Objective To assess the magnitude of suicidal ideation, attempts and associated factors among adults living with HIV attending antiretroviral therapy follow-ups at Tirunesh Beijing General Hospital, Addis Ababa.
Design Hospital-based observational, descriptive, cross-sectional study was conducted.
Setting A study was conducted in Tirunesh Beijing General Hospital, Addis Ababa from 8 February 2022 to 10 July 2022.
Participants Two hundred and thirty-seven HIV-positive youth were recruited for interviews, using the systematic random sampling technique. The Composite International Diagnostic Interview was used to assess suicide. Patient Health Questionnaire-9, the Oslo social support and HIV perceived stigma scale instruments were used to assess the factors. Bivariate and multivariate logistic regressions were computed to assess factors associated with suicidal ideation and attempt. Statistical significance was declared at p value <0.05.
Results The finding of the study revealed magnitude of suicide ideation and suicide attempt was 22.8% and 13.5%, respectively. Disclosure status (adjusted odd ratio (AOR)=3.60, 95% CI 1.44 to 9.01), history of using substances (AOR)=2.86, 95% CI 1.07 to 7.61), living alone (AOR=6.47, 95% CI 2.31 to 18.10) and having comorbidity or other opportunistic infection (AOR=3.74, 95% CI 1.32 to 10.52) are factors associated with suicide ideation while disclosure status (AOR=5.02, 95% CI 1.95 to 12.94), living arrangement (AOR=3.82, 95% CI 1.29 to 11.31) and depression history is a factor associated with suicide attempts (AOR=3.37, 95% CI 1.09 to 10.40).
Conclusion The finding of the study indicated the magnitude of suicide ideation and attempt is high among the subjects included in this study. Disclosure status, history of using substances, living alone and having comorbidity or other opportunistic infection are factors associated with suicide ideation while disclosure status, living arrangement and depression history are factors associated with a suicide attempt.
- HIV & AIDS
- Suicide & self-harm
- INFECTIOUS DISEASES
- INTERNAL MEDICINE
Data availability statement
No data are available. No additional data is available.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
To generate a representative sample, study participants were selected randomly.
Since the study design is cross-sectional study design it is not identified whether the relationship is temporal or not.
Again, there is no evidence to say whether exposure comes first or not. So, a follow-up-based investigation is needed.
According to the definition, suicide is defined as intentional self-inflicted death.1 A suicide attempt is an intentional but unsuccessful act of killing oneself and suicidal ideation is thought about killing oneself,2 WHO reports revealed that someone attempts suicide every 3 s and commits suicide somewhere in the world every 40 s.2
In the world, HIV/AIDS is one of the most serious health and development challenges. Based on the global HIV and AIDS statistics fact sheet 2021, 38.4 million people were living globally with HIV infection, 1.5 million people became newly infected and 650 000 HIV/AIDS-related deaths occurred during this year.3 Two-thirds of the victims were in sub-Saharan Africa, with 43% of new cases in eastern and southern Africa.4
The annual global suicide rate in the general public is 11.4 per 100 000 population which contributed to over 2.4% of the global burden of disease by the year 2020, and the rate of suicide will increase to one every 20 s. The national cost of suicide, including suicide attempts, in the USA in 2013 was $58.4 billion.5
Compared with the general public, people living with HIV/AIDS (PLWHA) have 7–36 times more risk of suicidal ideation and attempt.6 Throughout the progression of HIV infection, the pattern of suicide attempts and suicidal ideation may differ. The initial 6 months after the diagnosis of HIV and the onset of a physical complication of AIDS are high-risk periods for suicidality.7
A cross-sectional study conducted in semi-urban Uganda among 618 attendants at two HIV clinics reveals the prevalence of moderate to high risk for suicide at 7.8% and lifetime attempted suicide at 3.9%.7 Another survey at the University of Benin Teaching Hospital among 150 HIV-positive individuals reported that suicidal ideation was 43%.8 In Ethiopia, an institutional-based cross-sectional revealed that the proportion of suicidal ideation and attempt was 33.6% and 20.1%, respectively.9
The risk factors for suicide ideation and attempts among youth living with HIV/AIDS are sex, depression, clinical stage of HIV, death in a family and hospital admission. Additionally, HIV-related stigma and poor social support have also been risk factors for suicide.9
Suicidal ideation is frequent among PLWHA. Psychosocial health problems are the determining factors associated with suicidal ideation, and a syndemic effect of psychosocial health conditions was confirmed in predicting suicidal ideation.10
However, there is little report about suicide among HIV-positive adults in Ethiopia, which even showed some contradicting findings about the associated factors with suicidal ideation and attempts.9 11 The discrepancies among findings of former studies also need other supportive findings.
