A Comment on "Prevalence and Factors Associated with Depression among Clinically Stable People Living with HIV/AIDS on Antiretroviral Therapy".

Sir,

I read the article by Algoodkar et al. with considerable interest.[1] The authors reported the prevalence of depression in 100 people living with HIV/AIDS (PLWHAs) undergoing treatment in an antiretroviral therapy (ART) center to be 30%. These findings imply the need for regular screening of PLWHAs undergoing ART for depressive symptoms and appropriate mental health care according to the results of the screening. Nevertheless, I would like to point out two methodological concerns regarding the study:

The sample size of the study is quite small, and this reduces its validity. The authors reported excluding patients who reported ART adherence <95%. This needs justification since including these patients would have increased the sample size. Furthermore, including cases regardless of their ART adherence would have allowed comparing the prevalence of depressive symptoms among the PLWHAs who were ART adherent and those who were ART nonadherent

The study did not describe the method used for estimating ART adherence in the PLWHAs, but it was apparently based on a self-report method. Self-reported measures of ART adherence have low sensitivity and tend to overestimate adherence due to the self-desirability bias of the patients.[23] This can result in ART nonadherent cases being erroneously classified as ART adherent. Although the study purposively excluded PLWHAs with ART adherence <95%, still a large proportion reported depressive symptoms and lack of family support. Several previous studies across divergent cultures and health systems have reported the lack of family support as a predictor of poor ART adherence in PLWHAs.[45] The likelihood of achieving good adherence to ART in PLWHAs is also known to be low in those reporting depressive symptoms.[6] However, in contradiction, the results of the Algoodkar (2017) study suggest that nearly 30% of ART adherent patients experience depressive symptoms that are significantly associated with lack of family support. These findings indicate the possibility of some ART nonadherent cases being misclassified as ART adherent and being included in the study.

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