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Depression and Perceived Stress among Perinatal Women Living with HIV in Ibadan, Nigeria

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25 February 2023

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27 February 2023

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Abstract
Background: Pregnancy can be a period of increased psychological susceptibility for women living with HIV. This study aimed to determine the prevalence and factors associated with depression and psychological stress among women living with HIV during their perinatal period in Ibadan, Nigeria. Methods: This study was a facility-based cross-sectional survey conducted in three HIV treatment centers. The study population consisted of women living with HIV 18 years and above who were pregnant or had given birth within the last two years. Data obtained were analyzed using Statistical Package for Social Science version 25. Results: A total of 402 participants were eligible for this study. About 69.0% and 78.0% of the participants were depressed and had perceived stress respectively. Women who had positive partners (OR=0.60, 95% CI=0.20-1.30) were found to be significantly associated with perceived depression. Women who reported having a gestational age between 29-40 weeks (OR=0.054 95% CI = 0.006, 0.500) were found to be significantly associated with perceived stress. Factors associated with the co-occurrence of symptoms of depression and perceived stress were partner status, income level, family support, gestational age, and years on ART. Conclusions: Given the high prevalence of major depression, perceived stress, and the co-occurrence of depression and perceived stress among women living with HIV, mental health care should be incorporated into the routine maternal healthcare for all women, especially those living with HIV.
Keywords: 
Subject: Social Sciences  -   Psychology

Introduction

For decades, the HIV epidemic remains a significant global health challenge, with an estimated 38 million individuals infected globally1. Sub-Saharan Africa (SSA) accounts for 71% of the global population of people living with HIV (PLWH)2, with a prevalence rate of 1.4% in Nigeria making it the third most HIV-burdened country2. The burden of HIV in Nigeria is the highest among the female adult population and a known predisposition of maternal mortality with an estimated prevalence of 26.4% among pregnant cohorts 3, 4.
More women have been reported to have symptoms of depression in comparison to men and this gendered pattern has also been found to exist among PLWH5-7. WLWH especially in low and middle-income countries (LMICs), experience significant psychological challenges, such as depression, stress, and anxiety, as a result of their HIV diagnosis8, 9. Studies have also shown that WLWH is susceptible to suffering from more severe symptoms of mental illnesses such as depression, anxiety, and posttraumatic stress disorder7, 10.
Pregnancy and postpartum periods are some of the most vulnerable periods that may contribute to symptoms of depression in women11. The prevalence of depressive symptoms among pregnant women ranges from 11.4% to 40.0%, which is higher than that of women generally12, 13. In a study conducted in Nigeria, the prevalence of postpartum depression was found to be 35.6%14. Pregnant women frequently experience stress as well. Women's brains change structurally, psychologically, and behaviourally throughout pregnancy as they prepare for their new role as mothers15. These changes, however, make pregnant women more prone to stress16, which increases the likelihood of developing prenatal depression symptoms17.
Pregnancy can be a period of increased psychological susceptibility for WLWH due to a variety of environmental factors, disclosure concerns, and HIV-related stigma18. Studies conducted in LMICs, have found that pregnant and postpartum WLWH suffer from a high prevalence of depression19-21. Similarly, a systematic review was conducted in Africa which examined the prevalence of perinatal depression in HIV-infected women. The weighted mean prevalence of antenatal and postnatal depression was 23.4% and 22.5%, respectively22. Depression has also been found to be associated with adherence to care and therapy among pregnant WLWH21 which may result in treatment failure and increased vertical HIV transmission8. Additionally, psychological issues such as depression and stress may also have adverse effects on obstetric and neonatal outcomes and increase the risk of mother-to-child transmission (MTCT)23.
Women, particularly in developing countries, are more likely to be exposed to risk factors such as poor socioeconomic status which make them more susceptible to the development of perinatal depression24. Depression and psychological stress may act as critical barriers to HIV treatment and prevention as the conditions may be linked. Women are often newly diagnosed with HIV during pregnancy and receive a positive HIV diagnosis in an event that can generate worry as well as fear of transmitting the virus to an unborn child25.
Mental health disorders in pregnant WLWH must be understood in the context of women’s life circumstances. Understanding the magnitude of depression and stress, as well as their associated factors, among pregnant WLWH could provide important information that could aid in the mitigation of the poor mental health experienced by this group of women. To our knowledge, this study is among the few studies that have investigated the prevalence of depression and psychological stress among WLWH during pregnancy and the postpartum period in Nigeria. Thus, the present study aimed to determine the prevalence and factors associated with depression and psychological stress among WLWH during their perinatal period in Ibadan, Nigeria.

