
==== Front
Chin Med J (Engl)
Chin Med J (Engl)
CM9
Chinese Medical Journal
0366-6999
2542-5641
Lippincott Williams & Wilkins Hagerstown, MD

39164815
CMJ-2023-2807
10.1097/CM9.0000000000003202
00009
3
Original Article
Mental health disparities in people living with human immunodeficiency virus: A cross-sectional study on physician-patient concordance and treatment regimens
Shi Jinchuan 1
Zhang Zhongdong 1
Zhang Junyan 2
Zhang Yishu 3
Qiu Jiating 3
Liu Fang 4
Song Daoyuan 5
Ma Yanfang 6
Zhong Lianmei 7
Wang Hongxing 7
Liu Xiaolei 3
Yin Yanjie
1 The Second Infectious Disease Department, Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310023, China
2 Department of Clinical Epidemiology and Evidence-based Medicine, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi 030032, China
3 Department of Neurology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China
4 Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China
5 Department of Neurology, Affiliated Hospital of Yunnan University, Kunming, Yunnan 650031, China
6 Neurology Department, Qian’an People’s Hospital, Qian’an, Hebei 064499, China
7 Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
Correspondence to: Dr. Xiaolei Liu, Department of Neurology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China E-Mail: ring@vip.163.com
21 8 2024
20 9 2024
137 18 22232232
01 4 2024
Copyright © 2024 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

Abstract

Background:

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) can profoundly affect the mental health of the people living with HIV (PLWH), with higher rates of anxiety, depression, and sleep disturbances. The disparities in neuropsychological problems evaluated by physicians and self-assessed by patients are still unknown.

Methods:

A total of 5000 PLWH and 500 physicians from 167 hospitals were enrolled in this cross-sectional study from September 2022 to February 2023. 4-Item Patient Health Questionnaire (PHQ-4) was used for the evaluation of depressive issues and anxiety issues by PLWH. Each physician assessed 10 PLWH under their care for the presence of depressive or anxiety issues. The primary outcomes of this study are the concordance rates on the depressive issues and anxiety issues evaluation between physicians and PLWH. The Cohen’s kappa test was used to assess the agreement between physicians and PLWH.

Results:

The concordance rate for the evaluation of depressive issues is 73.84% (95% confidence interval [CI]: 72.60–75.04%), and it is significantly different from the expected rate of 80% (P <0.001). Similarly, the concordance rate for the evaluation of anxiety issues is 71.74% (95% CI: 70.47–72.97%), which is significantly different from the expected rate of 80% as per the null hypothesis (P <0.001). The overestimation rate by physicians on depressive issues is 12.20% (95% CI: 11.32–13.14%), and for anxiety issues is 12.76% (95% CI: 11.86–13.71%). The mismatch rate for depressive issues is 26.16% (95% CI: 24.96–27.40%), and for anxiety issues is 28.26% (95% CI: 27.02–29.53%). The underestimation rate by physicians on depressive issues is 13.96% (95% CI: 13.03–14.95%), and for anxiety issues is 15.50% (95% CI: 14.52–16.53%). For the treatment regiments, PLWH sustained on innovative treatment regimen (IR) related to a lower prevalence of depressive issues (odds ratio [OR] = 0.71, 95% CI: 0.59–0.87, P = 0.003) and a lower prevalence of anxiety issues (OR = 0.63, 95% CI: 0.52–0.76, P <0.001). PLWH switch from conventional treatment regimen (CR) to IR also related to a lower prevalence of depressive issues (OR = 0.79, 95% CI: 0.64–0.98) and a lower prevalence of anxiety issues (OR = 0.81, 95% CI: 0.67–0.99).

Conclusion:

Nearly one in three PLWH had their condition misjudged by their physicians. The findings underscore the need for improved communication and standardized assessment protocols in the care of PLWH, especially during the acute phase of HIV infection.

Keywords:

Human immunodeficiency virus
Depression
Anxiety
Mental health
Overestimation
Underestimation
OPEN-ACCESSTRUE
SDCT
==== Body
pmcIntroduction

The growing awareness is that some severe illnesses can greatly affect a person’s mental health, adding to the difficulties faced by patients and their support systems. Consequently, this strain on a nation’s healthcare system may have far-reaching and irreversible consequences.[1] Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) encompasses a spectrum of conditions that disrupt the human body’s immune system, leading to a wide range of sociocultural challenges within communities. This health issue imposes substantial costs on healthcare systems and often leads to the development of mental disorders in individuals affected by the virus.[1] According to a report released by the Joint United Nations Programme on HIV/AIDS (UNAIDS), the estimated number of people living with HIV (PLWH) worldwide in 2022 was approximately 39 million[2], with 1.05 million of those individuals residing in China.[3]

Numerous studies have provided substantial evidence that individuals affected by HIV/AIDS often experience heightened rates of depression and anxiety compared to the general population. Furthermore, sleep disturbances are a well-documented consequence of living with HIV.[4] These adverse mental health conditions can significantly impact one another, creating a complex interplay.[5678] The ramifications of poor mental health in this context are far-reaching.

