UNDERSTANDING THE INTERSECTION OF HIV, MENTAL HEALTH, AND AGING IN ZAMBIA

Abstract

In Zambia, as in much of sub-Saharan Africa, expanded access to antiretroviral therapy (ART) has transformed HIV into a chronic and manageable condition, resulting in a growing population of older people living with HIV (OPLWH). Because older age, HIV, and adverse socioeconomic circumstances are each associated with an increased risk of depression, OPLWH are particularly more vulnerable to depressive symptoms that may undermine long-term HIV self-management. Despite this, little is known about how OPLWH in Zambia experience and self-manage co-occurring HIV and depression, particularly how depressive symptoms are understood, experienced, embodied, and culturally expressed. This multiple-methods study combined quantitative and qualitative approaches to determine the proportion of OPLWH(n=51) with moderate to severe depressive symptoms (PHQ-9 ≥10), identify factors associated with depressive symptom severity, and explore the embodied and culturally shaped experiences of depression, together with barriers and facilitators to self-management of co-occurring HIV and depression. Quantitative data were analyzed to estimate the proportion of participants with moderate to severe-depressive symptoms (PHQ-9 ≥10). Factors associated with depressive symptom severity were assessed using bivariate analysis. Guided by the Individual and Family Self-Management Theory, in-depth interviews were then conducted with a purposive sample of 22 OPLWH with PHQ-9 scores ≥10 drawn from the quantitative sample and analyzed using template thematic analysis. A purposive subsample of 10 participants subsequently completed body mapping and in-depth interviews, which were analyzed using content and thematic analysis. Over half of participants (59%) reported moderate to severe depressive symptoms. Moderate to severe-depressive symptoms were significantly associated with alcohol use (p=0.016). Depressive symptoms were not merely a co-occurring condition with HIV but rather multidimensional, embodied, and socially contextualized experiences expressed through culturally meaningful idioms of distress such as “Kuganiza maningi” (thinking too much), reflecting a cultural understanding of distress rooted in broader social and economic adversity. Participants described experiences of dispersive symptoms as an interconnected and mutually reinforcing process in which cognitive symptoms, including persistent intrusive thoughts, worry, poor concentration, and self-doubt, contributed to somatic symptom manifestation such as fatigue, sleep disturbances, appetite changes, and bodily pain. These, in turn, evoked sadness, grief, and hopelessness and ultimately led to social withdrawal and reduced engagement in daily activities. In response, participants managed HIV and these depressive symptoms through two unequal self-management systems. HIV self-management benefited from regular clinic monitoring and support that promoted ART adherence, whereas depression management relied largely on informal strategies, including spirituality, social withdrawal,and engagement in social and physical activities, within the context of limited access to mental health care. While some participants reported disruption in their daily routines and clinic attendance due to depressive symptom experiences, most participants maintained optimal ART adherence. Family responsibility, faith, hope, selective disclosure and social support facilitated HIV and depressive symptom self-management, while poverty and food insecurity, limited mental health services and health system challenges were barriers to HIV and depressive symptom management. This dissertation demonstrates that depression among OPLWH in Zambia may be more common than currently recognized and often remains underestimated. It shows that self-management is shaped by interacting individual, interpersonal, health system, and structural barriers and facilitators, highlighting the need for integrated, person-centred care. Findings also show that depressive symptoms are multidimensional, embodied, interconnected and expressed through culturally meaningful idioms of distress. These findings underscore the importance of culturally responsive depressive symptom screening and the integration of mental health and self-management support in HIV care to improve the health and wellbeing of OPLWH in Zambia.