Editorial Depression in people living with HIV in sub-Saharan Africa: time to act Melanie Abas 1,2 , Gemma-Claire Ali 1,3 , Etheldra Nakimuli-Mpungu 4 and Dixon Chibanda 1,2 1 King’s College London Institute of Psychiatry, Psychology and Neuroscience, London, UK 2 Department of Psychiatry, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe 3 London School of Hygiene & Tropical Medicine, London, UK 4 Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda keywords Depression, HIV, sub-Saharan Africa, ART, adherence Introduction Sub-Saharan Africa remains the centre of the HIV and AIDS epidemic. As life expectancy increases for people living with HIV in the region, more attention is being paid to the impact of comorbid non-communicable disor- ders (NCDs) (WHO 2013). Much has been written about the importance of certain NCDs in people living with HIV – including cardiovascular disease, renal disease and certain cancers (Adebamowo et al. 2014; Bloomfield et al. 2014; Kalyesubula et al. 2014) – but too little attention has been given to the significant mental health burden. We argue that depression screening and treat- ment should be among the most important priorities for HIV care services in sub-Saharan Africa (SSA). We sup- port this by presenting evidence of the high prevalence of depression in people living with HIV in SSA, the nature and severity of disabilities associated with depression, the negative impact of depression on HIV progression and the cost-effectiveness of ‘best buy’ treatment options for depression (World Federation for Mental Health 2011). Prevalence of depression in people living with HIV in sub-Saharan Africa Depression is an important but neglected public health problem in sub-Saharan Africa. By depression, we are referring here to major depression or clinical depression, which is characterised by changes in mood, thinking, concentration, sleep, appetite, energy and in a person’s normal capacity to gain pleasure and motivation from life and the world around them. Diagnosis depends on a number of these symptoms being present consistently for at least a 2-week period, causing impair- ment in day-to-day activities and/or noticeable problems in relationships with others (APA 2013). The average prevalence of depression in SSA is roughly 5.5% (Ferrari et al. 2013), but it is higher in people living with HIV (Owe-Larsson et al. 2009; Breuer et al. 2011). Studies using good sample sizes and internation- ally accepted diagnostic criteria for major depression report a prevalence of around 8% among people living with HIV in SSA (Kinyanda et al. 2011; Gaynes et al. 2012). Even higher figures are reported in particular set- tings and population groups, for example post-natal mothers (Stranix-Chibanda et al. 2005; Adewuya et al. 2007; Chibanda et al. 2010; Nakimuli-Mpungu et al. 2011). Some of the excess depression prevalence found in people living with HIV can be explained by the chal- lenges of coping with diagnosis, disease symptoms, bereavement, relationship crises, social rejection, co-exist- ing poverty and the side effects of certain antiretrovirals (Gibbie et al. 2006). Inflammatory processes triggered by chronic stress, HIV infection itself or other HIV comor- bidities also contribute (Castelo et al. 2006; Lawson et al. 2011; Berk et al. 2013; Slavich & Irwin 2014). Studies conducted in high-income countries (HIC) suggest that depression may precede and even increase the risk of HIV acquisition (Sherr et al. 2011), making depression prevalence high among people living with HIV even before diagnosis or the onset of symptoms. In the later stages of AIDS, depression is a common reaction to living with deteriorating physical illness (Hughes et al. 2004; Mast et al. 2004; Nakimuli-Mpungu et al. 2011). Depression disability in people living with HIV Disability reflects the interaction between a person’s health impairments and the environment and society in which they live (WHO 2002). Disability is intrinsic to depression and its diagnosis. To be diagnosed with 1392 © 2014 John Wiley & Sons Ltd Tropical Medicine and International Health doi:10.1111/tmi.12382 volume 19 no 12 pp 1392–1396 december 2014