Mental Illness Among HIV-Infected Sex Workers in India: Validating the HADS Instrument

Purpose: HIV-infected sex workers comprise a significant proportion of the 2.5 million people living with HIV/AIDS (PLWHA) in India. While research has documented the high prevalence of mental illness among PLWHA and the role it plays in HIV-related risk behaviors, few studies have examined mental illness among HIV-infected sex workers in India. This study addresses this gap in our understanding of mental health in this population by testing the validity of the Hospital Anxiety Depression Scale (HADS) in a sample of HIV-infected sex workers in Sonagachi, Calcutta. Moreover, we seek to illustrate how cultural factors influence the manifestation of psychiatric symptoms.

Methods: The HADS instrument was translated into Bengali and administered to 100 PLWHA selected randomly from attendees of an HIV clinic in Sonagachi in 2007. After determining that factors weren't significantly correlated using exploratory principal components analysis (PCA) with oblique rotations, exploratory PCA with orthogonal rotations was conducted. Factors with eigenvalues greater than 1 were retained.

Results: The instrument demonstrated very high reliability in this population (Cronbach's alpha = 0.83). However, results differed significantly from those of previous studies on HADS. Evidence for a 3 factor solution was found: the first corresponded to the original depression factor, while the next 2 comprise what we define as two forms of anxiety: ruminative and occupational impairment anxiety. The 3 factors accounted for 55% of the variance. Factor loadings ranged from 0.43 to 0.77 (p<.05 for all). Predictive validity was established through significant correlations between factors and measures such as age and alcohol use. Three subscales emerged, as opposed to the two original subscales. A subset of the original depression items loaded onto the depression factor. However, loss of interest in life (originally a depression item), as well as items measuring anxious thoughts loaded onto a second factor defined as ruminative anxiety. A loss of interest in appearance (originally a depression item), and items measuring abnormal motor activity loaded onto a third factor we call occupational impairment anxiety.

Implications: Cultural factors influence how psychiatric symptoms are manifested and modify how the HADS subscales need to be interpreted. We argue that abnormal motor activity and loss of interest in one's appearance which load onto the third factor, are experienced as impediments to successful engagement in sex work and are thus manifested as occupational impairment anxiety. The instrument is thus able to discriminate between the different types of anxieties experienced in the context of sex work.

Research indicates that loss of motivation to live in India is accompanied by anxiety about how one's family will survive after one's death. Given the way death is experienced culturally, motivation to live is not an indicator of depressed status. We believe that this cultural factor explains why loss of interest in life loads onto ruminative anxiety rather than depression.

The results indicate that HADS is an appropriate instrument to measure depression and anxiety in this population, as long as the interpretations of the subscales and their scores are appropriately modified