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

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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Research reported in this publication was supported by the U.S. National Institutes of Health's National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute of Mental Health, the National Institute on Drug Abuse, the National Heart, Lung, and Blood Institute, the National Institute on Alcohol Abuse and Alcoholism, the National Institute of Diabetes and Digestive and Kidney Diseases and the Fogarty International Center under Award Number U01AI069924. AH was supported by an Ambizione fellowship (193381) from the Swiss National Science Foundation. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Aid for AIDS (AfA) HIV management programme has ethical approval to contribute data to the International epidemiology Databases to Evaluate AIDS (IeDEA). The Human Research Ethics Committee of the University of Cape Town, South Africa, and the Cantonal Ethics Committee Bern, Switzerland, authorised the analysis of the database. Beneficiaries of the medical insurance scheme or their guardians provided consent for their data to be used in research. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data were obtained from the IeDEA-SA. Data cannot be made available online because of legal and ethical restrictions. To request data, readers may contact IeDEA-SA for consideration by filling out the online form available at . Statistical code is available under .