Materials and Methods

Study Design and Setting

This study was a facility-based cross-sectional survey conducted in three (3) HIV treatment centers in Ibadan. The centers were; State Hospital, Adeoyo, Ringroad; Adeoyo Maternity Health Centre; and St Annes Anglican Hospital, Molete. A purposive sampling method was adopted in selecting the health facilities because anti-retroviral treatment is not available in all health facilities. Thus, the health institution provides comprehensive HIV services in addition to antenatal, delivery, and postnatal care.

Study Participants

The participants were randomly selected from the three HIV treatment facilities in Ibadan between September and November 2022. The study population consisted of WLWH over the age of 18 who were pregnant or had given birth within the last two years and were attending any of the three selected anti-retroviral treatment clinics in Ibadan, Oyo state, Nigeria. The exclusion criteria were women who had existing mental illnesses or were unable to provide explicit consent.

Data Collection

All the questionnaires were interviews administered to WLWH receiving treatment at any of the three anti-retroviral treatment clinics during the course of the study. 402 consented WLWH were enrolled in the study. Before administering the questionnaire, participants were provided with information sheets outlining the objective and scope of the study which was duly explained to the participants in English language or the local dialect (Yoruba).

Questionnaire

A structured questionnaire composed in the English language was administered to the participants, and clarification was provided by the investigators when requested. The questionnaire was divided into two sections. Section one obtained information on the participants’ social demographic, relationship, and support-related, behavioral, clinical, and pregnancy-related characteristics. After completing the first section, the participants were counseled to select their desired answers in section two, which assessed depression using the Edinburgh Postnatal Depression Scale (EPDS)26 and perceived stress using the Perceived Stress Scale-10 (PSS-10)27. The questions were explained verbally in the requisite local language (Yoruba) for those not fluent in English.
The Edinburgh Postnatal Depression Scale was used to assess symptoms of perinatal depression. The scale has 10 items with responses on a 4-point Likert scale ranging from 0 (absence of depressive moods) to 3 (worst mood). A total score ranging from 0 to 30 is calculated, and a cut-off point of ≥12 indicates an increased likelihood of clinical depression. The scale does not mention the words pregnancy, child, birth, or infant and has also been validated in a non-pregnant population.
Perceived stress was measured using the Perceived Stress Scale. The Perceived Stress Scale (PSS) is a 10-item self-report assessment of the stress domains of unpredictability, lack of control, burden overload, and stressful life circumstances. Responses are on a 5-point Likert scale ranging from 0 (never) to 4 (very often). The PSS score is the sum of all responses with higher scores indicating more perceived stress and can range from 0 to 40.

Statistical Analysis

Data obtained from the completed questionnaire and assessment tools were analyzed using Statistical Package for Social Science version 25. Descriptive statistics of demographic information for each participant were computed. Descriptive statistics were also used to describe the prevalence of depression and perceived stress. Factors associated with depression and perceived stress were evaluated using multivariate logistic regression.

Ethical Considerations

Ethical approval was obtained from the Lead City University Health Research and Ethics Committee (LCU-REC/22/125) as well as from the Oyo State Ministry of Health Research Ethics Committee (AD 13/479/44539).

Results

Sociodemographic Characteristics of Participants

A total of 402 participants were eligible in this study and the mean value of their age was 35.8 years (SD = 6.60 years). A total of 225 (56.0%) participants identified as Christians, the majority 92.3% of them were married and 352 (87.6%) participants were from the Yoruba tribe. Concerning their level of education, those who attained a secondary school education were the majority with 173 (43.0%) participants, while 334 (83.1%) participants were employed and 234 (58.2%) of the participants earn an income below 20,000.00 NGN. (See Table 1)

Relationship and Support-Related, Clinical, and Pregnancy-Related Characteristics of Participants