Thus, the current study aims to assess the predictors of suicidal ideation, and attempts among adults living with HIV attending antiretroviral therapy (ART) follow-ups at Tirunesh Beijing General Hospital.
Methods and materials
Study setting and period
Tirunesh Beijing General Hospital is located in Addis Ababa, Akaki Kality subcity, Woreda 01. The hospital was established in 2011. As informed by the hospital’s administration, it has more than 1000 staff members, and all major departments like internal medicine, surgery, gynaecology and obstetrics, and paediatric services are provided. The psychiatry services provided at Tirunesh Beijing Hospital include psychiatric emergency and psychiatry outpatient. Annually the number of patients served in the psychiatry clinic is about 2185. The hospital is built by the Chinese government and named Tirunesh Beijing in memory of athlete Tirunesh Debaba who won two gold medals in the Beijing Olympics. Currently, the organisation is administered under Addis Ababa Health Bureau. The number of HIV-positive patients attending follow-up at the Tirunesh Beijing is 1100. The study was conducted from 8 February 2022 to 10 July 2022 at Tirunesh Beijing General Hospital.
A hospital-based observational, descriptive, cross-sectional study was conducted.
Source of population
All HIV-infected adults receiving ART at Tirunesh Beijing General Hospital.
All HIV-infected adults attending ART follow-up at Tirunesh Beijing General Hospital fulfil the inclusion criteria.
Adult patients receiving ART follow-up at Tirunesh Beijing General Hospital.
Age group 15 years and above.
Those patients who are unable to respond or whom attendants are unable to give a sufficient response.
Sample size determination
The sample size (n) required for the study was calculated using the formula to estimate a single population proportion by considering the following assumptions.
Zα/2=critical value for normal distribution at 95% CI to 1.96 (Z value at alpha=0.05). According to the study conducted in 2018 at Addis Ababa, St. Paul’s Hospital Millennium Medical College, and St. Peter’s Specialized Hospital, the prevalence of suicidal attempts among ART attendants was 16.9%.11
Hence, according to the study; p=16.9%.
d(w)=margin of error of 0.05 with a 95% CI level.
The final sample size was 237 after adding a 10% non-response rate.
Totally 1100 patients are receiving ART at Tirunesh Beijing General Hospital. The desired sample was selected by systematic random sampling after calculating the K value which was 1100/237. Thus, the sample is selected for every four patients.
Presence or absence of suicidal ideation and suicidal attempt.
Sociodemographic factors: age, sex, employment condition, monthly income, education status, marital status, religion.
Clinical factors: CD4 count, HIV/AIDS stage and opportunistic infection.
Psychosocial factors: stigma, substance use variables and social support were the independent variables.
The patient was asked the question, ‘Have you ever seriously thought about committing suicide?’ and if the answer is yes, it was taken as suicidal ideation. However Suicidal ideation (or suicidal thoughts) means having thoughts, ideas or ruminations about the possibility of ending one’s life.10
Suicidal attempt is an attempt to die by suicide that results in survival.10 According to this study, the patient was asked the question, ‘Have you ever attempted suicide?’ and if the answer is yes, it was taken as a suicidal attempt.
Data collection tools and method
Data were collected by structured questionnaires through face-to-face interviews. The questionnaires contain three dimensions: sociodemographic part, clinical factors, and psychosocial factors.
