Depression And Anxiety As Barriers To Art Initiation, Retention In Care, And Treatment Outcomes In Kwazulu-Natal, South Africa

Background: Since mental health may influence HIV care among people living with HIV (PLHIV), we sought to evaluate the impact of anxiety and depression on ART initiation and HIV-related outcomes.Methods: We conducted a prospective cohort study of PLHIV in the Umlazi Township of KwaZulu-Natal, South Africa. We measured depression using the Patient Health Questionnaire (PHQ-9) and anxiety using the Generalized Anxiety Disorder (GAD-7) scale, both of which have been validated in sub-Saharan Africa, among all patients prior to receiving a positive HIV test. We then followed those who tested HIV+ for 12 months to determine their time to ART initiation, missing clinic visits or refills, retention in care, hospitalization, and death. We used logistic regression models, adjusted for socio-demographic characteristics such as age and sex, to examine the effects of baseline measures of depression and anxiety on ART initiation and HIV treatment outcomes.Findings: Among 2,319 adult PLHIV, mean age was 33 years (SD=9.3 years), 57% were female, and baseline median CD4 count was 317 cells/mm(3) (IQR=175-491 cells/mm(3)). In univariate analyses, depression was associated with slower rates of ART initiation. In adjusted models, PLHIV with depression had lower odds of initiating ART within 90 days of HIV testing (aOR=0.60, 95% CI=0.46, 0.79, p<0.01), and lower odds of being retained in care (aOR=0.77, 95% CI=0.60, 0.99, p = 0.04). By the end of the 12-month study period, odds of ART initiation among PLHIV with depression were higher than the first 90 days but still significantly lower compared to those without depression (aOR=0.72, 95% CI=0.52, 0.99, p = 0.04). Among PLHIV who initiated ART, depression was associated with a lower odds of missing clinic visits (aOR=0.54, 95% CI= 0.40, 0.73, p<0.01). Anxiety was strongly correlated with depression (r = 0.77, p<0.01) and had similar effects on HIV-related outcomes.Interpretations: The presence of depression is a significant barrier to ART initiation and retention in care among adult PLHIV in South Africa. Mental health screenings around the time of HIV testing may help improve linkage and HIV-related outcomes. (c) 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)