PLWH in China also grapple with depressive and anxiety symptoms, along with sleep disturbances. According to a systemic review[9] which enrolled 94 studies of PLWH in China from 1998 to 2014, the median prevalence of depressive symptoms among PLWH was 60.64% (range: 16–100%). Additionally, the median prevalence of anxiety symptoms was 43.13% (range: 11.11–97.53%). The sleep disturbances prevalence was 43.1% among PLWH.[10]

On the one hand, these mental disturbances can adversely affect patients’ overall performance,[1] disrupt their social relationships,[1] diminish their quality of life,[11] and even elevate the risk of suicide.[12,13] On the other hand, symptoms of depression and anxiety can also increase the risk of stroke[14] and cardiovascular disease,[15] as well as the likelihood of non-adherence to antiretroviral therapy (ART),[16,17] ultimately leading to a poorer prognosis[16,17] and, in severe cases, even death.[13]

Considering the high prevalence of mental health conditions among PLWH and the observed tendency for these issues to be frequently overlooked in clinical practice,[18] we hypothesized a significant disparity between the actual occurrence of neuropsychological problems in PLWH and their recognition by healthcare providers.

Methods

Ethics approval

This study followed the ethnic and scientific principles of Helsinki’s Declaration and regulation of Chinese law for Chinese Good Clinical Practice. The protocol was reviewed and approved by the Hangzhou Xixi Hospital Ethics Committee (2023-054). Each participant was informed about the purpose of the research and filled out their informed consent form before this study.

Study design

This is a cross-sectional study conducted in 24 provinces or municipalities among 500 physicians and 5000 PLWH from 167 hospitals conducted from September 2022 to February 2023.

Inclusion criteria

Hospitals and physicians: (1) Nationwide secondary or tertiary level of HIV-designated treatment hospitals; (2) With a minimum of 100 PLWH under treatment; (3) Attending physicians (AP) with at least 5 years of experience, associate chief physicians (ACP), and chief physicians (CP); (4) Willingness to participate in this study and agreement to sign the consent form.

PLWH: (1) Chinese citizen; (2) Adults with HIV-1 infection under treatment by the enrolled physicians; (3) Regularly use antiretroviral therapies for at least 3 months; (4) Can read and write Chinese normally; (5) Willing to join in this study and agree to sign the consent form.

Exclusion criteria

Hospitals and physicians: (1) Less than 100 PLWH received ART for a minimum of 3 months; (2) Physician at the level below attending physician; (3) No conventional treatment regimen (CR) has been prescribed in the past year.

PLWH: (1) Employee at a pharmaceutical company that is involved in the diagnosis and treatment of PLWH; (2) Clinically significant psychiatric/psychological disease; (3) Suffering from severe systemic disease(s); (4) A history of participating in other clinical studies within 3 months before the date of informed consent or currently participating in other clinical studies; (5) Recurred in other clinical studies; (6) Other situations that may affect full engagement.

Measures

A twenty-minute face-to-face survey was conducted for each of the physicians in this study. In the HIV/AIDS clinic, each physician consecutively enrolled 10 PLWH to participate in this study. If any individual refused or was unable to participate, the enrollment would be deferred to the next one in line. Additionally, considering the relatively low number of PLWH using innovative treatment regimens (IR) and aiming to enhance the statistical efficiency of the secondary research endpoints, the study specified that the last two enrolled patients must use IR (the choice of medication was unrestricted for the first eight patients). If neither of the last two individuals used IR, the enrollment would be extended to subsequent patients.

Physicians at HIV/AIDS clinics adhere to routine procedures for HIV diagnosis and treatment, documenting impressions related to mental health and sleep-related issues. This methodological approach aims to accurately mirror real-world complexities without interference. Physicians kept these impressions confidential for PLWH to minimize the influence on patients’ self-assessment. After the physicians’ evaluation, each PLWH conducted their self-assessment in another quiet room in a back-to-back scenario, assisted by a survey aide, who was also blinded to the results of the physicians’ evaluation. All the PLWH were required to finish the 4-item Patient Health Questionnaire (PHQ-4),[19] as well as the 4-item Jenkins Sleep Scale (JSS)[20] in a self-report, pencil-and-paper format between 2–5 minutes.

PHQ-4 is recognized for its reliability and validity as a concise self-report assessment among the general population.[21] This assessment encompassed the 2-item Patient Health Questionnaire (PHQ-2) for depression[22] and the other 2-item Generalized Anxiety Disorder Screener (GAD-2) for anxiety.[23] The total scores for PHQ-2 and GAD-2 fall within the range of 0–6. It was recommended to use scale scores of ≥3 for both the PHQ-2 and the GAD-2 to distinguish between the normal range and potential cases of depression or anxiety.[24] JSS was used to measure sleep disturbances,[20] which is one of the most commonly employed questionnaires in epidemiological studies.[25] The total score is calculated by summing the scores of all four items and ranges from 0 (indicating no sleep problems) to 20 (indicating the highest level of sleep problems). According to previous research,[25,26] a score of ≥12 is considered indicative of a high frequency of sleep disturbances.

Definition

Using the PHQ-4 for the assessment of mental health issues and the JSS for evaluating sleep problems among PLWH, the patient-reported outcomes (PRO) were utilized as a reference standard for evaluating their condition in similar contexts.