Out of the 402 participants that were interviewed 335 were aware of their partner's status; with 152 having positive partners. 246 (61.2%) had disclosed their status to their partners. 318 participants reported receiving adequate support from their partner and 287 reported receiving support from family and friends. All participants in the study sample had started anti-retroviral therapy at the time of their interview. The majority (48.3%) had been on ART for between 1 – 5 years. Most of the participants (93%) were virally suppressed with a viral load below 50 copies/mL. Out of the total participants, 263 (65.4%) were pregnant, 109 reported a gestational age of 5-13 weeks, 85 reported 14-28 weeks, and 69 reported 29-40 weeks. Only 73 (18.2%) of the women reported that the pregnancy was planned compared to 190 (47.3%) with an unplanned pregnancy. (See Table 2)

Depression and Perceived Stress among Pregnant WLHIV

About 69% of the participants were depressed and 78% had perceived stress. According to this study, depression and stress were significantly associated. (See Table 3)
Table 2. Relationship and support-related clinical and pregnancy-related characteristics.
Table 2. Relationship and support-related clinical and pregnancy-related characteristics.
Characteristics Total Antenatal (%) Postnatal (%)
Partners Status(n=402)
Positive 157 118(44.9) 39(28.1)
Negative 178 97(36.9) 81(58.3)
Not applicable 67 48(18.2) 19(13.7)
Status Disclosure to partner (n=402)
Yes 246 153(58.2) 93(66.9)
No 148 108(41.1) 40(28.8)
Not applicable 8 2(0.8) 6(4.3)
Perceived Social Support
Support from partner (n=402)
Yes 318 218(82.8) 100(72)
No 76 43(20.9) 33(23.8)
Not applicable 8 2(0.8) 6(4.3)
Support from other family and friends (n=402)
Yes 287 56(40.3) 83(59.7)
No 115 59(22.4) 56(40.3)
History of Conflict with Partner
Yes 128 80(30.4) 48(34.5)
No 266 181(68.8) 85(61.2)
Not applicable 8 2(0.8) 6(4.3)
Years On ART(n=402)
≤ 1 Year 85 50(19) 35(25.2)
≤ 5 Years 194 136(51.7) 58(41.7)
>5 Years 77 46(17.5) 15(10.8)
> 10 Years 46 31(11.8) 31(22.3)
Viral Load
<50 copies/mL 374 243(92.4) 131(94.2)
≥ 50 copies/mL 19 13(4.9) 6(4.3)
Target Not Detected (TND) 9 7(2.7) 2(1.4)
Problems in Previous Pregnancy (n=402)
Yes 175 104(39.5) 64(46)
No 227 159(60.5) 75(54)
Planned Pregnancy (n=263)
Yes 73 73(27.8) N/A
No 190 190(72.2) N/A
Gestational Age (n=263)
5-13 weeks 109 109(41.4) N/A
14-28 weeks 85 85(32.3) N/A
29-40 weeks 69 69(26.3) N/A
Table 3. Prevalence of Depression and Perceived Stress.
Table 3. Prevalence of Depression and Perceived Stress.
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Preprints 69148 i002

Factors Associated with Perinatal Depression

In the multivariate logistic regression model which examined factors associated with depressive symptoms (see Table 4), the status of the partner, income level, and gestational age was found to be significantly associated with depression. Women who had positive partners had lower higher odds of depression compared with women who had negative partners (OR=0.6, 95% CI =0.2-1.3). Women who earned an income below 20,000.00 Nigeria naira had 7.0 times higher odds of possible depression compared with women who earned more (OR=7.0, 95% CI= 1.2-40.9). Women who reported having a gestational age above 14 weeks had 5 times higher odds of depression (OR=4.7, 95% Cl=1.7-12.6).

Factors Associated with Perceived Stress

Following a multivariate logistic regression model examining factors associated with perceived stress, gestational age was found to be significantly associated with perceived stress. (See Table 5)

Factors Associated with the Co-Occurrence of Depression and Perceived Stress

A multivariate logistic regression model was used to examine the factors associated with the co-occurrence of symptoms of depression and perceived stress. Table 6 showed the status of the partner, income level, support from other family and friends, history of conflict with the partner, whether the pregnancy was planned, gestational age, having problems in a previous pregnancy, and years on ART were significant predictors. Women who earned an income below 20,000.00 NGN had 6 times higher odds of possible depression and perceived stress compared with women who earned more (OR=5.7, 95% CI 1.1-7.8). Women that had planned pregnancies had lower odds of experiencing depression and perceived stress when compared with those that had planned pregnancies (OR=0.3, 95% Cl =0.1-0.8). Also, women who reported experiencing problems in a previous pregnancy were twice as likely to experience a co-occurrence of depression and perceived stress (OR=2.1, 95% Cl =1.6-3.8). Women who reported having a gestational age above 14 weeks had 4.7 times higher odds of depression and perceived (OR=4.7, 95% Cl =4.0-5.5). Women that reported being on ART for 2 to 5 years as of the time of the survey were also found 2.3 times higher odds of experiencing a co-occurrence of depression and perceived stress(OR=2.3, 95% Cl =1.3-4.3).

