Excess mortality associated with mental illness in people living with HIV in Cape Town, South Africa: a cohort study using linked electronic health records

Abstract

Summary Background Mental disorders can adversely affect HIV treatment outcomes and survival. Data are scarce on premature deaths in people with mental disorders in HIV-positive populations, particularly in low-income and middle-income countries. In this study, we quantified excess mortality associated with mental disorders in HIV-positive people in South Africa, adjusting for HIV treatment outcomes. Methods For this cohort study, we analysed routinely collected data on HIV-positive adults receiving antiretroviral therapy (ART) in Cape Town, South Africa between Jan 1, 2004, to Dec 31, 2017. Data from three ART programmes were linked with routine medical records on mental health treatment from Jan 1, 2010, to Dec 31, 2017, and mortality surveillance data from the South African National Population Register up to Dec 31, 2017. People living with HIV aged 15 years or older who initiated ART at a programme site were eligible for analysis. We followed up patients from ART initiation or Jan 1, 2010, whichever occurred later, to transfer, death, or Dec 31, 2017. Patients were considered as having a history of mental illness if they had ever received psychiatric medication or been hospitalised for a mental disorder. We calculated adjusted hazard ratios (aHRs) with 95% CIs for associations between history of mental illness, mortality, and HIV treatment outcomes (retention in care with viral load suppression [VLS; viral load <1000 copies per mL], retention in care with non-suppressed viral load [NVL; viral load ≥1000 copies per mL], and loss to follow-up [LTFU; >180 days late for a clinic visit at closure of the database]) using Cox proportional hazard regression and multistate models. Results 58 664 patients were followed up for a median of 4·3 years (IQR 2·1–6·4), 2927 (5·0%) of whom had a history of mental illness. After adjustment for age, sex, treatment programme, and year of ART initiation, history of mental illness was associated with increased risk of mortality from all causes (aHR 2·98 [95% CI 2·69–3·30]), natural causes (3·00 [2·69–3·36]), and unnatural causes (2·10 [1·27–3·49]), compared with no history of mental illness. Risk of all-cause mortality in people with a history of mental illness remained increased in multivariable analysis adjusted for age, sex, treatment programme, year of ART initiation, CD4 count and WHO clinical stage at ART initiation, retention in HIV care with or without VLS, and LTFU (2·73 [2·46–3·02]). In our multistate model, adjusted for age, sex, year of ART initiation, cumulative time with NVL, and WHO clinical stage and CD4 cell count at ART initiation, rates of excess all-cause mortality in people with history of mental illness were greatest in patients retained in care with VLS (aHR 3·43 [95% CI 2·83–4·15]), followed by patients retained in care with NVL (2·74 [2·32–3·24]), and smallest in those LTFU (2·12 [1·78–2·53]). History of mental illness was also associated with increased risk of HIV viral...

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

“…Mental disorders are associated with poor HIV treatment outcomes, including low adherence, lack of viral load suppression, loss to follow-up and mortality. [12][13][14][15][16] 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 HIVassociated complications, preventing drug resistance and HIV transmission. Despite these benefits, there is a large 'treatment gap' in mental healthcare among people living with HIV in low-income and middle-income countries: most people affected by mental illness do not receive appropriate treatment.…”

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

“…In 2019, there were 7.7 million PLWH in South Africa, over 5 million of whom were receiving antiretroviral therapy (ART) (Joint United Nations Programme on HIV/AIDS (UNAIDS), 2020 ). Mental disorders are highly prevalent among PLWH (Olley et al ., 2003 ; Freeman et al ., 2006 ; Myer et al ., 2008 ) and associated with suboptimal HIV treatment outcomes, and increased mortality (Uthman et al ., 2015 ; Haas et al ., 2020a , 2020b ).…”

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

“…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). Despite the efficacy of ART in maintaining viral suppression, poor medication adherence among AYA-LWH has made viral suppression difficult to achieve.…”