Agreement between physicians and PLWH regarding the presence or absence of mental health issues was assessed. “Concordance” occurred when both the physician and the PLWH agreed on the presence or absence of mental health issues. “Mismatch” encompassed situations where physicians identified mental health issues while PLWH did not (overestimation) and when physicians did not identify mental health issues while PLWH reported them (underestimation). Stages of HIV infection were classified as acute, asymptomatic, and AIDS.[27] An “infectious hospital” refers to a healthcare facility dedicated exclusively to treating and caring for infectious patients, with the primary goal of isolating and preventing the transmission of infectious diseases. “Younger adult” refers to those PLWH whose age was at least 18 and below 60 years. “Older adult” refers to those PLWH whose age was at least 60 years.[28,29]

Treatment regiments

The treatments employed were categorized as CR and IR. Physicians determined whether to modify the medication based on the patient’s clinical treatment situation: initiating treatment with CR and maintaining CR usage (sustained on CR), starting treatment with CR and transitioning to IR (switch from CR to IR), initiating treatment with IR and transitioning to CR (switch from IR to CR), or initiating treatment with IR and maintaining IR usage (sustained on IR). Considering that PLWH often undergo combination therapy, if a patient’s treatment regimen includes only CR, it is classified as CR therapy. If any medication in the patient’s treatment regimen is an IR, the therapy is defined as IR treatment [Supplementary Table 1, http://links.lww.com/CM9/C68].

Sample size

The primary outcomes of this study are the concordance rate on the evaluation of depressive issues and the concordance rate on the anxiety issue evaluation between physicians and PLWH. The secondary outcomes were (1) the difference in the prevalence of anxiety issues and depressive issues assessed by physicians and PLWH; (2) the clinical attributes related to the prevalence of mental health issues; (3) the difference in the prevalence of sleep issues assessed by physicians and PLWH; (4) the difference in the prevalence of mental health and sleep-related issues between different treatment strategies.

In order to control the false discovery rate, Bonferroni correction[30] was used to make the type I error below 0.025 for each primary outcome.

Assuming that the concordance rate was 80% (null hypothesis proportions) on the anxiety issue evaluation and depressive evaluation between physicians and PLWH, respectively. There was a 5% lower concordance rate of these issues. Given an α (type I error) of 0.025 and a β (type II error) of 0.05, the required sample size of PLWH is 1130 for the concordance rate on anxiety issue evaluation testing and another 1130 for the concordance rate on depressive issue evolution testing. We recruited 5000 PLWH and 500 healthcare professionals in this study.

Statistical analysis

Continuous variables were expressed as mean followed by standard deviation (SD) or median (Q1–Q3). The Student’s t-test is used for normal distributional data, and the Mann–Whitney test is used for non-normal distributional data. Categorical variables were expressed as numbers (percentages). Pearson’s chi-squared test or Fisher’s exact test was used to test categorical variables. Univariate analysis and multivariate logistic regression models were employed to investigate clinical attributes associated with endpoints. The variables included in the multi-factor analysis are those with P-values less than or equal to 0.1 in the univariate analysis. Variables with clinically meaningful associations to endpoints were adjusted for, irrespective of their P-value. The results were presented using odds ratio (OR) together with the 95% confidence interval (CI). Cohen’s kappa testing was used to assess the level of agreement (concordance) between the evaluations by physicians and PLWH on the exact same person. For the results of κ value, 1 means perfect agreement, >0.75 represents excellent agreement, between 0.40 and 0.75 means fair to good agreement, and ≤0.40 means poor agreement beyond chance.[31] All hypothesis tests were two-sided, and statistical significance was defined as a P-value <0.05, and P <0.025 for both of the primary endpoints. Stata SE: 13, R (version 3.6.1, http://cran.r-project.org/), easy-R (www.empowerstats.com), and Prism (https://www.graphpad.com/scientific-software/prism/) were applied for the data analysis.

Results

All 683 nationwide secondary or tertiary level HIV-designated treatment hospitals with a minimum of 100 PLWH under treatment were included. A total of 364 hospitals could not participate in the survey due to pandemic prevention and control measures (hospital response rate 46.71%). Invitations were extended to 833 qualified physicians from 319 hospitals, and 333 declined to participate or did not provide feedback regarding their willingness to join the survey (physicians response rate 60.02%). Ultimately, 500 physicians from 167 hospitals were enrolled. Each physician was invited to participate in the survey, following the outlined procedure in the method section, and 10 PLWH under their treatment were invited to join. However, 2143 individuals either refused or were unable to participate. Consequently, a total of 5000 PLWH individuals were eventually enrolled in the study.

Among these 5000 PLWH, 3945 (78.90%) are male, 471 (9.42%) are elders, the median duration of ART usage is 28 months, 4188 (83.76%) have urban employee/resident basic medical insurance, 777 (15.54%) are self-paid, and 35 (0.7%) have their commercial insurance [Supplementary Table 2, http://links.lww.com/CM9/C68].

Evaluation results

Out of the total number of PLWH, 784 (15.68%) were assessed for depressive issues, and 913 (18.26%) were evaluated for anxiety issues by physicians. Meanwhile, 872 (17.44%) PLWH evaluated themselves for depressive issues, and 1050 (21.00%) assessed themselves for anxiety issues. In the context of sleep-related concerns, physicians identified sleep issues in 1110 participants (22.20%), whereas 1121 participants (22.42%) self-reported experiencing sleep issues [Supplementary Table 3, http://links.lww.com/CM9/C68].

