Mental health, substance use and viral suppression in adolescents receiving ART at a paediatric HIV clinic in South Africa

Abstract

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.

Prevalence and factors associated with common mental disorders in young people living with HIV in sub‐Saharan Africa: a systematic review

“…Various screening tools based on different cut‐off scores were also used to measure depressive (Table 2) or anxiety symptoms (Table 3). These screening tools included the 9‐item patient health questionnaire [76] used in six studies [49,53,57,60,77, 78], the centre for epidemiologic studies depression scale [79] used in four studies [51,54,56,62], the child depression inventory [80] used in four studies [58,59,81,82], Beck’s depression inventory [83] used in three studies [48,61,84], the revised children’s depression rating scale [85] used by Kim et al . [28], the hospital anxiety and depression scale [86] used by Sale & Gadanya [47], Reynold’s adolescent depression Scale [87] used by Paul et al .…”

“…Twenty‐nine studies reported the prevalence of either major depression or depressive symptoms [45‐67,77,78,81]. Of these, seven studies [50,55,58,59,65,66,78] additionally reported the prevalence of anxiety or its symptoms. No study investigated the prevalence of anxiety or its symptoms as a stand‐alone mental disorder among YLWH.…”

“…Recent reviews from SSA involving YLWH provide an overview of some of these factors because of broadly covering multiple psychiatric disorders [13,14], focussing on only one correlate – ART adherence [14] or including HIV‐positive young people up to 19 years only [13,14]. In this review, 19 studies reported the correlates of either major depression [64], symptoms of major depression [65] or depressive symptoms among YLWH [28,48,49,53,54,56,58,61,62,66,67,69,77,78,81,82,84]. Of these, four studies concurrently investigated correlates of anxiety symptoms [58,66,69,78].…”

“…In this review, 19 studies reported the correlates of either major depression [64], symptoms of major depression [65] or depressive symptoms among YLWH [28,48,49,53,54,56,58,61,62,66,67,69,77,78,81,82,84]. Of these, four studies concurrently investigated correlates of anxiety symptoms [58,66,69,78]. One study [68] independently focused on the correlates of anxiety symptoms.…”

IMPAACT 2016: Operationalizing HIV Intervention Adaptations to Inform the Science and Outcomes of Implementation

“…The drivers of SRH for AYA-LWH are diverse and multi-level (6)(7)(8). One well-established determinant of SRH is mental distress, and 9-19% of adolescents (10-19 years of age) living with HIV reported elevated rates of mental health problems, including depression, anxiety, and trauma (9). Mental distress is implicated in poor ART adherence among AYA-LWH (10)(11)(12), minimal engagement in HIV care (13), and increased sexual risk taking, all of which contribute to low viral suppression and onward transmission of HIV (13).…”