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

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.