Self-inflicted violence and suicide in people living with HIV/AIDS: a systematic review

Fernandes, Hugo; Lima, Daniel Vieira; Hino, Paula; Taminato, Mônica; Okuno, Meiry Fernanda Pinto

doi:10.1590/0034-7167-2021-0768

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REVIEW • Rev. Bras. Enferm. 75 (Suppl 3) • 2022 • https://doi.org/10.1590/0034-7167-2021-0768 copy

Self-inflicted violence and suicide in people living with HIV/AIDS: a systematic review

Violencia autoinfligida y suicidio en personas que viven con VIH/SIDA: una revisión sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to analyze intellectual productions on self-inflicted violence and suicide in people living with HIV/AIDS.

Methods:

a systematic review, carried out between March and April 2021, in the PubMed®/MEDLINE®, Web of Science and LILACS databases, subsidized in the Strengthening the Reporting of Observational Studies in Epidemiology. The period outlined was from 2011 to 2020.

Results:

a total of 199 studies were identified, and 16 composed the final sample, grouped into the categories: Sociodemographic characteristics of victims of self-inflicted violence/suicide and their intervening factors (pointing to young adults, especially homosexuals, with low social support and a history of mental illness or substance abuse as usual victims); Successful measures for suicide prevention/control in people living with HIV/AIDS (suggesting more frequent psychosocial and clinical follow-up of those starting antiretroviral and immunocompromised treatment).

Conclusions:

biopsychosocial follow-up, analysis of sociodemographic profile and intervening factors should be frequent in this population for disease prevention/control.

Descriptors:
HIV; Acquired Immunodeficiency Syndrome; Violence; Suicide; Systematic Review