Discussion

This study determined the prevalence and factors associated with depression and psychological stress among WLWH during their perinatal period in Ibadan, Nigeria. The study results show a high prevalence of perinatal symptoms (60.7%) with antenatal depression and postpartum depression having a prevalence of 61.6% and 58.9% respectively. The prevalence of perinatal depression is higher than 38.4% in a similar study in Ethiopia 21. The prevalence of antenatal depression of 61.6% as measured by the EPDS with a cut-off ≥13 is slightly higher than the prevalence found in a previous study in Ekiti State, Nigeria (49.5%)28, 47.6% in Addis Ababa, Ethiopia 21, and 52.5% in India among women on ART 29. The differences in prevalence might be due to differences in sociodemographic characteristics and tools used to assess depression. However, this finding buttresses the need to integrate mental health services into routine HIV care services especially among women to mitigate the adverse associated with maternal and child outcomes.
In the current study, the mean perceived stress was 20.01. This indicates moderate stress among WLHIV during the perinatal period. This finding is consistent with what was reported in another study carried out in Nigeria, in which the mean perceived stress was moderate among the study population30. The level of stress among the participants plausible predisposes to higher risks of mental disorders as it is in the general population and settings with social inequalities 31. Stress is an important risk factor for depressive symptoms 32. Similar to other studies, it was found that women within the study sample that reported depressive symptoms (64.0%) reported significantly higher levels of perceived stress than women without depressive symptoms (28.0%).
This study used multivariate analysis to highlight factors associated with perinatal depression and perceived stress in a sample of WLWH recruited from ART clinics. The study found that the status of the partner of participants was significantly associated with depression and perceived stress. With an odds ratio of 0.389, participants with a positive partner were less likely to report symptoms of depression and perceived stress as compared to women with negative partners. This may be due to the social support provided by a positive partner as opposed to a negative partner. Studies also corroborate that having a positive partner increases the likelihood of having access to help when sick, general support in form of finances as well as HIV-specific support 33. According to the study, participants who earned below 20,000 were 5.6 times more likely to report symptoms of depression and perceived stress. The results are consistent with those reported in studies in Ethiopia and South Africa, which presented that low income and unemployment were related to depression among HIV-positive women 24, 34. The reason could be that in low-income countries, women are pressured to default academics for poverty-related factors, which later result in their more prominent engagement in domestic work, as well as the lack of access to health education and awareness. This is ascribed to the possible negative interaction between mental disorders (e.g., depression) and poverty, primarily because, in principle, people with depression commonly perform poorly in their daily tasks 35. In addition, pregnancy may decrease their employability and even their potential to work because of the type of labor impoverished women may need to undertake 36.
The results from this study also revealed that having a planned pregnancy (OR=0.348, 95% Cl 0.149-0.819), is indicative of a lower likelihood of reporting symptoms of depression and perceived stress during the perinatal period. According to the study, pregnant women within their second (14-28 weeks) and third (29-40 weeks) trimesters were more likely to report symptoms of depression and perceived stress with odds of 4.7 and 3.7 respectively. This is in contrast with other studies which have reported no association between gestational age and depression among women living with HIV. This could be due to physiological changes which take place during this period which may be inclinatory to the development of depression. It could also be due to heightened anxiety during the third trimester 37, 38. This study indicates having problems in a previous pregnancy (OR = 2.10) was significantly associated with the co-occurrence of depression and perceived stress. This indicates that women living with HIV that had complications in their previous pregnancy were twice as likely to report symptoms of depression and perceived stress as compared to those that did not. This could be a result of the complications being events that were highly severe and stressful to them. This finding is in line with previous studies which reported that having previous complications in pregnancy is a significant factor in the development of depression 39.

