For decades, the HIV epidemic has remained a significant global health challenge, with an estimated 38 million individuals infected globally. Sub-Saharan Africa accounts for 71% of the worldwide population of people living with HIV (1), with a prevalence rate of 1.4% in Nigeria, making it the third most HIV-burdened country (1). Moreover, 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 (2, 3).

More women have symptoms of depression in comparison to men, and this gendered pattern exists among people living with HIV (4–6). Women living with HIV (WLHIV), especially in low and middle-income countries (LMICs), experience significant psychological challenges, such as depression, stress, and anxiety, due to their HIV diagnosis (7, 8). Studies have also shown that WLHIV is susceptible to more severe mental illness symptoms such as depression, anxiety, and posttraumatic stress disorder (6, 9).

Pregnancy and postpartum periods are some of the most vulnerable periods that may contribute to symptoms of depression in women (10). The prevalence of depressive symptoms among pregnant women ranges from 11.4 to 40.0%, which is higher than that of women generally (11, 12). In a study conducted in Nigeria, the prevalence of postpartum depression was 35.6% (13), while in Kenya, 44.2% (14) was reported among other locations where similar studies have been conducted. Furthermore, as previously reported in a study, mothers who experienced preterm deliveries had 5.75 times higher odds of developing symptoms associated with depression and anxiety compared to mothers who carried their pregnancies to full term. This elevated risk can be attributed to the unexpected nature of premature childbirth, catching the mothers off guard and leaving them unprepared for the delivery at that specific moment (14). Women’s brains change structurally, psychologically, and behaviorally throughout pregnancy as they prepare for their new role as mothers (15). These changes, however, make pregnant women more prone to stress (16), which increases the likelihood of developing prenatal depression and stress symptoms (17).

Pregnancy can increase psychological susceptibility to WLHIV due to environmental factors, disclosure concerns, and HIV-related stigma (18). Studies conducted in LMICs have found that pregnant and postpartum WLHIV suffer from a high prevalence of depression and psychological stress (19–21). Similarly, a systematic review in Africa 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%, respectively (22). Depression is also associated with adherence to care and therapy among pregnant WLHIV (21), which may result in treatment failure and increased vertical HIV transmission (7). Psychological issues such as depression and stress may also adversely affect obstetric and neonatal outcomes and increase the risk of mother-to-child transmission (23).

Women, particularly in developing countries, are more likely to be exposed to risk factors such as poor socioeconomic status, making them more susceptible to perinatal depression (24). Depression and psychological stress may be critical barriers to HIV treatment and prevention as the conditions may be linked. In addition, women newly diagnosed with HIV during pregnancy and receiving a positive HIV diagnosis can generate worry and fear of transmitting the virus to an unborn child (25).

According to the Cohen and Wills Framework, the relationship between HIV-related stress and depression was assessed (26), focusing on the interplay between stress, social support, and their impact on an individual’s well-being. The authors introduced the buffering hypothesis, which suggests that social support can act as a protective factor against the adverse effects of stress on an individual’s mental and physical health (26). Hence, the framework explores how a strong social support system can mitigate the adverse consequences of stress, ultimately contributing to better overall psychological and physiological outcomes. This conceptual framework has been influential in understanding the role of social support in coping with various stressors and its implications for health and well-being (Figure 1) (26).

Pregnancy is a significant life change and can affect mental health, and the specific challenges WLHIV faces may exacerbate these effects. Therefore, it is essential to consider their holistic situation when providing care and support (20). Therefore, understanding the magnitude of depression and stress, as well as their associated factors, among perinatal WLHIV could provide important information that could aid in mitigating the poor mental health experienced by this group of women. This study is among the few studies investigating the prevalence of depression and psychological stress among WLHIV during pregnancy and the postpartum period in Nigeria. Thus, the study aims to determine the prevalence and factors associated with depression and psychological stress among WLHIV during their perinatal period in Ibadan, Nigeria, and to assess the relationship between HIV-related stress and depression among WLHIV.

This study determined the prevalence and factors associated with depression and psychological stress among WLHIV during their perinatal period in Ibadan, Nigeria. The study results show a prevalence of 63.9 and 79.9% for depression and stress, respectively, among the respondents (20, 33). 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%) (27), 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 12.27 among the pregnant and 14.41 among the non-pregnant respondents. This incident indicates moderate stress among WLHIV during the perinatal period. This finding is consistent with what was reported in another study in Nigeria, in which the mean perceived stress was moderate among the study population (31). 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 (32). Stress is a significant risk factor for depressive symptoms (34). Similar to other studies, it was found that women within the study sample who 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 WLHIV recruited from ART clinics. The study found that the status of the participants’ partners was significantly associated with depression and perceived stress. According to the study, participants who earned below 20,000 NGN 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, 35). The reason could be that in low-income countries, women are pressured to default academics for poverty-related factors, resulting in more prominent engagement in domestic work and the lack of access to health education and awareness. This factor 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 (36). In addition, pregnancy may decrease their employability and even their potential to work (21) because of the impoverished labor women may need to undertake (37).

