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times more likely to not use or occasionally use condoms, It also appears that depression is more common in patients
respectively, compared to those who were not depressed. with lower educational levels, those who are unemployed
and those who are overweight (BMI, > 25). Having a job and
Discussion sufficient income is one of the most important social factors
affecting health and has a significant impact on the mental
Whilst many studies have looked at the prevalence of state of individuals. Unemployment or low-income work
condom use in different populations, including PLWH, promote the cycle of poverty and limit access to healthcare. 30,31
research on condom use in people with mood disorders,
including depression, is very limited. Considering the Eighty-two per cent of depressed PLWH had poor sleep
importance of using condoms in PLWH in the prevention of quality. Poor sleep quality can lead to daily drowsiness,
the transmission of infection to others, as well as the mood swings, decreased quality of social interaction,
importance of the infected patients’ health, this study exacerbation of depression, anxiety and increased high-risk
evaluated the relationship between depression and condom behaviours. It is also a risk factor for mood disorders.
32
33
use in PLWH in Tehran. The results of the present study Downing et al. found that good sleep quality is associated
showed that less than 40% of the participants in the study with less depression and anxiety and more self-efficient
used condoms continuously, and almost 30% did not use condom use in PLWH. 34
condoms at all. A study conducted by Lotfi et al. on 121 HIV-
positive people in Karaj reported that about 60% of Lack of questions about the reasons for not using condoms in
participants had not used condoms during sexual intercourse patients is one limitation of our study, as identifying the
in the preceding 3 months. Similar studies in London and barriers to protective behaviour could play an essential role
14
Uganda reported a prevalence of condom use of 73% and in planning strategies to remove these barriers. Another
65% in PLWH, respectively. 23,24 The differences observed limitation is the use of face-to-face interviews for data
between Iranian and non-Iranian PLWH can be a result of collecting, which was challenging in some cases, given Iran’s
cultural differences, lower levels of education and lack of cultural, religious and social context. This may have led to
sufficient knowledge about the importance of continuous various biases (interviewer and reminder bias or bias of
and correct use of condoms amongst Iranian PLWH, social desirability). Thirdly, it was a cross-sectional study,
25
carelessness and lack of continuous access to condoms. and we could not evaluate the transmission of the virus to
Depression in PLWH is associated with unreliable condom sexual partners in the depressed and non-depressed patients.
use, with drug and alcohol misuse, poor adherence to Fourthly, we did not assess the patients’ viral load, which can
treatment, detectable viral load on ART, and high-risk sexual also affect the transmission of the virus to patients’ sexual
behaviour. Considering the high prevalence of depression partners. Fifthly, we used a questionnaire to see whether the
8,9
amongst Iranian PLWH and the sequelae of depression, there patients were depressed or not, which is another limitation of
is a need for interventions to address the depression problem our study as confirmation of depression by a psychologist
amongst Iranian PLWH. More than half of those living with could give a more accurate assessment.
HIV in the present study had depression. Only 19% reported
regular condom use. Wagner et al. evaluated the effects of Conclusion
ART and depression on condom use in Ugandan PLWH.
They found that over time, depression is accompanied in In this study, we evaluated the prevalence of depression in
24
PLWH by a reduction in the persistent use of condoms. An PLWH and its associations with sleep quality and condom
American study confirmed a relationship between depression use. The prevalence of depression in Iranian PLWH is
and the failure to use condoms in PLWH with uninfected relatively high, and interventions are needed to address this
partners. 26 problem. Furthermore, depressed PLWH have worse sleep
quality and use condoms less frequently compared to non-
depressed PLWH. Interventions to improve the sleep quality
In our study, depression was more common in men than in
women. Shadloo et al. evaluated the prevalence of and mood of PLWH may be valuable considering their
associations with condom use.
psychological issues amongst Iranian PLWH: mood
disorders, including major depressive disorder, were more Acknowledgements
prevalent in males than females (34.5% vs. 28.8%,
respectively). Pasdar et al. evaluated the association Competing interests
27
between dietary intake and depression in PLWH in Iran and The authors declare that they have no financial or personal
found depression to be more common amongst Iranian males relationships that may have inappropriately influenced them
living with HIV than females. In a systematic review and in writing this article.
28
meta-analysis, Rezaei et al. evaluated depression globally
amongst PLWH and noted a prevalence of 8% amongst
males. This was significantly higher compared to females. Authors’ contributions
29
Men clearly are at significant risk of depression, and test and All authors contributed to the design and implementation of
treat programs that care for PLWH need to address the issue the research, the analysis of the results and the writing of the
proactively. manuscript.

http://www.sajhivmed.org.za 172 Open Access