Conclusion

This study reveals a substantial prevalence of depression, perceived stress, and the co-occurrence of depression and perceived stress in the population of WLHIV. The study recommends that screening for prenatal and postpartum depression and access to mental health interventions should be part of routine maternal healthcare for all women, especially those living with HIV.

Author Contributions

The following statements should be used “Conceptualization, O.C. and F.T.; methodology, A.L., S.B., and F.T.; software, S.B., and H.O..; validation, F.T.., A.L., and Z.A.; formal analysis, S.B.; investigation, Z.A., I.A., and D.R.; resources, F.T.; data curation, S.B., F.T., and H.O.; writing—original draft preparation, F.T., and A.L.; writing—review and editing, A.L., O.A., D.R., H.O., D.N., and A.S.; supervision, F.T., and O.C. All authors have read and agreed to the published version of the manuscript.”

Funding

This research received no external funding.

Institutional Review Board Statement

“The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Lead City University, Ibadan (Protocol code: LCU-REC/22/125 and date of approval: September 05, 2022) as well as from the Oyo State Ministry of Health Research Ethics Committee (Protocol code: AD 13/479/44539 and date of approval: August 15, 2022).

Informed Consent Statement

“Informed consent was obtained from all subjects involved in the study.”

Data Availability Statement

The data used to support the findings of this study are available from the corresponding author upon request.

Acknowledgments

This work was supported by grants from Fogarty International Center (FIC) and the National Institute of Health (Funding provided by Fogarty Training Grant: D43TW010934-03). The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of Interest

“The authors declare no conflict of interest.”

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Table 1. Characteristics of study participants (n =402).
Table 1. Characteristics of study participants (n =402).
Characteristics Total n=402 Antenatal (n=263) Postnatal (n=139)
Age (n=402)
Mean (S.D) 35.8(6.6)
Religion
Christianity 225 150(57%) 75(54%)
Islam 176 113(43%) 64(46%)
Tribe
Yoruba 352 225(85.6) 127(91.4)
Igbo 29 21(8) 8(5.8)
Hausa 20 16(6) 4(2.9)
Others 1 1(0.4) 0
Level of Education
Primary Level 94 53(20.2) 41(29.5)
Secondary Level 173 107(40.7) 66(47.5)
Tertiary Level 90 68(25.9) 22(15.8)
None 45 35(13.3) 10(7.2)
Marital Status
Married 371 246(93.5) 125(89.9)
Divorced 9 6(2.3) 3(2.2)
Widowed 8 7(2.7) 1(0.7)
Separated 8 4(1.5) 4(2.9)
Single 6 0 6(4.3)
Type of Partner
Spouse 373 247(93.9) 126(90.6)
Steady 11 7(2.7) 4(2.9)
Casual 10 7(2.7) 3(2.2)
None 8 2(0.8) 6(4.3)
Employment Status
Employed 334 225(85.6) 109(78.4)
Unemployed 68 38(14.4) 30(21.6)
Income Level
<20,000 234 157(59.7) 77(55.4)
20,000-30,000 48 19(7.2) 29(20.9)
31,000-40,000 77 60(22.8) 17(12.2)
41,000-50,000 27 13(4.9) 14(10.1)
>51,000 16 14(5.3) 2(1.4)
Table 4. Factors of perinatal depression.
Table 4. Factors of perinatal depression.
Variable Depression (EPDS ≥ 13)  
 
Odd Ratio		  
 
P-value
Overall Antenatal Postpartum
Status of Partner
Positive 110 82 28 0.560(0.242, 1.297) 0.012
Negative 103 60 43 Ref
Status Disclosure
No 158 109 49 4.750(0.681,33.131) 0.092
Yes 82 52 30 Ref
Income Level
<20,000 121 72 49 6.963(1.184,40.951) 0.032
20,000-30,000 37 19 18 3.046(0.421,22.041) 0.270
31,000-40,000 60 52 8 5.481(0.808,37.179) 0.082
41,000-50,000 16 11 5 4.768(0.552,41.182) 0.156
>51,000 10 8 2 Ref
Support from Other Family and Friends
No 84 49 35 0.500(0.246,1.015) 0.050
Yes 160 113 47 Ref
History of Conflict with Partner
No 140 99 41 2.462(1.315,4.608) 0.005
Yes 100 62 38 Ref
Gestational Age
14-28 weeks 73 73 N/A 4.677(1.740,12.574) 0.002
29-40 weeks 54 54 N/A 0.219(0.059, 0.817) 0.024
5-13 weeks 35 35 N/A Ref
Problems in Previous Pregnancy
No 37 37 N/A 1.323(0.758,2.309) 0.325
Yes 125 125 N/A Ref
Years on ART
≤ 1 Year 48 28 20 2.007(0.996,4.044) 0.051
≤ 5 Years 102 74 28 1.869(1.008,3.465) 0.047
> 5 Years 56 34 22 Ref
> 10 Years 38 26 12 0.623(0.236,1.643) 0.339
Table 5. Factors associated with perceived stress.
Table 5. Factors associated with perceived stress.
Variable Stress(PSS-10 ≥ 14)  
 
