The treatment gap for mental disorders in adults enrolled in HIV treatment programmes in South Africa: a cohort study using linked electronic health records

Abstract

Aims Mental disorders are common in people living with HIV (PLWH) but often remain untreated. This study aimed to explore the treatment gap for mental disorders in adults followed-up in antiretroviral therapy (ART) programmes in South Africa and disparities between ART programmes regarding the provision of mental health services. Methods We conducted a cohort study using ART programme data and linked pharmacy and hospitalisation data to examine the 12-month prevalence of treatment for mental disorders and factors associated with the rate of treatment for mental disorders among adults, aged 15–49 years, followed-up from 1 January 2012 to 31 December 2017 at one private care, one public tertiary care and two pubic primary care ART programmes in South Africa. We calculated the treatment gap for mental disorders as the discrepancy between the 12-month prevalence of mental disorders in PLWH (aged 15–49 years) in South Africa (estimated based on data from the Global Burden of Disease study) and the 12-month prevalence of treatment for mental disorders in ART programmes. We calculated adjusted rate ratios (aRRs) for factors associated with the treatment rate of mental disorders using Poisson regression. Results In total, 182 285 ART patients were followed-up over 405 153 person-years. In 2017, the estimated treatment gap for mental disorders was 40.5% (95% confidence interval [CI] 19.5–52.9) for patients followed-up in private care, 96.5% (95% CI 95.0–97.5) for patients followed-up in public primary care and 65.0% (95% CI 36.5–85.1) for patients followed-up in public tertiary care ART programmes. Rates of treatment with antidepressants, anxiolytics and antipsychotics were 17 (aRR 0.06, 95% CI 0.06–0.07), 50 (aRR 0.02, 95% CI 0.01–0.03) and 2.6 (aRR 0.39, 95% CI 0.35–0.43) times lower in public primary care programmes than in the private sector programmes. Conclusions There is a large treatment gap for mental disorders in PLWH in South Africa and substantial disparities in access to mental health services between patients receiving ART in the public vs the private sector. In the public sector and especially in public primary care, PLWH with common mental disorders remain mostly untreated.

Diagnosis and treatment of opioid-related disorders in a South African private sector medical insurance scheme: a cohort study

“…The South African estimate is taken from household survey data and programmatic opioid treatment centre data. Our study estimate of 0.1% likely underestimates the true prevalence in this cohort because substance use and mental health disorders often remain undiagnosed and untreated (Demyttenaere et al, 2004;Ruffieux et al, 2021;Seedat et al, 2008). To understand the full extent of the opioid epidemic in South Africa, accurate data from all healthcare sectors are needed.…”

“…First, our study likely underestimates the incidence of opioid-related disorders because our case definition relied on diagnoses and treatment as proxies for opioid-related disorders. In South Africa, mental health and substance use disorders often remain undiagnosed and untreated (Ruffieux et al, 2021), and our definition of opioid-related disorders would miss individuals with undiagnosed and untreated opioid-related disorders. The stigma attached to substance use disorders (P.W.…”

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

“…Importantly, conclusions regarding access to mental health care cannot be generalised to patients accessing public sector HIV care programs. In a previous study, we showed that, in South Africa’s public sector, rates of ascertainment and treatment of mental disorders are much lower than in the private sector [35]. Interventions aimed at addressing the high burden of mental illness amongst people living with HIV are needed in both the public and private sectors in South Africa.…”

Symptoms of common mental disorders and adherence to antiretroviral therapy among adults living with HIV in rural Zimbabwe: a cross-sectional study

“…Early detection and effective management of mental disorders among people living with HIV may improve the quality of life of affected individuals, ART adherence and viral load suppression [17,18], thus reducing the incidence of HIV-associated complications, preventing drug resistance and HIV transmission. Despite these benefits, there is a large ‘treatment gap’ in mental health care among people living with HIV in low- and middle-income countries: most people affected by mental illness do not receive appropriate treatment [19,20].…”