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Open Access

Peer-reviewed

Research Article

Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

  • Yi-Tseng Tsai,

    Roles Writing – original draft

    Affiliations Department of Nursing, An Nan Hospital, China Medical University, Tainan, Taiwan, Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    ⨯
  • Sriyani Padmalatha K. M.,

    Roles Writing – original draft

    Affiliations Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Operating Room Department, National Hospital of Sri Lanka, Colombo, Sri Lanka

    ⨯
  • Han-Chang Ku,

    Roles Writing – original draft

    Affiliations Department of Nursing, An Nan Hospital, China Medical University, Tainan, Taiwan, Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    ⨯
  • Yi-Lin Wu,

    Roles Writing – original draft

    Affiliation Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    ⨯
  • Nai-Ying Ko

    Roles Writing – original draft

    nyko@mail.ncku.edu.tw

    Affiliations Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    ⨯

Abstract

Death by suicide is a major public health problem. People living with human immunodeficiency virus (PLHIV) have higher risk of suicidal behavior than the general population. The aim of this review is to summarize suicidal behavior, associated risk factors, and risk populations among PLHIV. Research studies in six databases from January 1, 1988, to July 8, 2021, were searched using keywords that included “HIV,” “suicide,” and “risk factors.” The study design, suicide measurement techniques, risk factors, and study findings were extracted. A total of 193 studies were included. We found that the Americas, Europe, and Asia have the highest rates of suicidal behavior. Suicide risk factors include demographic factors, mental illness, and physiological, psychological, and social support. Depression is the most common risk factor for PLHIV, with suicidal ideation and attempt risk. Drug overdosage is the main cause of suicide death. In conclusion, the current study found that PLHIV had experienced a high level of suicidal status. This review provides an overview of suicidal behavior and its risk factors in PLHIV with the goal of better managing these factors and thus preventing death due to suicide.

Citation: Tsai Y-T, K. M. SP, Ku H-C, Wu Y-L, Ko N-Y (2023) Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review. PLoS ONE 18(3): e0269489. https://doi.org/10.1371/journal.pone.0269489

Editor: Saeed Ahmed, Rutland Regional Medical Center, UNITED STATES

Received: October 23, 2021; Accepted: May 22, 2022; Published: March 20, 2023

Copyright: © 2023 Tsai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: we analysis data from published article therefore no data availability.

Funding: funding for this publication covered by An-Nan Hospital, China Medical University, Tainan, Taiwan (Grant No: ANHRF109-24). However, the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Death due to suicide is a major public health problem worldwide. According to the World Health Organization (WHO), approximately 700,000 people died worldwide due to suicide every year (an average of one death every 40 s) [1]. Suicide is a global phenomenon and can occur at any age. Acquired immunodeficiency syndrome (HIV) and human immunodeficiency virus (AIDS) is also a common public health issue, and currently there are more than 37.9 million people living with HIV/AIDS around the world [2]. The rate of suicide deaths in People living with HIV (PLHIV) is 100-fold higher than the rate that has been reported in the general population [3]. Prevalence estimates of suicidal ideation, attempts, and plans among people living with HIV/AIDS were more common and serious than those in the general population [4]. Suicide attempt rates among PLHIV with mental disorders and psychiatric treatment have continued to increase from the pre-highly active antiretroviral therapy (Pre-HAART) era (1988–1995) to the HAART era (1996–2008) from 27.8% to 35.1%, respectively [5].

Suicidal behavior is complex, with different levels of severity, ranging from suicidal ideation to suicide attempts and ultimately to the end of life by death due to suicide. Suicidal ideation is defined as thoughts, considerations, or plans to die by suicide, whereas suicide attempts are defined as failed attempts to die by suicide where the person survives [6–8]. That suicidal ideation is more common than suicide attempt and death by suicide, and the presence of suicidal ideation increases the risk of suicide attempt and death by suicide. The suggest a complex interrelationship between behavior and suicide attempts [8, 9]. Suicidal ideation is an important predictor of subsequent suicide attempts and dying by suicide [9, 10].

