Impact of mental health on HIV-related outcomes in a South African township

HIV continues to be a significant public health concern in sub-Saharan Africa, with South Africa currently having the largest HIV epidemic. Additionally, there is a paucity of research exploring the potential effects of mental health on HIV-related outcomes in sub-Saharan Africa. Our objective was to better understand the impact of mental health on the course of HIV treatment and short-term clinical outcomes. We conducted a prospective cohort study among 1,878 HIV-positive adults from the Umlazi township of South Africa. We measured depression using the Patient Health Questionnaire (PHQ-9) and measured anxiety using the Generalized Anxiety Disorder (GAD-7) scale. Various multivariate regression models, adjusting for socio-demographic characteristics, were used to examine the effects of baseline depression and anxiety on several outcomes. Outcomes of interest included linkage to care and time to ART initiation, retention in care, treatment adherence, CD4+ cell count, HIV viral load, hospitalizations, and mortality. In adjusted models, depression was associated with a lower odds of being linked to care, defined as initiation antiretroviral therapy within 90 days of testing positive (OR=0.72, 95% CI=0.53-0.98, p=0.03), as well as a slower ART initiation rate throughout the one-year study period (HR=0.81, 95% CI=0.70-0.95, p<0.01). Although among those who initiated ART, depression was associated with a lower likelihood of missing medication refills (OR=0.66, 95% CI=0.43-0.99, p=0.04) and missing clinic visits (OR=0.58, 95% CI=0.43-0.80, p<0.01). Anxiety had a similar effect, with individuals who reported anxiety symptoms having a lower likelihood of missing clinic visits (OR=0.61, 95% CI=0.43-0.89, p<0.01). These results emphasize the need to identify barriers to HIV care initiation associated with poor mental health.