The study results indicate that there is a significant difference between physicians and PLWH in the evaluation of depressive issues, a significant difference is observed, with physicians reporting a lower evaluation by approximately −1.76% (95% CI: −3.22% to −0.30% P <0.018). Similarly, in the evaluation of anxiety issues, physicians reported a lower evaluation by approximately −2.74% (95% CI: −4.30% to −1.18% P = 0.001). Meanwhile, the evaluations of sleep issues by physicians and PLWH are similar with differences of −0.22% (95% CI: −1.85 to 1.41%, P = 0.792) [Supplementary Table 3, http://links.lww.com/CM9/C68].

Evaluation concordances-the primary outcomes

The concordance rate for the evaluation of depressive issues is 73.84% (95% CI: 72.60–75.04%) (κ = 0.0539, P <0.001), and it is significantly different from the expected rate of 80% as per the null hypothesis (P <0.001). Similarly, the concordance rate for the evaluation of anxiety issues is 71.74% (95% CI: 70.47–72.97%) (κ = 0.1054, P <0.001), which is significantly different from the expected rate of 80% as per the null hypothesis (P <0.001) [Table 1].

Table 1 The concordance rate on depressive and anxiety issue evaluation.

Neuropsychiatric disorders	Concordance	Non-concordance	Concordance rate (%)	Mismatch rate (%)	Z	P-value*	κ-value	P-value†	
Both (+)	Both (–)	Physician (+) PLWH (–) Overestimation	Physician (–) PLWH (+) Underestimation	
Depressive issue	174
(3.48)
(3.01–4.03)	3518
(70.36)
(69.08–71.61)	610
(12.20)
(11.32–13.14)	698
13.96
(13.03–14.95)	73.84
(72.60–75.04)	26.16
(24.96–27.40)	–10.96	<0.001	0.0539	0.0004	
Anxiety issue	275
(5.50)
(4.90–6.17)	3312
(66.24)
(64.92–67.54)	638
(12.76)
(11.86–13.71)	775
(15.50)
(14.52–16.53)	71.74
(70.47–72.97)	28.26
(27.02–29.53)	–14.67	<0.001	0.1054	<0.0010	
Data shown as n (%) (95% CI) or 95% CI. *P-value is for the testing of the comparison with 80%, the rate of the null hypothesis. †P-value is for the Cohen’s kappa testing. CI: Confidence interval; PLWH: People living with HIV.

The mismatch rate for depressive issues is 26.16% (95% CI: 24.96–27.40%), comprising an overestimation rate of 12.20% (95% CI: 11.32–13.14%) and an underestimation rate of 13.96% (95% CI: 13.03–14.95%). Similarly, the mismatch rate for anxiety issues is 28.26% (95% CI: 27.02–29.53%), with an overestimation rate of 12.76% (95% CI: 11.86–13.71%) and an underestimation rate of 15.50% (95% CI: 14.52–16.53%) [Table 1].

There were significant variations in concordance rates. These rates ranged from 51.95% for the evaluation of depressive issues among individuals in the acute HIV phase to 80.00% for the assessment of depressive issues among those with private commercial insurance. Importantly, these differences in concordance rates held statistical significance across various HIV stages for both anxiety and depressive evaluations (P <0.001, Supplementary Table 4, http://links.lww.com/CM9/C68).

In the multivariate logistic regression analysis [Supplementary Table 5, http://links.lww.com/CM9/C68], it was observed that PLWH in the asymptomatic and AIDS phases were more likely to exhibit concordance with their physicians both on depressive issue and anxiety issue. Regarding the evaluation of depressive issues and in comparison to the acute HIV phase, for those in the asymptomatic phase, the OR for concordance was 2.99 (95% CI: 2.28–3.93, P <0.001); among those in the AIDS phase, the OR for concordance was 2.32 (95% CI: 1.74–3.10, P <0.001). Physicians were more likely to have their concordance with older adults with OR = 1.29 (95% CI: 1.03–1.63, P = 0.028).

Specifically, in the context of anxiety issue evaluation, when compared to the acute HIV phase, for those in the asymptomatic phase, OR for concordance was 2.50 (95% CI: 1.91–3.28, P <0.001). For individuals in the AIDS phase, the OR for concordance was 2.28 (95% CI: 1.71–3.04, P <0.001) [Supplementary Table 5, http://links.lww.com/CM9/C68].

The levels of physicians showed no correlation with either the concordance rates for depressive issues or those for anxiety issues [Supplementary Table 5, http://links.lww.com/CM9/C68].

Stratified analysis about the mismatch on mental health issues

Table 2 shows the stratified analysis of the evaluation of depressive issues, several noteworthy trends emerged. Younger adults exhibited a higher likelihood of being overestimated in comparison to their older counterparts (12.65% vs. 7.86%, P = 0.002). Similarly, PLWH receiving treatment in secondary hospitals were more prone to overestimation relative to those in tertiary hospitals (19.71% vs. 11.65%, P <0.001). Furthermore, PLWH in the acute infection phase had a significantly greater likelihood of being overestimated compared to those in the asymptomatic and AIDS phases (45.45% vs. 8.81% vs. 15.09%, P <0.001). The overestimation rates on depressive issues increased with the physicians’ level, showing as follows: AP: 10.36%, ACP: 13.31%, CP: 14.21% (P = 0.002).