Data were collected by interviewing the selected study participants and reviewing medical records using a validated questionnaire which was adapted from the following studies.12–15 WHO’s Composite International Diagnostic Interview suicide manual was used to assess suicidal ideation and attempt.12 Depression was assessed using the Patients Health Questionnaire version-913 while social support was measured using the Oslo Social Support scale14 and stigma related to HIV/AIDS was assessed by the perceived HIV stigma scale.15 The reliability of the data was checked by Cronbach’s alpha tests.
Data collection was done by trained data collectors. The data were collected by two data collectors. The questionnaires were first prepared in English and then translated into Amharic and back to English to ensure consistency and understandability.
Data quality control
Predata collection, the questionnaires were organised in an orderly manner and translated into the local language Amharic language by linguistics. Experienced data collectors were selected and training was given on how to collect data, record data and ethical approaches. A pretest was done on 5%12 of the sample size before the actual data collection. Amendments were made to questions after pretesting. The data collectors were given a brief orientation about the data collection tool and how to collect data before data collection. Code was given to each candidate during data collection. The principal investigator was in overall control, supervised and supported the work of data collectors.
Data processing and analysis
Data were checked for completeness and consistency and then it was cleaned, coded and entered using Epidata V.3.1 and it was exported to the SPSS software V.25 for analysis. Descriptive statistics were used to describe the study population about relevant variables. Logistic regression was fitted to identify the association between dependent and independent variables. The bivariate logistic regression analysis was conducted to select candidate variables for the multivariable model. Those variables that show association with the outcome variable at a p value less than 0.2 were included in the multivariable logistic regression model. Both crude and adjusted ORs with their corresponding 95% CI were used to determine the strength of association. Multi-collinearity was checked by running a collinearity diagnostic (variance inflation factor and correlation matrix). The final multivariable model goodness of fit was checked using Hosmer and Lemeshow. A p value of less than 0.5 was used to declare the statistical significance of the finding in this study. The result was presented using text, tables and graphs based on the types of data.
Patient and public involvement
Socioeconomic and sociodemographic factors
About 237 respondents participated in this study which yield to 100% response rate. The median age of respondents was 39 years old with a 14 years IQR. The majority of respondents, 127 (53.6%) were women and the majority of respondents 166 (70%) were married. The majority of respondents 118 (49.7%) attained college or university while most of the respondents 70 (29.5%) were housewives. About 28 (11.8%) lived alone while the majority of respondents 178 (75.1%) were living with family. Almost all of the respondents 213 (89.9%) have a bank account to save their income. About 39 (16.5%) of respondents have no separate bedrooms (table 1).
Psychosocial related variables
The finding of the study indicated that 20 (8.4%) patients had a history of family death with suicide. The majority of respondents 127 (53.6%) were rating social support as moderate and 20 (8.4%) respondents had HIV-perceived stigma. About 24 (10.1%) of respondents had a history of depression and 15 (6.3%) history of mental illness. The majority of respondents 199 (84%) had never used substances while 29 (12.2%) currently using substances. About 197 (83.1%) of patients’ health statuses were disclosed (table 2).
The majority of respondents 212 (89.5%) were categorised under WHO clinical stage I and the majority of respondents 157 (73.7%) had a CD4 level of 500 or greater. About 31 (13.1%) have an opportunistic infection or comorbid disease while about 95 (40.1%) of respondents have a history of hospital admission (table 3).
Magnitude of suicide ideation and attempt
The finding of the study revealed that 22.8% of respondents were ideated for suicide. Among them, 12 (5.10%) were suicide ideated during the month of data collection. Likewise, 32 (13.5%) of respondents attempted suicide while 2 (0.8%) attempted during the month of data collection (figure 1).
Factors associated with suicidal ideation
In the bivariate analysis, disclosure status, life-time substance use, living arrangement, comorbidity or other opportunistic infection, CD4 level, HIV perceived stigma, family death, history of depression, history of family suicide, current substance use and WHO clinic stage were significantly associated with suicide ideation (table 4). And hence, entered into the multivariable regression model.
After adjusting the effect of other variables (confounders), using multivariable logistic regression, disclosure status, history of using substances, living arrangements and having comorbidity or other opportunistic infection were significantly associated with suicide ideation (table 4).