Author, year	Country	Journal	Objective(s)	Outcomes
Wonde M(¹⁴14 Wonde M, Mulat H, Birhanu A, Biru A, Kassew T, Shumet S. The magnitude of suicidal ideation, attempts and associated factors of HIV positive youth attending ART follow ups at St. Paul's hospital Millennium Medical College and St. Peter's specialized hospital, Addis Ababa, Ethiopia. PLoS One[Internet]. 2019 [cited 2021 Mar 12];14(11):e0224371. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830816/ https://www.ncbi.nlm.nih.gov/pmc/article... ), 2019	Ethiopia	PLoS One	Assess the magnitude and factors associated with the ideation and suicide attempt among HIV-positive young people in follow-up of antiretroviral therapy.	Suicidal ideation and attempts were statistically significant for females. History of family death and perceived HIV stigma were significantly associated with suicidal ideation. The presence of opportunistic infections and low social support were associated with suicide attempts and self-inflicted violence.
Wang W(¹⁵15 Wang W, Chen X, Li S, Yan H, Yu B, Xu Y. Cusp Catastrophe Modeling of Suicide Behaviors among People Living with HIV in China. Nonlinear Dynamics Psychol Life Sci [Internet]. 2019 [cited 2021 Mar 01];23(4):491-515. Available from: https://pubmed.ncbi.nlm.nih.gov/31586499/ https://pubmed.ncbi.nlm.nih.gov/31586499... ), 2019	China	Psychol Life Sci	Test a nonlinear cusp catastrophe modeling on suicidal behavior in PLWHA^* * PLWHA - person living with HIV/AIDS; .	Suicidal behaviors and self-inflicted violence are prevalent among PLWHA^* * PLWHA - person living with HIV/AIDS; in China. Psychosocial aspects such as income and AIDS stigma were associated with an increased risk of suicide.
Mandell LN(¹⁶16 Mandell LN, Rodriguez VJ, De La Rosa A, Abbamonte JM, Sued O, Cecchini D, et al. Suicidal Ideation Among Adults Re-engaging in HIV Care in Argentina. AIDS Behav [Internet]. 2019 [cited 2021 Mar 01];23(12):3427-34. Available from: https://pubmed.ncbi.nlm.nih.gov/31049810/ https://pubmed.ncbi.nlm.nih.gov/31049810... ), 2019	Argentina	AIDS Behav	Analyze the risk factors for suicidal ideation in PLWHA^* * PLWHA - person living with HIV/AIDS; .	Younger age, increased depressive symptoms and drug abuse, decreased motivation to comply with treatment, and fewer months since starting antiretroviral therapy were identified as risk factors.
Lu HF(¹⁷17 Lu HF, Sheng WH, Liao SC, Chang NT, Wu PY, Yang YL, et al. The changes and the predictors of suicide ideation and suicide attempt among HIV-positive patients at 6-12 months post diagnosis: a longitudinal study. J Adv Nurs [Internet]. 2019 [cited 2021 Apr 03];75(3):573-84. Available from: https://onlinelibrary.wiley.com/doi/10.1111/jan.13883 https://onlinelibrary.wiley.com/doi/10.1... ), 2019	Taiwan	J Adv Nurs	Analyze the changes and predictors of ideation/self-injury and suicide attempt and the moderating effects of psychosocial factors in PLWHA^* * PLWHA - person living with HIV/AIDS; between 6 and 12 months after diagnosis.	History of depressive disorders or symptoms and social support from friends significantly predicted suicide attempt and self-violence.
Bengtson AM(¹⁸18 Bengtson AM, Pence BW, Mollan KR, Edwards JK, Moore RD, O'Cleirigh C, et al. The Relationship between Efavirenz® as Initial Antiretroviral Therapy and Suicidal Thoughts Among HIV-Infected Adults in Routine Care. J Acquir Immune Defic Syndr[Internet]. 2017 [cited 2021 Apr 03];76(4):402-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5659970/ https://www.ncbi.nlm.nih.gov/pmc/article... ), 2017	USA	J Acquir Immune Defic Syndr	Analyze the effect of Efavirenz® on suicidal ideation or self-inflicted violence.	There was no evidence that initiating ART^ ART - antiretroviral therapy. containing Efavirenz® increased the risk of suicidal thoughts and violence against oneself.
Kalungi A(¹⁹19 Kalungi A, Seedat S, Hemmings SMJ, van der Merwe L, Joloba ML, Nanteza A, et al. Association between serotonin transporter gene polymorphisms and increased suicidal risk among HIV positive patients in Uganda. BMC Genet [Internet]. 2017 [cited 2021 Apr 03];18(1):71. Available from: https://bmcgenomdata.biomedcentral.com/articles/10.1186/s12863-017-0538-y https://bmcgenomdata.biomedcentral.com/a... ), 2017	Uganda	BMC Genet	Investigate the genetic risk factors associated with certain phenotypes of suicidal behavior.	The SA allele at the 5-HTTLPR /rs 25531 locus was associated with increased risk of suicide among PLWHA^* * PLWHA - person living with HIV/AIDS; .