Table 2 Stratified mismatch analysis on depressive issue.

Item	Overestimation	Underestimation	Mismatch	
%	95% CI, %	χ2	P-value	%	95% CI, %	χ2	P-value	%	95% CI, %	χ2	P-value	
Sex													
Male	12.12	11.13–13.17	0.12	0.728	13.81	12.77–14.93	0.33	0.567	25.93	24.59–27.32	0.51	0.477	
Female	12.51	10.65–14.65	14.50	12.50–16.76	27.01	24.42–29.78	
Age													
≥18 and <60 years	12.65	11.71–13.65	9.16	0.002	13.89	12.91–14.93	0.21	0.650	26.54	25.27–27.85	3.60	0.058	
≥60 years	7.86	5.74–10.66	14.65	11.73–18.14	22.51	18.95–26.50	
Hospital level													
Secondary	19.71	15.81–24.29	19.19	<0.001	9.41	6.72–13.01	6.28	0.012	29.12	24.53–34.18	1.65	0.199	
Tertiary	11.65	10.76–12.65	14.29	13.32–15.33	25.94	24.71–27.22	
Hospital type													
General	11.55	10.47–12.73	3.16	0.076	14.92	13.71–16.22	6.19	0.013	26.47	24.95–28.06	0.41	0.523	
Infectious	13.25	11.80–14.84	12.41	11.00–13.96	25.65	23.74–27.66	
HIV stages													
Acute	45.45	39.13–51.93	285.70	<0.001	2.60	1.17–5.67	28.57	<0.001	48.05	41.66–54.51	70.27	<0.001	
Asymptomatic	8.81	7.90–9.81	15.01	13.85–16.25	23.82	22.42–25.28	
AIDS	15.09	13.28–17.10	13.24	11.53–15.15	28.33	25.99–30.79	
Physicians level													
AP	10.36	9.16–11.70	12.98	0.002	16.56	15.07–18.17	23.65	<0.001	26.92	25.11–28.81	1.35	0.509	
ACP	13.31	11.79–15.00	12.50	11.02–14.15	25.81	23.80–27.94	
CP	14.21	12.24–16.43	10.93	9.20–12.95	25.14	22.63–27.83	
Medical insurance												
UERBMI	12.66	11.68–13.70	5.04	0.080	14.04	13.02–15.13	0.27	0.872	26.70	25.38–28.06	4.04	0.132	
Self-pay	9.91	8.00–12.22	13.64	11.40–16.24	23.55	20.70–26.67	
Commercial insurance	8.57	2.74–23.76	11.43	4.29–27.07	20.00	9.74–36.68	
ACP: Associate chief physician; AIDS: Acquired immunodeficiency syndrome; AP: Attending physician at least 5 years; CI: Confidence interval; CP: Chief physician; UERBMI: Urban employee/resident basic medical insurance.

Conversely, PLWH in tertiary hospitals were more likely to be underestimated when compared to those in secondary hospitals (14.29% vs. 9.41%, P = 0.012), and PLWH in general hospitals were also inclined to experience underestimations (14.92% vs. 12.41%, P = 0.013). Furthermore, PLWH in the asymptomatic and AIDS phases tended to be underestimated in contrast to those in secondary hospitals and those in the acute phase (15.01% and 13.24% vs. 2.60%, P <0.001). The underestimation rates on depressive issue decreased with the physician’s level, showing as follows: AP: 16.56%, ACP: 12.50%, CP: 10.93% (P <0.001) [Table 2].

Table 3 shows the stratified analysis of anxiety issue evaluations, distinct patterns emerged. Younger adults compared to older adults (13.09% vs. 9.55%, P = 0.028), PLWH treated in secondary hospitals compared to tertiary hospitals (20.29% vs. 12.21%, P <0.001), those PLWH in the acute stage compared to asymptomatic and AIDS (44.16% vs. 9.80% and 14.87%, P <0.001), and higher levels of physicians (CP: 14.58%, ACP: 13.31%, AP: 11.45%, P = 0.029) tended to higher rates of overestimation.

Table 3 Stratified mismatch analysis on anxiety issue.