According to this finding, disclosure status was a factor associated with suicide ideation, based on that the patients who were not disclosed were nearly three and half times more committed to suicide when compared with those who were disclosed (adjusted odd ratio (AOR)=3.60, 95% CI 1.44 to 9.01). Similarly, patients who have a history of using substances were 2.8 times more likely to have suicidal ideation as compared with those who have no history of using substances (AOR=2.86, 95% CI 1.07 to 7.61). Living arrangements were found to be other predictors of suicidal ideation according to finding patients who lived lonely were nearly six and half times more likely to have suicidal ideation as compared with those who live with family or partners (AOR=6.47, 95% CI 2.31 to 18.10). Having comorbidity or other opportunistic infection was another factor associated with suicide ideation, rendering finding patients with comorbidity or opportunistic infection were 3.74 times more likely to have suicide ideation as compared with those who have no opportunistic or comorbidity disease (AOR=3.74, 95% CI 1.32 to 10.52) (table 4).
Factors associated with suicidal attempt
In the bivariate analysis, disclosure status, living arrangement, history of depression, CD4 level, HIV perceived stigma, history of family suicide, current substance use, comorbidity or other opportunistic infection, family death, WHO clinic stage and life-time substance use were significantly associated with suicide attempts (table 5). And hence, entered into the multivariable regression model.
After adjusting the effect of other variables (confounders), using multivariable logistic regression, disclosure status, living arrangements and history of depression were significantly associated with suicide attempt (table 5).
Disclosure status can be led to suicidal attempts, according to this finding patients who did not disclose were five times more likely to attempt suicide as compared with those who did disclose (AOR=5.02, 95% CI 1.95 to 12.94). Similarly, living alone was another predictor, as finding patients who lived alone were 3.82 times more likely to attempt suicide as compared with those who live with family or partners (AOR=3.82, 95% CI 1.29 to 11.31). Depression history was another factor associated with a suicide attempt, according to this finding patients who had a history of depression were 3.37 times more likely to attempt suicide as compared with those who had no history of depression (AOR=3.37, 95% CI 1.09 to 10.40) (table 5).
The finding of the study revealed the magnitude of suicide ideation was 22.8%, 95% CI 17.85% to 28.6%, which is consistent with a study conducted in the USA which was a 26%,16 cross-sectional study conducted at a large primary healthcare facility in a rural area of KwaZulu-Natal, South (27.5%),17 a study conducted in Tunisia 26.9%,18 a study conducted in the St. Paul’s Hospital Millennium Medical College and St. Peter’s Specialized Hospital 27.2%11 and other study conducted in Addis Ababa 22.5%.19
Nevertheless, the magnitude of suicide ideation revealed by this study was less than the study conducted in Nanjing, China 31.6%,10 the study conducted in Kampala, Uganda 31%,20 a study conducted in Debark District Hospital Northwest, Ethiopia 33.6%9 and far from a study conducted at Amanuel Mental Specialized Hospital 48.4%.21 The discrepancy with a study conducted in Amanuel Mental Specialized Hospital might be due to variation variations like respondents means the respondents at Amanual Hospital are mostly with mental illness which may facilitate the case. Similarly, the variation study conducted in Uganda, Kampala and the study conducted in China might be due to variations in sociodemographic and socioeconomic variation.
Likewise, the magnitude of suicide ideation obtained by our study is greater than the study conducted in Kaduna metropolis, Nigeria (16%),22 and the study conducted in Dessie Referral Hospital 9.4%.23 The variation in the study conducted in Nigeria might be due to sociodemographic variation and the nature of the study participant.
The finding of the study indicated the magnitude of a suicide attempt is 13.5%, 95% CI 9.68% to 18.5%. which is in line with a study conducted in the USA (13%),16 a study conducted at the St. Paul’s Hospital Millennium Medical College and St. Peter’s Specialized Hospital 16.9%,11 another study conducted in Addis Ababa (13.9%).19
The magnitude of suicide attempts revealed by this study is greater than the study conducted in Tunisia 7.3%23 and the study conducted in Dessie Referral Hospital, northeast Ethiopia (3.3%).18 The discrepancy might be due to variations in the situational condition or health status of respondents since our study was conducted among PLWHA and also it may be due to current economic stability.