Liu Y(²⁰20 Liu Y, Niu L, Wang M, Chen X, Xiao S, Luo D. Suicidal behaviors among newly diagnosed people living with HIV in Changsha, China. AIDS Care [Internet]. 2017 [cited 2021 Apr 13];29(11):1359-63. Available from: https://pubmed.ncbi.nlm.nih.gov/28593797/ https://pubmed.ncbi.nlm.nih.gov/28593797... ), 2017	China	AIDS Care	Assess the prevalence of suicidal and self-injurious behaviors among PLWHA^* * PLWHA - person living with HIV/AIDS; and explore the relationships between HIV-related stress, depression, anxiety and social support and suicidal ideation after HIV infection diagnosis.	The prevalence of suicidal behaviors is high among PLWHA^* * PLWHA - person living with HIV/AIDS; . Suicidal ideation was statistically associated with the onset of AIDS symptoms, the stress of diagnosis, the presence of previous depressive and anxiety symptoms, and low social support.
Egbe CO(²¹21 Egbe CO, Dakum PS, Ekong E, Kohrt BA, Minto JG, Ticao CJ. Depression, suicidality, and alcohol use disorder among people living with HIV/AIDS in Nigeria. BMC Public Health [Internet]. 2017 [cited 2021 Apr 07];17(1):542. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4467-5 https://bmcpublichealth.biomedcentral.co... ), 2017	Nigeria	BMC Public Health	Verify the prevalence and factors associated with major depressive episodes, suicide and alcohol use disorder among people living with HIV/AIDS.	Major depressive episodes were significantly associated with having planned suicide or self-inflicted violence. Suicidal ideation was significantly associated with major depressive episodes, marital status (married) and religion (Christian). Women were less likely to be diagnosed with alcohol disorders.
Carrieri MP(²²22 Carrieri MP, Marcellin F, Fressard L, Préau M, Sagaon-Teyssier L, Suzan-Monti M, et al. Suicide risk in a representative sample of people receiving HIV care: time to target most-at-risk populations (ANRS VESPA2 French national survey). PLoS One [Internet]. 2017[cited 2021 Apr 03];12(2):e0171645. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0171645 https://journals.plos.org/plosone/articl... ), 2017	France	PLoS One	Identify the main suicide risk factors in PLWHA^* * PLWHA - person living with HIV/AIDS; , to subsidize the classification of suicide risks, violence against oneself and psychiatric care.	Women and men who have sex with men (MSM) were at higher risk. Reports of social contexts related to discrimination, homelessness and feelings of loneliness were the main predictors of risk.
Kang CR(²³23 Kang CR, Bang JH, Cho SI, Kim KN, Lee HJ, Ryu BY, et al. Suicidal ideation and suicide attempts among human immunodeficiency virus-infected adults: differences in risk factors and their implications. AIDS Care [Internet]. 2016 [cited 2021 Apr 15];28(3):306-13. Available from: https://www.tandfonline.com/doi/abs/10.1080/09540121.2015.1093593 https://www.tandfonline.com/doi/abs/10.1... ), 2016	South Korea	AIDS Care	Identify differences in risk factors between suicidal ideation and suicide attempts among HIV-infected adults.	Being young and a middle-aged adult, living with someone, having a history of opportunistic AIDS-defining disease, having a history of treatment for depression, having low social support and a fragile psychological state were risk factors for suicidal ideation found. Being a beneficiary of South Korea’s National Medical Care, reporting economic barriers to treatment, having a history of treatment for depression, and poor psychological status were factors for suicide attempts.
Mollan KR(²⁴24 Mollan KR, Smurzynski M, Eron JJ, Daar ES, Campbell TB, Sax PE, et al. Association between Efavirenz® as initial therapy for HIV-1 infection and increased risk for suicidal ideation or attempted or completed suicide: an analysis of trial data. Ann Intern Med. 2014;161(1):1-10. https://doi.org/10.7326/M14-0293. https://doi.org/10.7326/M14-0293.... ), 2014	USA	Ann Intern Med	Compare the time of suicidal ideation, attempt, or consummation with antiretroviral regimens containing Efavirenz® versus without Efavirenz® for initial HIV treatment.	Initial treatment with an antiretroviral regimen containing Efavirenz® was associated with a 2-fold increased risk of suicidal ideation, attempt, or consummation compared to a regimen without Efavirenz®.