Item	Overestimation	Underestimation	Mismatch	
%	95% CI, %	χ2	P-value	%	95% CI, %	χ2	P-value	%	95% CI, %	χ2	P-value	
Sex													
Male	12.93	11.92–14.01	0.47	0.492	15.26	14.17–16.42	0.82	0.364	28.19	26.80–29.61	0.05	0.826	
Female	12.13	10.30–14.25			16.40	14.28–18.76			28.53	25.88–31.33			
Age (years)													
≥18 and <60 years	13.09	12.14–14.11	4.80	0.028	15.35	14.32–16.43	0.88	0.349	28.44	27.14–29.77	0.76	0.384	
≥60 years	9.55	7.21–12.56			16.99	13.85–20.65			26.54	22.74–30.72			
Hospital level													
Secondary	20.29	16.35–24.91	18.60	<0.001	8.24	5.74–11.68	14.70	<0.001	28.53	23.97–33.57	0.01	0.909	
Tertiary	12.21	11.30–13.18			16.03	15.00–17.11	28.24	26.97–29.55			
Hospital type													
General	11.52	10.44–12.70	11.15	0.001	16.57	15.30–17.92	7.07	0.008	28.09	26.53–29.70	0.11	0.735	
Infectious	14.76	13.24–16.43			13.77	12.30–15.39	28.53	26.55–30.60			
HIV stages													
Acute	44.16	37.87–50.64	236.76	<0.001	3.03	1.45–6.23	36.69	<0.001	47.19	40.82–53.65	44.32	<0.001	
Asymptomatic	9.80	8.85–10.85			17.03	15.81–18.33			26.84	25.38–28.35			
AIDS	14.87	13.07–16.87			13.76	12.02–15.70			28.62	26.28–31.09			
Physicians level													
AP	11.45	10.19–12.84	7.07	0.029	17.74	16.20–19.39	17.37	<0.001	29.19	27.33–31.12	1.90	0.386	
ACP	13.31	11.79–15.00			14.53	12.95–16.28			27.85	25.78–30.02			
CP	14.58	12.59–16.83			12.43	10.58–14.55			27.01	24.43–29.75			
Medical insurance													
UERBMI	12.89	11.91–13.94	1.26	0.532	15.43	14.36–16.55	1.61	0.448	28.32	26.97–29.70	0.13	0.935	
Self-pay	11.84	9.75–14.31			16.22	13.79–18.98			28.06	25.01–31.32			
Commercial insurance	17.14	7.82–33.55			8.57	2.74–23.76			25.71	13.82–42.76			
ACP: Associate chief physician; AIDS: Acquired immunodeficiency syndrome; AP: Attending physician at least 5 years; CI: Confidence interval; CP: Chief physician; UERBMI: Urban employee/resident basic medical insurance.

When considering overestimation and underestimation together, there is no difference in mismatch rates among physicians at different levels. The mismatch rates for the evaluation of depressive issues were AP: 26.92%, ACP: 25.81%, CP: 25.14% (P = 0.509, Table 2). Similarly, the mismatch rates for the evaluation of anxiety issues were AP: 29.19%, ACP: 27.85%, CP: 27.01% (P = 0.386, Table 3).

Conversely, PLWH in tertiary hospitals compared to secondary hospitals (16.03% vs. 8.24%, P <0.001), individuals treated in general hospitals compared to infectious hospitals (16.57% vs. 13.77%, P = 0.008), PLWH in asymptomatic and AIDS stages compared to the acute stage (17.03% and 13.76% vs. 3.03%, P <0.001), and physicians in a lower level (AP: 17.74%, ACP: 14.53%, CP: 12.43%, P <0.001) were more likely to make underestimations on anxiety issues [Table 3].

Risk factors related to PLWH-reported mental health issues

The results of the multivariate logistic regression analysis indicate several factors associated with the prevalence of depressive issues among PLWH. PLWH treated in tertiary hospitals (OR = 1.79, 95% CI: 1.26–2.56, P = 0.001) and those with hepatitis B virus (HBV) (OR = 1.86, 95% CI: 1.43–2.42, P <0.001) are related to a higher prevalence of depressive issue. On the other hand, PLWH treated in infectious hospitals (OR = 0.71, 95% CI: 0.61–0.84, P <0.001), those in asymptomatic phase (OR = 0.68, 95% CI: 0.49–0.94, P = 0.018) or in AIDS phase (OR = 0.64, 95% CI: 0.45–0.90, P = 0.010), those with hypertension (OR = 0.68, 95% CI: 0.47–0.97, P = 0.035), those who switched their treatment from CR to IR (OR = 0.79, 95% CI: 0.64–0.98, P = 0.030), and those who sustained on IR (OR = 0.71, 95% CI: 0.59–0.87, P = 0.001), are related to a lower prevalence of depressive issue [Supplementary Table 6, http://links.lww.com/CM9/C68].

The results of the multivariate logistic regression analysis indicate several factors associated with the prevalence of anxiety issues among PLWH. PLWH treated in tertiary hospitals showed an increased likelihood of experiencing anxiety issues (OR = 1.58, 95% CI: 1.16–2.17, P = 0.004). Individuals with HBV had a higher prevalence of anxiety issues (OR = 1.57, 95% CI: 1.22–2.03, P <0.001). Conversely, several factors were associated with a lower prevalence of anxiety issues, including PLWH treated in infectious hospitals (OR = 0.74, 95% CI: 0.64–0.86, P <0.001), PLWH in the asymptomatic phase (OR = 0.65, 95% CI: 0.47–0.88, P = 0.006) or in the AIDS phase (OR = 0.67, 95% CI: 0.48–0.93, P = 0.016), individuals with hypertension (OR = 0.64, 95% CI: 0.45–0.89, P = 0.009), those who switched their treatment from CR to IR (OR = 0.81, 95% CI: 0.67–0.99, P = 0.035), and those who sustained on IR (OR = 0.63, 95% CI: 0.52–0.76, P <0.001) [Supplementary Table 6, http://links.lww.com/CM9/C68].

PLWH who switched their treatment from CR to IR (OR = 0.69, 95% CI: 0.57–0.84, P <0.001) and those who sustained on IR (OR = 0.65, 95% CI: 0.54–0.77, P <0.001) reported a lower frequency of sleep-related issues compared to those who remained on CR treatment [Supplementary Table 6, http://links.lww.com/CM9/C68].