Suicidal behavior is a complicated process that ranges in degree of severity, from thinking about killing oneself (i.e., suicidal ideation) to doing it (i.e., suicide attempt and death by suicide). In the current study provided insights into the relationships among HARRT, depression, and suicidal status in PLHIV and evidence that depression played a mediating role in the association between suicide ideation and attempt. However, the relationship between these three-suicide behavior is unclear; for example, relationship between HARRT, and death by suicide or depression, and suicide attempts, therefore, this study will be a better feasibility to understanding relationship between these three-suicide behavior and could help prevent suicidal behavior in PLHIV, in whom suicide is a significant public health problem of HIV-infected adults. It is important to categorization of suicidal behaviors among PLHIV due to lack of overview of scope reviewing in this population, even suicide became significant life-threatening event in PLHIV [9].

In general, primary research studies consider only one or two suicidal behavior, such as only suicidal ideation or attempts, or both suicidal ideation and suicide attempts, within a single center or country. Some studies included specific at-risk populations like perinatal women, homosexual men, and prisoners with HIV. However, these studies did not involve all at-risk populations and their risk behavior [11–16]. In previous primary research, among PLHIV, poor social support, HIV stigma, mental disorders, and associated comorbidities were associated with increased suicide rates. Improvements in antiretroviral therapy have led to better survival rates in PLHIV; however, suicidal behavior remain a major health issue [17, 18].

Thus, exploring suicidal behavior using a wide range of global research studies is vital for primary healthcare professionals to plan early recognition of this and suicide prevention strategies. The aim of this review is to provide an overview of the rates of suicidal behavior and associated suicide risk factors among PLHIV. Detection of suicidal ideation and suicide attempts is important in planning early suicide prevention and optimizing HIV/AIDS management.

Materials and methods

This review has been registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY, Reg No: INPLASY202170033).

Search strategy

Literature was searched using the following six databases: Embase, Ovid MEDLINE, CENTRAL, Web of Science, Academic Search Complete, and Psychology & Behavioral Sciences Collection. This was done after meeting with a public health librarian (the author CJF) and two members of the research team to clarify goals and further define the selection criteria to develop the literature search strategy. This review included studies published between January 1, 1988 and July 8, 2021 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines [19].

English synonyms such as AIDS, T-lymphotropic virus, or human T-cell lymphotropic virus, type III human T-cell leukemia virus, type III lymphadenopathy-associated virus, LAV-HTLV-III, HTLV-III-LAV, type III infection, or HTLV-III infection were used in each database to identify suicidal behavior among PLHIV. We also used several control phrases from the Emtree and Medical Subject Headings (MeSH) databases. For Emtree, these included “Human immunodeficiency virus,” “Human immunodeficiency virus infection,” “suicidal behavior,” or “automutilation,” and “suicide,” and for MeSH, they included “HIV infections,” “HIV,” or “self-injurious behavior.” We supplemented the search results with the EndNote X9 bibliographical database, and the search results were manually screened, including the reference lists of relevant articles and previous systematic reviews to confirm the sensitivity of the search strategy (S1 File) [20].

Eligibility criteria

The inclusion criteria were as follows: (1) the studies provided primary data on the prevalence or incidence of suicidal ideation, suicide attempts, or suicides measured using validated assessment tools or coded medical report data within a population-based study; (2) the participants were aged ≥15 years; (3) the participants were diagnosed with HIV/AIDS; and (4) the report was an original, published article in English or Chinese. The following types of studies were excluded: (1) the study population did not include PLHIV; (2) those unrelated to suicide; and (3) case report and review studies.

Titles and abstracts were independently screened by three researchers based on the inclusion and exclusion criteria after automatically removing duplicates using EndNote X9. Then, the full text of the selected studies was reviewed independently by three researchers, with any disagreement resolved by a fourth researcher to avoid selection bias. Disagreements regarding article inclusion were resolved by discussion between all authors.

Quality assessment

All eligible studies were assessed for quality of evidence using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies Scale, which contains nine items and four responses (yes, no, unclear, and not applicable) [21]. Studies with a total score of 8 and above were considered to have high quality evidence and were included in this systematic review. Study quality and risk of bias were independently assessed by three researchers, with any disagreements resolved by a fourth researcher.

Data extraction

The authors YT and HC conceptualized the study and developed the research protocol. YT created the initial draft of the data extraction chart containing the study characteristics of interest a priori. YT, HC, and YL identified articles for full-text review. Full data extraction was then carried out independently on each article by YT, HC, and YL, and any disagreements were resolved through discussion with a fourth author. Data extraction was recorded on a standardized Excel sheet. The following details were listed: the name of the authors and the publication year, the name of the journal, country, setting, study design, sample size, included risk factors for suicide, available measurement tools, and prevalence of suicide ideation, suicide attempts, and completed suicide (Table 1).

