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. We followed participants for 12 months to determine their time to ART initiation, missing clinic visits or refills, retention, hospitalization, and death. We used Cox proportional hazards and logistic regression models, adjusted for socio-demographic characteristics, 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, 57% were female, and baseline median CD4 count was 317 cells/mm3. 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), slower ART initiation rate during the study period (aHR=0‧71, 95% CI=0‧62, 0‧ 82), and lower odds of being retained in care (aOR=0‧77, 95% CI=0‧60, 0‧ 99). 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). Anxiety was strongly correlated with depression (r=0‧77) and had similar effects on ART initiation and HIV-related outcomes. Interpretations: The presence of depression or anxiety are significant barriers 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. Funding: Infectious Disease Society of America Education & Research Foundation and National Foundation for Infectious Diseases (PKD); Massachusetts General Hospital Executive Committee on Research (PKD); the Harvard University Center for AIDS Research [AI060354] (PKD); the National Institute of Allergy and Infectious Diseases [AI108293, AI143351] (PKD). Declaration of Interest: We declare that we have no competing interests. Ethical Approval: The study was approved by the University of Washington’s Institutional Review Board (IRB #49563) and the University of KwaZulu-Natal’s Medical Research Ethics Committee (Protocol #BF052/13). All study participants provided written informed consent.