Identification of suicidal ideation in HIV-infected patients : development of a suicide risk assessment tool and a suicide intervention plan for HIV-infected patients following voluntary counselling and testing.

Abstract

ABSTRACT Background. Globally, suicide and HIV/AIDS remain two of the greatest healthcare issues, particularly in low- and middle-income countries where approximately 85% of suicides occur. Every year, more than 800,000 people die from suicide; this roughly corresponds to one death every 40 seconds, and the World Health Organization (WHO) estimates that by 2020 the rate of death will increase to one every 20 seconds. HIV/AIDS patients in South Africa have a higher suicide risk than the general population and may an increased frequency and severity of suicidal ideation depending on the different intervals in the continuum of HIV disease progression. Several studies have observed a relationship between the increase in suicide and HIV in South Africa, but due to the paucity of empirical data, this relationship remains inconclusive. Suicide in HIV-infected persons is multifactorial. Risk factors include: a history of attempted suicide; fears of social isolation; feelings of hopelessness; fear of losing control of life; elevated levels of depression; denial; and poor coping strategies. Despite the introduction of antiretroviral therapy (ART), the suicide rate remains more than three times higher among HIV-infected persons than in the general population. Although international findings on the correlation between suicide and HIV/AIDS are diverse, results show compelling evidence to screen for suicide risk and intervene as early as possible. Objectives. The main objectives of this research were: (i) to determine the prevalence of suicidal ideation in HIV-positive persons following voluntary HIV counselling and testing (VCT); (ii) to develop and validate a suicide risk screening scale (SRSS) for use in HIV-infected persons post HIV diagnosis; (iii) to implement and evaluate a brief suicide preventive intervention (BSPI) for use in the period immediately following HIV diagnosis. Methods. A quantitative methodology was used with a cross-sectional, correlational and regression analysis in the prevalence study. Participants completed a sociodemographic questionnaire, Beck’s Hopeless Scale and Beck’s Depression Inventory. Drawing 14 items from two established screening tests, the SRSS was developed and assessed. Validity, internal consistency and receiver-operating curves were used to determine the sensitivity and specificity of the tool. Following confirmation that recently diagnosed HIV-positive persons were at risk for suicidal behaviour, a BSPI was implemented and its efficacy evaluated with the validated SRSS. Statistical analysis included generalised linear modeling, and Pearson’s and McNemar’s chi-square analyses. Results. There was an increase in suicidal ideation over a six-week period following a positive HIV diagnosis, from 17.1% to 24.1%. Suicidal ideation was significantly associated with seropositivity, age and gender, with the majority of affected patients falling in the younger age category. Young males had an 1.8 times higher risk for suicidal ideation than females. Lower education and traditional beliefs were also significantly associated with an HIV-positive status upon testing. The SRSS was implemented and, despite certain limitations, was considered to be a valuable screening tool for suicidal ideation at VCT clinics. The BSPI was associated with a clinically significant decrease in the rate of suicidal ideation over time, providing preliminary evidence on its efficacy. Conclusion. Significant correlations exist between hopelessness, depression and suicidal ideation; these serve as important markers that should alert healthcare professionals to underlying suicide risks in HIV-positive patients. Screening for suicide risk and possible suicidal behaviour should form a routine aspect of comprehensive patient care at VCT clinics to assist with effective prevention and treatment. Healthcare workers at VCT clinics should be trained in suicide prevention interventions and the importance of educating vulnerable HIV-positive patients on suicide-prevention strategies. Further longitudinal studies are recommended to enable researchers to observe and differentiate between the variables that may be more prevalent at different stages of HIV, as well as the impact of ART on suicidal behaviour.