This study also revealed that having a problem with previous pregnancy was a risk factor for depression among WLHIV. According to the study, pregnant women within their first (5–13 weeks) and third (29–40 weeks) trimesters have lower chances of developing depression. In contrast to other research that has found no link between gestational age and depression among women with HIV, our findings suggest that physiological changes during this stage may contribute to the onset of depression. Alternatively, the increased anxiety that women experience in the third trimester could also play a role (38, 39). This study indicates that problems in a previous pregnancy were significantly associated with the co-occurrence of depression and perceived stress. Our findings suggest that WLHIV who experienced complications in their previous pregnancy are twice as likely to report symptoms of depression and perceived stress compared to those who did not have such complications. This result could be because their complications were particularly severe and stressful for them. This result is consistent with previous studies highlighting a link between prior pregnancy complications and an increased risk of depression (40).

The prevalence of respondents with suicidal thoughts was examined, and the results indicate significant differences between those without depressive symptoms and those with depressive symptoms. Among respondents without depressive symptoms, a small proportion reported never having suicidal thoughts, while the majority experienced suicidal thoughts quite often. These findings are related to other studies conducted in Ethiopia (33), United States (41) and South Africa (42), which highlight the variability in the prevalence of suicidal thoughts among individuals with and without depressive symptoms. Most respondents with depressive symptoms did not report experiencing suicidal thoughts, which suggests that suicidal ideation may not be as prevalent in this population as anticipated (41, 42).

Further research is needed to understand the factors influencing the presence and severity of suicidal thoughts in individuals with depressive symptoms. Qualitative studies could provide valuable insights into the subjective experiences and contextual factors contributing to suicidal ideation. Such information would be crucial for developing targeted interventions and support systems to address the mental health needs of this population.

The study has several limitations that should be taken into consideration. Firstly, the sample used in the study was recruited from ART clinics, which may introduce sampling bias and limit the generalizability of the findings. The results may not represent all WLHIV in the general population who may not receive care at these clinics or be on ART. Secondly, the study design employed was cross-sectional, which hinders the establishment of causal relationships between the variables under investigation. A longitudinal study design would have been more suitable to determine the temporal relationship between perinatal depression, perceived stress, and associated factors. Thirdly, the study relied on self-report measures to assess depressive symptoms and perceived stress, which are subjective and prone to recall or social desirability bias.

Moreover, the study’s findings may have limited generalizability as it was conducted in a specific setting, namely Ibadan, Nigeria. Cultural, social, and economic factors unique to this context may have influenced the prevalence of depression and stress among WLHIV. Thus, caution should be exercised when applying these findings to other regions or countries. Lastly, the study solely relied on quantitative data, neglecting qualitative data that could have provided a deeper understanding of the experiences and perceptions of WLHIV regarding perinatal depression and stress. Incorporating qualitative data would have provided richer insights into the lived experiences of WLHIV and the contextual factors contributing to mental health outcomes.

Addressing these limitations in future research would enhance the findings’ validity, generalizability, and comprehensiveness, enabling a more nuanced understanding of perinatal depression and stress among WLHIV.

This study revealed a high prevalence of depressive symptoms among WLHIV during their perinatal period. Low income, previous pregnancy complications, and gestational stage were associated with depression and perceived stress. The findings highlight the need for integrating mental health services into routine HIV care to address the adverse outcomes associated with maternal and child health. Additionally, while the prevalence of suicidal thoughts was relatively low among respondents with depressive symptoms, further research is warranted to understand the complex interplay between depression and suicidal ideation. Comprehensive assessments and targeted interventions are essential to address the mental health needs of women living with HIV during the perinatal period.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

This study involving humans was conducted following the ethical principles of the Declaration of Helsinki. The study was approved by Ethics Committee of Lead City University, Ibadan (protocol code: LCU-REC/22/125) as well as from the Oyo State Ministry of Health Research Ethics Committee (protocol code: AD 13/479/44539). The study was conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article.

FA: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing – original draft, Writing – review & editing. OA: Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing. AL: Data curation, Formal analysis, Investigation, Methodology, Writing – original draft. SB: Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft. ZA: Data curation, Methodology, Writing – original draft. IA: Data curation, Methodology, Writing – original draft. MO: Data curation, Investigation, Methodology, Writing – original draft, Writing – review & editing. OO: Investigation, Methodology, Writing – original draft. AD: Data curation, Formal analysis, Investigation, Methodology, Writing – original draft. RS-A: Writing – original draft. AG: Data curation, Investigation, Methodology, Writing – original draft. DN: Data curation, Formal analysis, Methodology, Writing – original draft. AS: Writing – review & editing, Data curation, Investigation, Methodology, Writing – original draft. OE: Conceptualization, Data curation, Investigation, Validation, Visualization, Writing – review & editing.