Chikezie UE(²⁵25 Chikezie UE, Otakpor AN, Kuteyi OB, James BO. Suicidality among individuals with HIV/AIDS in Benin City, Nigeria: a case-control study. AIDS Care [Internet]. 2012 [cited 2021 Apr 17];24(7):843-5. Available from: https://pubmed.ncbi.nlm.nih.gov/22272812/ https://pubmed.ncbi.nlm.nih.gov/22272812... ), 2012	Nigeria	AIDS Care	Compare the prevalence of suicidal ideation and self-harm in PLWHA^* * PLWHA - person living with HIV/AIDS; with workers from a local government.	More than one-third (34.7%) of PLWHA^* * PLWHA - person living with HIV/AIDS; versus 4% of controls expressed suicidal ideation in the previous month, with 9.3% attempting suicide in the six months prior to the study. The most common type of attempt was a drug overdose. Being a woman, unemployment, comorbidities, living alone and having a partner with the disease were associated with suicidal ideation or self-injury. It is suggested that physicians routinely question PLWHA^* * PLWHA - person living with HIV/AIDS; to reduce mortality.
McManus H(²⁶26 McManus H, Petoumenos K, Franic T, Kelly MD, Watson J, O'Connor CC, et al. Australian HIV Observational Database. Determinants of suicide and accidental or violent death in the Australian HIV Observational Database. PLoS One. [Internet] 2014 [cited 2021 Apr 15];19;9(2):e89089. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0089089 https://journals.plos.org/plosone/articl... ), 2014	Australia	PLoS One	Identify associations between suicide and accidental death or violent death in PLWHA^* * PLWHA - person living with HIV/AIDS; .	The immune status of people with HIV contributed to the risk of suicide and accidental or violent death (CD4<500 cell/mm³). The number of psychiatric/cognitive diagnoses contributed to the level of risk, but many psychosocial factors were not individually significant.
Almeida SM(²⁷27 Almeida SM, Barbosa FJ, Kamat R, Pereira AP, Raboni SM, Rotta I, et al. HNRC Group. Suicide risk and prevalence of major depressive disorder (MDD) among individuals infected with HIV-1 subtype C versus B in Southern Brazil. J Neurovirol[Internet]. 2016 [cited 2021 Apr 5];22(6):789-798. Available from: https://pubmed.ncbi.nlm.nih.gov/27431676/ https://pubmed.ncbi.nlm.nih.gov/27431676... ), 2016	Brazil	J Neurovirol	Examine the frequency and severity (including suicide) of major depressive disorder among PLWHA^* * PLWHA - person living with HIV/AIDS; and compare with people without the virus. Identify whether there are differences in between people living with HIV subtypes B and C.	The current suicide risk, defined as during the last month, was found in 18% of participants in PLWHA^* * PLWHA - person living with HIV/AIDS; and none in the non-HIV group. There were no differences between HIV subtypes B and C.
López JD(²⁸28 López JD, Shacham E, Brown T. Suicidal Ideation Persists Among Individuals Engaged in HIV Care in the Era of Antiretroviral Therapy. AIDS Behav [Internet]. 2018 [cited 2021 Apr 19];22(3):800-5. Available from: https://pubmed.ncbi.nlm.nih.gov/28063073/ https://pubmed.ncbi.nlm.nih.gov/28063073... ), 2018	USA	AIDS Behav	Assess persistent suicidal ideation in PLWHA^* * PLWHA - person living with HIV/AIDS; in the era of antiretroviral therapy.	Suicidal ideation was reported in 13% of the sample. It is suggested that basic needs should be met and improve understanding of how symptoms of psychological distress and violence against oneself are expressed can improve barriers in managing PLWHA care^* * PLWHA - person living with HIV/AIDS; .
Alderete-Aguilar C(²⁹29 Alderete-Aguilar C, Cruz-Maycott R, Candela-Iglesias M, Rodríguez-Estrada E, Reyes-Terán G. Assessment of depression, anxiety, hopelessness and suicidal risk in HIV+ inpatients. Salud Ment[Internet]. 2017 [cited 2021 Apr 15];40(1):23-28. Available from: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252017000100023 http://www.scielo.org.mx/scielo.php?scri... ), 2017	Mexico	Salud Ment	Assess the presence of anxiety, depression, hopelessness and suicide risk in HIV + patients hospitalized at admission and discharge.	At admission, 10.4% of patients had a score above the cut-off point for suicide risk; 1.7% had high levels of hopelessness; 5.2% had clinical depression; and 7% had clinical anxiety. The comparison of scores at admission and discharge showed significant reductions in all levels of symptoms.