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Table 1. Study characteristic of selected 193 studies.

https://doi.org/10.1371/journal.pone.0269489.t001

Qualitative synthesis

Qualitative synthesis was conducted using data extraction findings to explore the key themes within the selected studies. Three researchers independently conducted the qualitative synthesis on the baseline risk factors of the participants and suicidal ideation rate, suicide attempt rate, and completed suicide rate (Table 1). We created a structural model related to the consistent risk factors after final agreement among all authors.

Results

Study identification

After searching the six databases, 8,055 articles published from January 1, 1988, to July 8, 2021, were identified (Ovid Medline, 878; Embase, 2,123; CINAHL, 815; Web of Science, 2,450; Academic Search Complete, 1,357; Psychology & Behavioral Sciences Collection, 388; manual search, 44). After removing 3,205 duplicate articles, 4,850 articles were screened for the title and abstract. Of these, 1,954 met the inclusion criteria and they were eligible to be considered for reading in the systemic review. The remaining 2,896 articles were excluded for the following reasons: 1,716 did not mention HIV/AIDS; 820 did not mention suicidal behavior; 262 did not clearly assess the outcome variables; and 98 were not available in full text format. After quality assessment, 193 articles were included in this scoping review (Fig 1). All included studies were published as a full article in peer-reviewed journal.

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Fig 1. PRISMA style flow diagram included studies.

https://doi.org/10.1371/journal.pone.0269489.g001

Characteristics of the included studies

According to the WHO regions [22], 69 studies were performed Region of the Americas [9, 17, 20, 24–80], followed by 45 in Europe Region [5, 29, 31, 77–121], 45 in Africa Region [13, 18, 21, 126–164], 26 in Western Pacific Region [9, 165–190], 2 in the Eastern Mediterranean Region [191, 192], and 6 South-East Asian Region[9, 16, 168, 169, 171, 181] (Fig 2A). A total of 130 articles were published during the past 10 years (2011–2021) (Fig 2B).

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Fig 2.

A. Studies distribution according to world health organization (WHO) regions. B. Years of publications. C. Types of studies. D. Study setting.

https://doi.org/10.1371/journal.pone.0269489.g002

There were 121 studies conducted with cross-sectional study designs, 37 cohort studies, 24 retrospective studies, six longitudinal studies, three case-control studies, and two prospective studies (Fig 2C). According to the study settings, 88 studies were conducted in a hospital setting, 35 referenced databases, 64 were conducted in clinics or community centers, 4 were performed in prisons, and 2 were done at palliative care centers (Fig 2D).

107 articles used measurement tools to identify the condition of suicidal behavior and risk factors. There were 66 articles on suicidal ideation, 38 on suicidal attempts, 47 on completed suicide, 39 on suicidal ideation and attempts, 1 on suicidal ideation and death by suicide [95], and three on suicidal ideation, suicide attempts, and completed suicides [78, 79, 91]. Most of the studies evaluated risk factors; however, 23 did not mention risk factors (Table 1).

Epidemiology of suicidal behaviors among PLHIV

Suicidal ideation around the world.

The Pre HAART era from 1990 to 1996, suicidal ideation prevalence rate is 28.6 to 55% in United States [24, 27, 187, 188]; 50.5% in United Kingdom [79]; and 1.18% in Spain [78].

In the Post-HAART era, from 1997 to 2021, the suicidal ideation prevalence rate was 60% to3.3% in the United States [10, 20, 34–36, 39, 41, 43, 44, 45–49, 55, 63, 66, 68, 71, 74–76, 133]; 69% to 16% in the United Kingdom [80, 105, 112]; 13.2% to 6.3% in France [82, 85, 95, 106]; 9.2% in Greece [115]; 11.4% to 6.2% in Africa [13, 21, 125, 126, 130, 134, 135, 138, 154, 156]; 8.8% to 6.2% in Uganda [142–144, 147, 148, 153]; 34.7% to 35.3% in Nigeria [129, 145, 149, 157]; 35.6% to 21% in Argentina [75, 77]; 67% in Australia[195]; 50% in Brazil [16, 17]; 9.2% to 22% in Canada [50, 67]; 14% in Columbia [69]; 36% in Estonia [109]; 33.6% to 8.2% in Ethiopia [13, 139, 146, 190–192]; 14% in Nepal [174, 177]; 48% in the Netherlands [99]; 34% to 32.6% in China [9, 12, 164, 167, 174, 175, 178, 182, 183, 193]; 39.3% to 27.2% in Taiwan [13, 161, 176, 177, 179, 180]; 10% to 12.8% in Tanzania [155, 158]; to 23.3% in Indonesia [9]; 10.4% in Mexico [65]; 7.1% in Malawi [137]; 12.1% in Romania [92]; 56% in Russia [98]; 44% to 20% in Korea [173, 181]; 15.4% in Iran [186]; and 30.4% in Zimbabwe [159] (S1 Table).