For a detailed analysis of sleep issues, please refer to Supplementary Table 6, http://links.lww.com/CM9/C68 in the Supplementary Document-1, http://links.lww.com/CM9/C68. The distribution of each IR proposition in this study is presented in Supplementary Table 7, http://links.lww.com/CM9/C68 in the Supplementary Document-1, http://links.lww.com/CM9/C68, with bictegravir/emtricitabine/tenofovir alafenamide fumarate leading at 51.11%.

For comprehensive information on the outcomes across various age groups, please refer to Supplementary Tables 8–15, http://links.lww.com/CM9/C69.

Discussion

This is a pilot study to survey both physicians and PLWH about the issues of mental health across China. Considering that the utilization of the ultra-brief PHQ-4 is advisable due to its efficiency, along with its relatively high sensitivity and specificity, especially in situations where time are limited,[19,32,33] PHQ-4 from patient self-report was utilized as the standard for judging depressive and anxiety status.[34,35] Our data showed that the prevalence of depressive and anxiety issues among HIV-infected inmates in China was 17.44% and 21.00%, respectively.

As early as the 1980s, it was discovered that individuals infected with HIV had a higher prevalence of neuropsychiatric disorders compared to the general population,[36] with depression and anxiety disorders being the most common.[37,38] Such mental disorders in PLWH have been identified as being linked with the suboptimal HIV treatment outcomes.[39] According to the data of 2017, the prevalence of depression and anxiety among global HIV-infected individuals was as high as 31%[1] and 22.9–33.3%.[40] Our data, while slightly lower than the global figures reported in 2017, still significantly exceeds the rates in the general population (3.8% and 4.0%) as reported by the WHO in 2022.[41] As indicated in the WHO report, mental disorders are common among individuals affected by HIV.[42] HIV-related mental disorders can have adverse effects on the overall management of HIV infection, including reduced willingness for HIV screening, lower rates of ART initiation,[43] decreased ART adherence,[44] and a lower likelihood of achieving virological suppression,[45] all of which increase the risk of HIV transmission.[46] Neuropsychiatric disorders also contribute to a decreased quality of life for patients[11] and an increased risk of mortality.[13,47] Given the high prevalence and the impact of the mental disorders associated with PLWH, it is necessary to assess the mental condition in PLWH.[48]

Our analyses revealed a significant disparity in the assessment of mental health conditions between physicians and patients. Alarmingly, nearly one in three PLWH had their mental health status misjudged by physicians, with discrepancies observed in 26.16% for depressive issues and 28.26% for anxiety issues. Physicians tended to underestimate the presence of depression in 13.96% of cases and anxiety in 15.50% of cases while overestimating the conditions in 12.20% of depressed patients and 12.76% of anxious patients.

Notably, our stratification analysis indicated that these mismatches were particularly prevalent during the acute phase of PLWH, with a notable prevalence of overestimations in both depressive and anxiety assessments. The acute phase represents the earliest stage of HIV infection, typically occurring within a few weeks after initial exposure. During this phase, many individuals experience flu-like symptoms due to rapid viral replication, and there may be a temporary drop in CD4-positive T-cell counts.[49,50] In the initial stage, patients often have questions and concerns, which can sometimes prompt doctors to over-assess the patient’s anxiety and depression levels. Conversely, in the asymptomatic and AIDS stages, physicians tended to underestimate both depression and anxiety. The asymptomatic phase follows the acute stage, during which HIV continues to replicate, albeit at a slower rate, and CD4 cell counts decrease gradually.[51] The underestimation observed during the asymptomatic phase could potentially be attributed to the fact that patients in this stage tend to infrequently report symptoms or complaints related to their mental health. The AIDS phase represents the final stage of the disease,[52] marked by a significant reduction in CD4 cell count to less than 200 cells/mm3, and it is characterized by pronounced symptoms. Physicians often prioritize addressing these symptomatic aspects, which can sometimes lead them to overlook the mental health conditions of the patients. The consistent mismatch observed throughout the entire course of AIDS underscores the tendency of specialists to subjectively assess the presence of depression and anxiety based on the patient’s primary complaints. This highlights a potential deficiency in standardized assessment protocols and the need for improved communication and comprehensive discussion in patient care.

Our study also highlighted that younger adults were more prone to overestimations of anxiety and depression when compared to older adults. This contrast in assessment might be attributed to the fact that younger individuals tend to be more open in seeking help and discussing their mental well-being. They often have more extensive social networks and greater access to peer support, which could potentially influence physicians’ judgments. Furthermore, our survey revealed disparities in mental health assessments for PLWH across infectious disease hospitals and general hospitals, as well as different levels of healthcare facilities.

In addition, the stratified analysis showed that whether it is anxiety or depression, CP and ACP (senior level) tend to overdiagnoses. In contrast, APs (junior level) may overlook, which could be related to clinical experience. These findings underscore that relying solely on clinical experiences to evaluate the mental health status of PLWH is far from sufficient.

Consequently, it underscores the importance of involving psychiatrists in the comprehensive management of PLWH throughout their entire journey. Psychiatrists bear a crucial responsibility in ensuring the timely diagnosis and treatment of HIV-related mental conditions, thereby contributing to the improvement of both short-term and long-term patient outcomes. Given their frontline role in addressing HIV-related issues, psychiatrists should adopt a proactive approach in screening patients for HIV infection, regardless of symptom severity or risk factors. This approach is pivotal in the ongoing battle against HIV.