Author, year	Study design	Sample	STROBE score
Wonde M(¹⁴14 Wonde M, Mulat H, Birhanu A, Biru A, Kassew T, Shumet S. The magnitude of suicidal ideation, attempts and associated factors of HIV positive youth attending ART follow ups at St. Paul's hospital Millennium Medical College and St. Peter's specialized hospital, Addis Ababa, Ethiopia. PLoS One[Internet]. 2019 [cited 2021 Mar 12];14(11):e0224371. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830816/ https://www.ncbi.nlm.nih.gov/pmc/article... ), 2019	Cross-sectional	413	B
Wang W(¹⁵15 Wang W, Chen X, Li S, Yan H, Yu B, Xu Y. Cusp Catastrophe Modeling of Suicide Behaviors among People Living with HIV in China. Nonlinear Dynamics Psychol Life Sci [Internet]. 2019 [cited 2021 Mar 01];23(4):491-515. Available from: https://pubmed.ncbi.nlm.nih.gov/31586499/ https://pubmed.ncbi.nlm.nih.gov/31586499... ), 2019	Cross-sectional	523	B
Mandell LN(¹⁶16 Mandell LN, Rodriguez VJ, De La Rosa A, Abbamonte JM, Sued O, Cecchini D, et al. Suicidal Ideation Among Adults Re-engaging in HIV Care in Argentina. AIDS Behav [Internet]. 2019 [cited 2021 Mar 01];23(12):3427-34. Available from: https://pubmed.ncbi.nlm.nih.gov/31049810/ https://pubmed.ncbi.nlm.nih.gov/31049810... ), 2019	Cross-sectional	360	B
Lu HF(¹⁷17 Lu HF, Sheng WH, Liao SC, Chang NT, Wu PY, Yang YL, et al. The changes and the predictors of suicide ideation and suicide attempt among HIV-positive patients at 6-12 months post diagnosis: a longitudinal study. J Adv Nurs [Internet]. 2019 [cited 2021 Apr 03];75(3):573-84. Available from: https://onlinelibrary.wiley.com/doi/10.1111/jan.13883 https://onlinelibrary.wiley.com/doi/10.1... ), 2019	Cohort (from June 2015 to October 2016)	113	A
Bengtson AM(¹⁸18 Bengtson AM, Pence BW, Mollan KR, Edwards JK, Moore RD, O'Cleirigh C, et al. The Relationship between Efavirenz® as Initial Antiretroviral Therapy and Suicidal Thoughts Among HIV-Infected Adults in Routine Care. J Acquir Immune Defic Syndr[Internet]. 2017 [cited 2021 Apr 03];76(4):402-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5659970/ https://www.ncbi.nlm.nih.gov/pmc/article... ), 2017	Cohort (between 2011 and 2014)	597	A
Kalungi A(¹⁹19 Kalungi A, Seedat S, Hemmings SMJ, van der Merwe L, Joloba ML, Nanteza A, et al. Association between serotonin transporter gene polymorphisms and increased suicidal risk among HIV positive patients in Uganda. BMC Genet [Internet]. 2017 [cited 2021 Apr 03];18(1):71. Available from: https://bmcgenomdata.biomedcentral.com/articles/10.1186/s12863-017-0538-y https://bmcgenomdata.biomedcentral.com/a... ), 2017	Cross-sectional	600	B
Liu Y(²⁰20 Liu Y, Niu L, Wang M, Chen X, Xiao S, Luo D. Suicidal behaviors among newly diagnosed people living with HIV in Changsha, China. AIDS Care [Internet]. 2017 [cited 2021 Apr 13];29(11):1359-63. Available from: https://pubmed.ncbi.nlm.nih.gov/28593797/ https://pubmed.ncbi.nlm.nih.gov/28593797... ), 2017	Cross-sectional	557	B
Egbe CO(²¹21 Egbe CO, Dakum PS, Ekong E, Kohrt BA, Minto JG, Ticao CJ. Depression, suicidality, and alcohol use disorder among people living with HIV/AIDS in Nigeria. BMC Public Health [Internet]. 2017 [cited 2021 Apr 07];17(1):542. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4467-5 https://bmcpublichealth.biomedcentral.co... ), 2017	Cross-sectional	1,187	A
