Mental health, longitudinal ART adherence, and viral suppression among adolescents and adults living with HIV in South Africa: a cohort study

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Abstract
Introduction: Mental disorders are highly prevalent among people living with HIV and are associated with adverse HIV treatment outcomes. We assessed HIV treatment outcomes in patients with and without mental health diagnoses by sex and age. Methods: Using hospital, outpatient and pharmacy claims and laboratory data from 2011 to 2020, we followed HIV-positive adolescents and adults aged ≥15 years who enrolled in a South African private sector HIV treatment programme. We performed a longitudinal trajectory analysis to identify patients with similar adherence patterns and examined associations between mental health diagnoses and adherence patterns using multinomial logistic regression. We examined non-adherence and viral non-suppression (VNS, viral load >400 copies/mL) in patients with and without mental health diagnoses by sex and age using mixed-effects Poisson regression models. Results: 54,378 patients were followed for a median of 3.5 years (IQR 1.9-6.4), 20,743 (38%) of whom had received a mental health diagnosis. 90% of patients had HIV viral load <400 copies/mL, 73% had continuously high adherence, 13% had decreasing adherence, 6% had increasing adherence, and 7% were continuously non-adherent. Mental health diagnoses were associated with decreasing adherence (aRR 1.41, 95% CI 1.28-1.55), increasing adherence (aRR 1.59, 95% 1.41-1.79), and continuous non-adherence (aRR 2.02, 95% 1.81-2.25). The risk of VNS was increased among patients with organic mental disorders (aRR 1.55, 95% CI 1.22-1.96), substance use disorders (aRR 1.53 95% CI 1.19-1.97), serious mental disorders (aRR 1.30, 95% CI 1.09-1.54), and depression (aRR 1.19, 95% CI 1.10-1.28) compared to patients without mental health diagnoses. The risk of VNS was also increased among men (aRR 1.48, 95% CI: 1.31-1.67), adolescents (15-19 years, aRR 2.72, 95% CI 2.29-3.24) and young adults (20-24 years, aRR 2.29, 95% CI 1.83-2.85) compared to adults aged 25-34 years. Adolescents and young adults with and without mental health diagnoses had low viral suppression rates (≤66%); women aged 45 or older with mental health diagnoses had suppression rates of 92-95%. Conclusion: Our study highlights the need for psychosocial interventions to improve HIV treatment outcomes, particularly for adolescents and young adults, and supports strengthening mental health services in paediatric and general HIV treatment programs.
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