In our study, we identified several factors associated with depression and anxiety among PLWH. Notably, a significant association between PLWH receiving treatment in tertiary medical institutions and those concurrently diagnosed with HBV, showed a higher prevalence of depressive and anxiety issues. Conversely, PLWH in the asymptomatic or AIDS phases, as well as those who switched from CR to IR or sustained on IR, displayed a lower prevalence of both depressive and anxiety issues.

Among all the factors, it is noteworthy that the treatment regimen was closely related to the mental condition. Patients sustained on CR or switched from IR to CR had a relatively higher risk for depression and anxiety. In comparison, switching from CR to IR reduced the prevalence of depression by 18% and anxiety by 17%. Nevertheless, sustaining IR reduced the prevalence of depression by 26% and anxiety by 34%. Since 2003, the Chinese government has offered free combination ART to PLWH under the National Free Antiretroviral Treatment Program.[53] This initiative has resulted in a significant rise in the viral suppression rate[54] and a decline in the HIV mortality rate.[55] However, among PLWH receiving CR, long-term usage of Efavirenz (EFV) has been linked to a higher prevalence of symptoms associated with mental disorders.[56] Even when reducing the dosage, there was no significant improvement in neuropsychiatric symptoms such as depression, anxiety, and suicidal ideation.[57] Presently, the 5-year discontinuation rate attributed to drug-related adverse effects stands at 0.8%,[58] with more favorable central nervous system (CNS) outcomes observed among individuals treated with IR.[59] The findings from this study suggest that IR may also have a potential role in reducing anxiety and depression. Further exploration in large-scale cohort studies is warranted to investigate these potential benefits.

Findings also illustrated that the prevalence of depression and anxiety is higher in PLWH who also have concurrent HBV infection. Concurrent infection with HIV, HBV, and hepatitis C virus (HCV) often occurs due to the commonality in risk factors for acquisition.[60] Given the increased health burden on individuals co-infected with multiple conditions, it is logical that the prevalence of depression and anxiety is comparatively higher in this group. Limited research has explored the mental impact of co-infections in PLWH, highlighting the importance of further investigation in this area. This survey also found a relatively higher prevalence of depression and anxiety during the acute phase of AIDS. The comparatively mild symptoms, along with the stigma associated with the disease, fear, and PLWHs’ limited comprehension of HIV infection, may collectively contribute to the heightened prevalence of depression and anxiety.

In general, the screening rates, treatment rates, and overall management of HIV-related neuropsychiatric disorders are suboptimal.[39] The focus of this presented study on physician-patient concordance is motivated by a commitment to enhancing the clinical care of individuals with mental health conditions, particularly among PLWH. Our findings underscore the crucial role of utilizing neuropsychological scales, engaging psychiatrists, fostering multi-disciplinary diagnosis and treatment approaches, mitigating stigma and communication barriers, and providing supports in physician training and education, which are essential for enhancing physicians’ understanding of PLWH. Apprehending the clinical implications of physician–patient discordance holds broader public health significance, as the disparity has the potential to stimulate advancements in diagnosis, treatment, communication, and overall healthcare delivery. Further research is warranted to explore effective strategies for the seamless integration of mental health services into HIV treatment programs.

As a study employing a cross-sectional design, our research exhibits several noteworthy limitations. First, while we enrolled all the available qualified physicians and hospitals, the non-random selection for PLWH could potentially influence the observed prevalence of mental health issues in the study. Second, as the primary outcomes of this study focused on the concordance rates in the evaluation of depressive and anxiety issues between physicians and PLWH, information regarding the treatments of neurological issues or psychiatric treatment was not obtained. Finally, the mental health and sleep issues reported in our study only represent a status, not the final prevalence confirmed by psychiatric diagnosis among PLWH.

In conclusion, the prevalence of mental health issues is high among the PLWH in this study, and what’s even more concerning is that nearly one-third of them have been misjudged by healthcare providers. The clinical meaning of the disparity lies in its potential to drive improvements in diagnosis, treatment, communication, and overall healthcare delivery.

Acknowledgment

All authors extend their gratitude to Bothwin Clinical Consultant for their contributions to data analysis for this study.

Funding

This work is supported by grants from the National Natural Science Foundation of China (No. 82160272), and Yunnan Science and Technology Leading Talents Project, Young and Middle-aged Academic and Technical Leaders Reserve Talents Project (No. 202405AC350046), the Research Program of Yunnan Science and Technology Department (No. 202101AT070151), and the Project of Technology Innovation Team of Kunming Medical University (No. CXTD202104 to X.L).

Conflicts of interest

None.

Supplementary Material

Jinchuan Shi, Zhongdong Zhang, and Junyan Zhang contributed equally to this work.

How to cite this article: Shi JC, Zhang ZD, Zhang JY, Zhang YS, Qiu JT, Liu F, Song DY, Ma YF, Zhong LM, Wang HX, Liu XL. Mental health disparities in people living with human immunodeficiency virus: A cross-sectional study on physician-patient concordance and treatment regimens. Chin Med J 2024;137:2223–2232. doi: 10.1097/CM9.0000000000003202
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