Correspondingly, the magnitude of suicide attempts revealed by this study is less than the study conducted in Kampala, Uganda (20%)20 and the study conducted in Debark District Hospital Northwest, Ethiopia 20.1%.11 The variation in a study conducted in Debark district may be due to differences in sample size and sociodemographic variation. Likewise, the dissimilarity with the study conducted might be due to methodological variation.
The study indicated disclosure status was found to be a predictor of both suicide ideation and attempt, according to our finding patients who were not disclosed nearly three and half times more had suicidal ideation when compared with those who were disclosed. Likewise, a patient who did not disclose were five times more likely to attempt suicide as compared with those who did disclose. This finding agreed with the study conducted in Uganda.24
Similarly, the study indicated living alone is another factor associated with both suicide ideation and attempt. According to the finding of the study living alone can increase the odds of suicide ideation by 6.47 and suicide attempts by 3.82 which is consistent with the study conducted in Youth Living in the Slums of Kampala, Uganda.20
Likewise, according to the finding of the study history of substance use is a factor associated with suicide ideation which is inconsistent with a study conducted in Zewuditu memorial hospital and St. Paul’s Hospital Millennium Medical College, and St. Peter’s Specialized Hospital.11 19 However, it contributes directly or indirectly to suicide ideation and attempt.
Comorbidity or opportunistic infection was found to be another predictor of suicide ideation, according to our findings, patients with comorbidity or opportunistic infection increase the odds of suicide ideation by 3.74 which is consistent with a study conducted in Ethiopia.9
Correspondingly, the study revealed a history of depression increases the odds of suicide ideation, according to our study patients who had a history of depression were 3.37 times more likely to attempt suicide as compared with those who had no history of depression. This is consistent with the study conducted in Zewuditu memorial hospital and St. Paul’s Hospital Millennium Medical College and St. Peter’s Specialized Hospital.11 19
Limitations of the study
Since the study design is cross-sectional study design it is not identified whether the relationship is temporal or not. Again, there is no evidence to say whether exposure comes first or not. So, a follow-up based investigation is needed.
The finding of the study indicated the magnitude of suicide ideation and attempt is high. Disclosure status, history of using substances, living alone and having comorbidity or other opportunistic infection are factors associated with suicide ideation while disclosure status, living arrangement and depression history are factors associated with a suicide attempt. The authors want to recommend health workers work on behavioural changes of patients using the substance, which is one of the predictors that led to suicide ideation. It is better if health workers treat patients with opportunistic infections early and follow the treatment protocol of ART to reduce the risk of opportunistic infection. Psychological support and follow-up are recommended for patients living alone and with a history of depression.
Data availability statement
No data are available. No additional data is available.
Patient consent for publication
This study involves human participants and ethical approval for this study was obtained from the Institution Review Board (IRB) of Addis Ababa Health Bureau with reference number 204/2022. Also, a permission letter was taken from Tirunesh Beijing General Hospital. Written informed consent was obtained from all study participants during data collection. The study participants were assured of confidentiality by excluding their names during the period of data collection. The rights are given to study participants to refuse, stop or withdraw from the interview at any time. Confidentiality was maintained throughout the study. Participants gave informed consent to participate in the study before taking part.
The authors would like to acknowledge Addis Ababa Health Bureau for providing ethical clearance, data collectors, supervisors and study participants for their willingness to participate in the study, and all staﬀs working at Tirunesh Beijing General Hospital for their dedicated cooperation.
Contributors MTK, EA, LW, DS and AOL participated in the conception and design of the study. MTK carried out data collection. MTK, EKB, EA, LW, SH, AOL and DS participated in the data analysis and interpretation. EKB, LW and AOL drafted the manuscript, and EA, MTK, LW and AOL reviewed and edited the manuscript. MTK is responsible for the overall content as the guarantor. All authors read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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.