Suicide attempts around the globe.

In the Pre-HAART era, from 1994 to 1996, the suicidal attempt prevalence rate was 21.8% to 42.8% in the United States [28, 160]; 21.4% in the United Kingdom [79]; and 4.02% in Spain [78].

In the Post-HAART era, from 1997 to 2021, the suicidal attempt prevalence rate was 21% to 16.9% in the United States [20, 37, 38, 43–45, 45, 53, 54, 56, 59, 64, 75]; 31% to 6.6% in the United Kingdom [80, 89, 91, 93, 96, 97]; 22% in France [120, 121]; 14% in Greece [115]; 72% in Spain [103]; 54% to 6% in Africa [123, 127, 135, 150, 151]; 17.4% to 13% in Uganda [124, 128, 132, 142–144, 152]; 9.3% to 2.3% in Nigeria [18, 129, 145, 149]; 27% to 85.2% in Australia [189, 194]; 18% in Brazil [62]; 10.3% to 5% in Canada [50, 67]; 9% in Columbia [69]; 20% in Estonia [109]; 17% in Nepal [169]; 34% in the Netherlands [99]; 17% in the Nepal [169]; 8% to 12.2% in China [164, 178, 179, 182, 193]; 26.7% to 9.7% in Taiwan [162, 165, 166, 176, 177, 179, 180]; 23% in India [181]; 36% in Russia [98]; 11% in Korea, 28% in Ukraine [118]; and 20.4% in Puerto Rico [58] (S2 Table).

Distribution of death due to suicide around the world.

In the Pre-HAART era, from 1988 to 1996, the completed suicide incidence rate was 680.56–4.9per 100,000 person years in the United States [23, 25, 30, 32, 195]; 0.5% in the United Kingdom [79]; 25% in the Sweden [77]; 0.47% in the Spain [78]; and 8.13% to 13% in the Netherlands [29, 31]. The death rate due to suicide went from 0.68 per 100 person-years in 1988 to 0.05 in 1996 in the United States [23, 25, 30, 32].

In the Post-HAART era, from 1997 to 2020, the completed suicide prevalence rate was 8.7% to 7.6% in the United States [17, 33, 47, 52, 70, 84, 86, 87]; 12.9% to 7% in the United Kingdom [88, 91, 102, 104, 107, 113]; 6% to 4.1% in France [81, 83, 95, 108, 111]; 1.48% in Greece [110]; 0.6%–1.3% in Spain [90, 117]; 4% to 6.2% in Germany [114, 136]; 6% to 1% [104, 105, 120]; 4% in Australia [196]; 7% to 8.2% in Canada [16, 61]; 7.8% in Japan [184]; 5.5% in Taiwan [163]; 15.5% in Thailand [168]; and 38.6% in Denmark [94]. The death due to suicide incidence rate went from 0.03 per 100 person years in 2010 to 0.47 in 2016 in Canada [16, 61], 0.16 per 100 person-years in Switzerland [5], and was 0.04 per 100 person years in 2015 to 0.02 in 2017 in UK [102, 107] (S3 Table).

Risk factors for suicide behavior among PLHIV

In this review, the identified causes of death by suicide included drug overdose, gunshot, jumping, drug poisoning, suffocation, and cutting wrists (Table 2). Additionally, we found that suicide-related risk factors included demographic, physiological, social, environmental, and psychological factors (Fig 3).

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Fig 3. Relationship of suicide type and risk factor among people living HIV as a model there are 5 variations in people living with hiv suicide model.