Odd Ratio		  
 
P-value
Overall Antenatal Postnatal
Status of Partner
Negative 148 113 35 0.363(0.104,1.266) 0.112
Positive 166 95 71 Ref
Status Disclosure
No 138 102 36 2.026(0.173,23.757) 0.574
Yes 228 145 83 Ref
Income Level
<20,000 218 147 71 0.193(0.041,0.915) 0.038
20,000-30,000 46 19 27 0.078(0.078,0.009) 0.019
31,000-40,000 72 59 13 0.316(0.052,1.917) 0.210
41,000-50,000 24 12 12 0.277(0.0.035,2.177) 0.222
>51,000 13 11 2 Ref
Support from other family and friends
No 107 55 52 0.632(0.240,1.663) 0.353
Yes 266 193 73 Ref
Gestational Age
14-28 weeks 84 84 N/A 0.323(0.083,1.261) 0.104
29-40 weeks 61 61 N/A 0.054(0.006, 0.500) 0.010
5-13 weeks 103 103 N/A Ref
Problems in Previous pregnancy
No 214 150 64 1.489(0.613,3.620) 0.379
Yes 159 98 61 Ref
Years on ART
≤ 1 Year 84 50 34 0.214(0.023,1.970) 0.174
≤ 5 Years 175 123 52 1.875(0.611,5.753) 0.272
> 5 Years 73 46 27 Ref
> 10 Years 41 29 12 2.175(0.552,8.568) 0.267
Table 6. Factors of depression and perceived stress.
Table 6. Factors of depression and perceived stress.
Variable Depression and Stress (EPDS ≥ 13, PSS-10 ≥ 14)  
 
Odd Ratio		  
 
P-value
Overall Antenatal Postpartum
Status of Partner
Positive 108 80 28 0.389(0.165,0.915) 0.031
Negative 122 70 52 Ref
Status Disclosure
No 84 53 31 0.571(0.270,10.735) 0.571
Yes 170 112 58 Ref
Income Level
<20,000 124 73 51 5.690(1.050,7.832) 0.044
20,000-30,000 39 19 20 1.706(0.256,11.363) 0.581
31,000-40,000 63 52 11 2.973(0.491,17.998) 0.236
41,000-50,000 21 12 9 2.781(0.353,21.921) 0.332
>51,000 12 10 2 Ref
Support from other family and friends
No 89 117 53 0.488(0.244,0.976) 0.042
Yes 170 49 40 Ref
History of Conflict with Partner
No 156 106 50 2.462(1.315,4.608) 0.005
Yes 98 39 59 Ref
Planned Pregnancy
Yes 35 35 N/A 0.348(0.149, 0.819) 0.015
No 131 131 N/A Ref
Gestational Age
29-40 weeks 52 52 N/A 3.673(1.339,10.077) 0.012
14-28 weeks 79 79 N/A 4.677(0.042,0.529) 0.003
5-13 weeks 35 35 N/A Ref
Problems in Previous Pregnancy
Yes 106 52 54 2.106(1.157,3.833) 0.015
No 153 114 39 Ref
Years on ART
≤ 1 Year 53 31 22 1.988(0.997,3.963) 0.051
≤ 5 Years 112 75 37 2.343(1.282,4.281) 0.006
> 5 Years 59 36 23 1.016(1.061,0.430) 0.971
> 10 Years 35 24 11 Ref
Viral Load
Target not detected (TND) 7 6 1 0.446(0.046,4.289) 0.485
<50 copies/mL 243 154 89 0.901(0.272,2,982) 0.864
>=50 copies/mL 9 6 3 Ref
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