Introduction Mental health problems are prevalent in adolescents living with HIV (ALHIV), often remain untreated, and may negatively affect antiretroviral therapy (ART) adherence and viral suppression. We implemented routine mental health screening at a paediatric ART clinic to improve the identification and management of mental health problems in ALHIV. In this report, we examine screening outcomes, associated patient characteristics and the odds of unsuppressed viral load in ALHIV screening positive for mental disorders. Methods Adolescents aged 10 to 19 years attending Rahima Moosa Hospital in Johannesburg, South Africa between February 1, 2018, and January 1, 2020, were offered mental health screening at each routine HIV care visit. The screening included four pre‐screening questions followed by full screening (conditional on positive pre‐screening) for depression (Patient Health Questionnaire‐9 [PHQ‐9]), suicide (Adolescent Innovations Project [AIP]‐handbook), anxiety (Generalized Anxiety Disorder‐7 [GAD‐7]), post‐traumatic stress disorder (PTSD) (Primary Care PTSD Screen [PC‐PTSD‐5]) and substance use (CAGE Adapted to Include Drugs [CAGE‐AID]). We assessed screening outcomes and calculated adjusted odds ratios for associations between positive screening tests at the first screen and unsuppressed viral load (>400 copies/mL) at the measurement taken closest to the date of screening, within hundred days before and one day after screening. Results Out of 1203 adolescents who attended the clinic, 1088 (90.4%) were pre‐screened of whom 381 (35.0%) underwent full screening, 48 (4.4%) screened positive for depression (PHQ‐9 ≥10), 29 (2.8%) for suicidal concern, 24 (2.2%) for anxiety (GAD‐7 ≥10), 38 (3.2%) for PTSD (PC‐PTSD‐5 ≥3), 18 (1.7%) for substance use (CAGE‐AID ≥2) and 97 (8.9%) for any of these conditions. Positive screening for depression (aOR 2.39, 95% CI 1.02 to 5.62), PTSD (aOR 3.18, 95% CI 1.11 to 9.07), substance use (aOR 7.13, 95% CI 1.60 to 31.86), or any condition (aOR 2.17, 95% CI 1.17 to 4.02) were strongly associated with unsuppressed viral load. Conclusions ALHIV affected by mental health problems have increased rates of unsuppressed viral load and need specific clinical attention. The integration of routine mental health screening in paediatric ART programmes is a feasible approach for identifying and referring adolescents with mental health and adherence problems to counselling and psychosocial support services and if needed to psychiatric care.

Adolescents living with HIV comprise a significant patient population in sub Saharan Africa but are poorly retained in care with consequent increased mortality and morbidity. We conducted in-depth interviews with 25 adolescents living with HIV engaged in care from five clinics in Johannesburg regarding their recommendations for the healthcare system. Findings included advocating for adolescent clinics, recognizing the importance of clinic-based support groups, valuing the influence lay counselors have in providing healthcare to adolescents, improving widespread education of vertical HIV transmission and meaningfully linking clinics to the community. Our study offers guidance to the differentiated care model recommended for adolescent treatment highlighting that a positive youth development approach and use of lay and peer counselors may act as cornerstones of this model. Serving the mental health needs of adolescents living with HIV in a responsive manner may strengthen their use of the system and elevate it to a source of resilience.

Introduction: There are few data on the prevalence of mental health problems among adolescents living with HIV in low- and middle-income countries and the evidence on associations between mental health problems and viral load suppression is inconsistent. We assessed the prevalence of mental health problems among adolescents receiving antiretroviral therapy (ART) at a large paediatric HIV clinic in South Africa and examined associations between mental health problems and viral load suppression. Methods: We implemented routine mental health screening at Rahima Moosa Mother and Child Hospital in Johannesburg. Adolescents aged 10-19 years were offered screening for depression (Patient Health Questionnaire-9 [PHQ-9]), suicide (Adolescent Innovations Project [AIP]-handbook), anxiety (General Anxiety Disorder-7 [GAD-7]), trauma (Primary Care PTSD Screen for DSM-5 [PC-PTSD-5]), and substance use (CAGE Adapted to Include Drugs [CAGE-AID]) at each routine HIV care visits. We assessed screening outcomes between February 1, 2018, and January 1, 2020 and calculated odds ratios for associations between positive screening outcomes and unsuppressed viral load (>400 HIV-RNA copies/ml). Results: Out of 1,203 adolescents who attended the clinic, 1,088 (90.4%) were screened at a median age of 13 years (IQR 10-15). In total, 97 (8.9%) screened positive: 48 (4.4%) for depression (PHQ-9 ≥10), 29 (2.8%) for suicidal concern, 24 (2.2%) for anxiety (GAD-7 ≥10), 38 (3.2%) for trauma (PC-PTSD-5 ≥3), and 18 (1.7%) for substance use (CAGE-AID ≥2). Positive screening for depression (aOR 2.39, 95% CI 1.02-5.62), trauma (aOR 3.18, 95% CI 1.11-9.07), substance use (aOR 7.13, 95% CI 1.60-31.86), or any mental health condition (aOR 2.17, 95% CI 1.17-4.02) were strongly associated with unsuppressed viral load. Conclusions: HIV-positive adolescents who are affected by mental health or substance use problems are a highly vulnerable population, who merit specific clinical attention. Strategies for screening and management of mental health and substance use problems in adolescents on ART in low- and middle- income countries need to be developed and evaluated.

These guidelines are intended as a reference document to assist HIV nurse and doctor clinicians in managing mental health disorders. It is intended to improve awareness, knowledge and capacity to support patients living with HIV and mental health disorders.

Integrated Access to Care and Treatment (I ACT) for adolescents is an educational support group initiative conducted monthly by trained healthcare providers (counsellors/health promoters). It follows a defined educational curriculum of six topics including, HIV/AIDS, disclosure, sexual and reproductive and mental health. Qualitative assessments, conducted midway of I ACT implementation at four primary healthcare facilities in North West province, South Africa, aimed to explore the perceptions of healthcare providers and the experiences of adolescents living with HIV (ALHIV). Face-to-face interviews were conducted with healthcare providers (n = 4), Facility Managers (n = 4) and ALHIV 15-19 years (n = 15). Interviews were recorded, transcribed, translated, verified and a content analysis performed. ALHIV reported the benefit and educational value of I ACT support groups. Healthcare providers shared their experience with initiating the groups and Facility Managers highlighted implementation challenges. In this study I ACT for adolescents supported ALHIV needs and promoted engagement with healthcare providers and peers. Sustaining I ACT for adolescents will require additional health system strengthening like provision of human and material resources.