The factors are from risk factors in data which study suicide ideation, suicide attempt and completed suicide.

https://doi.org/10.1371/journal.pone.0269489.g003

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Table 2. Risk factors of suicide among people living with HIV.

https://doi.org/10.1371/journal.pone.0269489.t002

Among the demographic factors, there were inconsistent risk factors for suicidal behavior such as gender (male [5, 33, 34, 81, 90, 111, 120], female [41, 92, 105]), age (young age [13, 16, 75, 77, 113, 138, 164], middle age[10, 18, 80, 142, 178], older age [9]), sexual orientation, education level, In respect to specific psychological symptoms and disorders, depression, substance abuse, anxiety, intravenous drug use, post-traumatic stress disorder, major mood disorders, and mental disorders were found to be consistent suicide risk factors [21, 22, 56, 65, 68, 74, 78, 97, 102, 116, 132, 135, 138, 141, 145–147, 149, 154, 155, 157, 158, 159, 172, 173, 154, 187, 192]. Among the physiological factors were HAART side effects, poor immune status, physical symptoms, comorbid illnesses, insomnia, CD4 cell count, unmonitored viral load, neurocognitive developmental disorders, opportunistic infections, and medical status; an inconsistent risk factor was HIV exposure time. The social factors of quality of life, living alone, less coping self-efficacy, violence, bullying, incarceration, and bereavement were inconsistent risk factors for suicidal behavior. However, low social support was a consistent risk factor. Among the environmental factors, socioeconomic status, ethnicity, and having children were inconsistent risk factors; however, discrimination and religion [142, 149, 193] were consistent risk factors (Table 2 and Fig 3).

Measurement tools of the suicide behaviors suicidal behavior and risk factors

Within the included 193 studies, we found that 12 different scales were used to measured suicidal behavior and its risk factors; 26 studies used the Beck depression inventory scale, 8 used the Beck scale for suicide ideation, and 4 used the five-item brief symptom rating scale (Table 3).

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Table 3. Measurement instrument of suicide.

https://doi.org/10.1371/journal.pone.0269489.t003

Discussion

About 40 million people of the global population are currently living with HIV/AIDS. The era of HAART treatment has brought significant improvements in patient longevity and quality of life [202]; however, PLHIV experience a heavy burden of psychosocial conditions that are frequently undiagnosed and untreated. The pooled incidence of suicide completion among PLHIV globally was 10.2 per 1000 population, translating to a 100-fold greater suicide completion rate compared with the global population rate of 0.09/1000 population for 2019 [3, 203]. Therefore, this scoping review of 193 studies included an overview of three types of suicidal behavior among PLHIV as follows: suicidal ideation, suicidal attempts, and dying by suicides. We also included risk factors and associations of suicidal behavior according to demographic, social, physiological, psychological, and environmental factors. We identified consistent and inconsistent risk factors among the three types of suicidal behavior (Fig 3).

In total, this review encompasses 729,189 participants from 49 countries with all eligible articles published during the past 33 years (1988 to 2021). Two-thirds of the studies were published in the last five years (80/193). We found that there was an increasing trend toward conducting research related to suicidal behavior and risk factors among PLHIV globally.

Most studies were conducted in the United States or were performed by researchers from the United States conducting research in other countries, especially in Africa or developing countries (i.e., Nepal and Thailand). This is likely due to global funding strategies and continuing education programs conducted by United States universities along with partnership programs in other countries[14, 44, 75, 127, 129, 137, 138, 140–142, 144, 145, 154, 156, 157, 163, 186]. Most studies were conducted in hospitals and clinics. However, long-term observational data were extracted from databases as well, and of four studies conducted in prisons, three were in Taiwan [170, 171, 181], and one were in United States [73].

According to the findings of this review, the prevalence rate was highest in the United States, United Kingdom, Australia, and Russia for suicidal ideation, suicide attempts rate was highest in the United States, Australia, and Spain, and death due to suicide rate was highest in Denmark, and Thailand among PLHIV from 2000 to 2020. The highest suicide ideation rate was in the UK [84], followed by Australia [195], and the US [37]. The highest suicide attempt rate was in Australia [195], with the second highest in Spain [107], and third in South Africa [127]. The highest completed suicide rate was in Denmark [98], followed by Thailand [173], and France [112]. These findings may be since these countries have the most liberal laws on doctor-assisted suicide or gun control or could be due to economic recessions and societal pressure [26, 28, 204, 205]. These differences could be attributed to discrepancies in cultural differences, religious dimensions, and socioeconomic status, and not just by geographical location alone [4]. Previous research has identified psychological disorders and suicide are extremely connected and established in high-income countries, with many suicides occurring impulsively in moments of crisis with a breakdown in the ability to deal with life stresses. This review also found similar results[206, 207].

