poor Health Days Percent 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Excellent Good Fair Poor/Very Poor Physical Mental Health None 1 -3 days 4 -7 days 8 -14 days 15+ days

Indicator: Multidimensional Scale of Perceived Social Support (MSPSS) Support of Significant Other Family Support Friend Support 60 60 60 50 50 50 40 40 40 30 30 20 20 10 10 10 0 Low Medium High 30 20 Low Medium High

Results • Of the 410 WLWH, 17. 5% had a score of PHQ-8> 10 (current depression). • In all types of households, women with higher levels of social support were less likely to report depression. • Based on the regression analysis, support of family and friends was associated with a 35% (OR = 0. 65; p <0. 05) and 22% (OR = 0. 78; p <0. 05) decrease in the chances of depression by one unit of increase in family and friends support, respectively. • Compared to male-headed households, the chances of depression were significantly higher among women living in female-headed households (OR = 2. 33; p <0. 05) and kinship-based households (OR = 2. 02; p = 0. 06).

Conclusion • Given the sociocultural context of family life in Kazakhstan, we have determined that marital status is important for the psychological well-being of women. • Single women living with HIV can receive lower levels of support, which can negatively affect their mental health. • On a broader level, women may not receive enough support from their husbands, but marriage seems to be positively related to their psychological well-being. • These data emphasize the importance of psychosocial interventions for the treatment of depression among PLHIV in Kazakhstan. • The sociocultural context should be considered when designing effective interventions.

Acknowledgement • NYS International Research Training Program (NYSITRP), • Almaty City AIDS CR Leadership • L-A Mc. Nutt, Ph. D; J. Urbaeva, Ph. D, SPH UАlbany • Kaz. NMU and Almaty AIDS Cr colleagues participating in interviewing women living with HIV