Carrieri MP(²²22 Carrieri MP, Marcellin F, Fressard L, Préau M, Sagaon-Teyssier L, Suzan-Monti M, et al. Suicide risk in a representative sample of people receiving HIV care: time to target most-at-risk populations (ANRS VESPA2 French national survey). PLoS One [Internet]. 2017[cited 2021 Apr 03];12(2):e0171645. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0171645 https://journals.plos.org/plosone/articl... ), 2017	Cross-sectional	3,022	A
Kang CR(²³23 Kang CR, Bang JH, Cho SI, Kim KN, Lee HJ, Ryu BY, et al. Suicidal ideation and suicide attempts among human immunodeficiency virus-infected adults: differences in risk factors and their implications. AIDS Care [Internet]. 2016 [cited 2021 Apr 15];28(3):306-13. Available from: https://www.tandfonline.com/doi/abs/10.1080/09540121.2015.1093593 https://www.tandfonline.com/doi/abs/10.1... ), 2016	Cross-sectional	457	B
Mollan KR(²⁴24 Mollan KR, Smurzynski M, Eron JJ, Daar ES, Campbell TB, Sax PE, et al. Association between Efavirenz® as initial therapy for HIV-1 infection and increased risk for suicidal ideation or attempted or completed suicide: an analysis of trial data. Ann Intern Med. 2014;161(1):1-10. https://doi.org/10.7326/M14-0293. https://doi.org/10.7326/M14-0293.... ), 2014	Cohort (from 2001 to 2010)	5,332	A
Chikezie UE(²⁵25 Chikezie UE, Otakpor AN, Kuteyi OB, James BO. Suicidality among individuals with HIV/AIDS in Benin City, Nigeria: a case-control study. AIDS Care [Internet]. 2012 [cited 2021 Apr 17];24(7):843-5. Available from: https://pubmed.ncbi.nlm.nih.gov/22272812/ https://pubmed.ncbi.nlm.nih.gov/22272812... ), 2012	Case-control (March to May 2008)	300 (case n=150, control n=150)	B
McManus H(²⁶26 McManus H, Petoumenos K, Franic T, Kelly MD, Watson J, O'Connor CC, et al. Australian HIV Observational Database. Determinants of suicide and accidental or violent death in the Australian HIV Observational Database. PLoS One. [Internet] 2014 [cited 2021 Apr 15];19;9(2):e89089. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0089089 https://journals.plos.org/plosone/articl... ), 2014	Case-control (between January 1999 and March 2012)	81 (case n=27, control n=54)	B
Almeida SM(²⁷27 Almeida SM, Barbosa FJ, Kamat R, Pereira AP, Raboni SM, Rotta I, et al. HNRC Group. Suicide risk and prevalence of major depressive disorder (MDD) among individuals infected with HIV-1 subtype C versus B in Southern Brazil. J Neurovirol[Internet]. 2016 [cited 2021 Apr 5];22(6):789-798. Available from: https://pubmed.ncbi.nlm.nih.gov/27431676/ https://pubmed.ncbi.nlm.nih.gov/27431676... ), 2016	Cross-sectional	61	B
López JD(²⁸28 López JD, Shacham E, Brown T. Suicidal Ideation Persists Among Individuals Engaged in HIV Care in the Era of Antiretroviral Therapy. AIDS Behav [Internet]. 2018 [cited 2021 Apr 19];22(3):800-5. Available from: https://pubmed.ncbi.nlm.nih.gov/28063073/ https://pubmed.ncbi.nlm.nih.gov/28063073... ), 2018	Cross-sectional	648	B
Alderete-Aguilar C(²⁹29 Alderete-Aguilar C, Cruz-Maycott R, Candela-Iglesias M, Rodríguez-Estrada E, Reyes-Terán G. Assessment of depression, anxiety, hopelessness and suicidal risk in HIV+ inpatients. Salud Ment[Internet]. 2017 [cited 2021 Apr 15];40(1):23-28. Available from: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252017000100023 http://www.scielo.org.mx/scielo.php?scri... ), 2017	Cohort (from February to November 2013)	115	B

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[1] Corresponding author: Hugo Fernandes E-mail: hugoenf@yahoo.com.br