The most frequently used methods used of suicide are hanging and pesticide poisoning in Western countries[17, 26, 28, 30, 54, 80–83]. Reported risk factors for suicide attempts include mental and physical health problems, socioeconomic problems, and drug and alcohol use/abuse [208] According to our finding in when we considered about South-East Asian Region, most common suicide behavior is death due to suicide, compared with suicide attempts and suicide ideation. Because of educational status of family and social pressure also the social discrimination and stigma are more common in Asian countries than elsewhere in the world [206, 207].

Depression and suicidal thinking occur frequently alongside HIV/AIDS, triggering profound detrimental impacts on quality of life, treatment adherence, disease progression, and mortality [177, 209]. According to this scoping review, 85 articles dealing with depression, the most common death-related factor for PLHIV is suicide ideation, and their attempted suicide behavior risk is due to depression which is its common cause. Bullying, which includes stigmatization and discrimination, can also drive people to suicide as it increases social isolation. Substance abuse and overdose or severe physical disease are also recognized causes. According to this review findings, Caribbean countries and the Middle East showed the lowest death rates due to suicide.

This study is a global overview of suicidal behavior and associated risk factors among PLHIV. There are some important new findings in this review. First, our review provides both prevalence and incidence rates as well as risk factors for suicide ideation, suicide attempt, and death by suicide among PLHIV. Second, the current study includes findings from diverse populations of patients with HIV from 1988–2021, while previous reviews mostly focused on certain risk populations. Third, our study provides a group association and risk factors for suicidal ideation, suicide attempts, and death due to suicide. Therefore, we believe our findings suggest definite trends and factors that could prevent suicidal behavior among PLHIV, which future studies should examine further.

The limitations of this study were the lack of information regarding ethnic groups, cultural backgrounds, and religious perspectives of suicidal behavior and risk factors among PLHIV. Future studies should focus on these factors prospectively. Also, this large number of studies contained different type of confounding factors and it is difficult to control all confounding one time, however it will not influence to review findings because we would provide overview of suicidal behaviors only. Still did not make any causal relationship furthermore future study designed how to manage confounding such an incident if suicide actions. Also study quality is deferent to each study, not ranked study quality in terms of sample size, biases, etc. same as different scales/ measurement tools were used which also affects consistency in studies can consider some limitations.

Conclusion

This scoping review presents a global view of suicidal behavior in 49 countries and included 193 primary research studies. We found that the Americas, Europe, and some Asia countries have the highest rates of suicidal behavior also after free access of antiviral therapy and post-HAART era, there has been an increasing trend in suicidal behavior. Depression, low quality of life, low social support, substance use, and drug abuse are the most common risk factors for suicidal behavior. Our study lacks information on ethnicity, cultural background, and religious perspectives of PLHIV, and those need to be considered in future studies. This review provides an overview of suicidal behavior and risk factors for future healthcare development plans and prevention of suicide in PLHIV.

Clinical applications

This study will provide data on global suicidal ideation, suicide attempts, and completed suicide as well as the epidemiology and risk factors associated with completed suicides among people living with HIV. The findings of this review can be used as scientific evidence in the design of protocols and clinical practice guidelines intended to manage the wellbeing of PLHIV worldwide. It is also a reference for future researchers who plan to examine suicidal behavior and the risk factors among diverse populations. This study has practical implications for the management of people with HIV and preventing suicide at the global level. Given the high prevalence of suicide in high-risk populations such as people with HIV and the challenges related to preventing suicide, our study findings could support suicide prevention efforts by presenting the prevalence and incidence rates for suicide, as well as the associated risk factors among PLHIV.

Supporting information

S1 Table. Suicide ideation rate among people living with HIV.

https://doi.org/10.1371/journal.pone.0269489.s001

(DOCX)

S2 Table. Suicide attempt rate among people living with HIV.

https://doi.org/10.1371/journal.pone.0269489.s002

(DOCX)

S3 Table. Death due to suicide rate among people living with HIV.

https://doi.org/10.1371/journal.pone.0269489.s003

(DOCX)

S1 File. SRSearchForm.

https://doi.org/10.1371/journal.pone.0269489.s004

(DOCX)

S1 Checklist.

https://doi.org/10.1371/journal.pone.0269489.s005

(DOCX)

Acknowledgments

The authors thank all the other authors of the included studies.

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