Title : Mental health and HIV treatment outcomes: The impact of depression on art adherence and viral suppression among women living with HIV in Sub-Saharan African nations
Abstract:
In recent years, remarkable progress has been made toward achieving the UNAIDS 95-95-95 targets for diagnosing, treating, and achieving viral suppression in individuals living with HIV. While African nations with historically high HIV prevalence have shown substantial gains, disparities persist, particularly among women. Between 2016 and 2022, viral suppression and ART uptake improved markedly across multiple countries, though significant barriers remain. Depression and other mental health challenges have emerged as critical barriers to ART adherence and viral suppression, disproportionately affecting women, possibly due to stigma, emotional distress, and limited social support. Integrating mental health services in other nations into HIV care programs has proven essential to address these challenges, however the presence of such programs is presently limited. This analysis compared the proportion of women achieving viral suppression (<200 HIV copies/mL) and >95% ART adherence between 2016 and 2022 in seven high-burden African nations, while examining depression's role in 2022 outcomes. The study included data from 7,078 women with confirmed HIV serology from seven high-burden African nations. ART adherence improved significantly across all nations: Eswatini rose from 79% to 91% (p<0.001), Tanzania from 62% to 81% (p<0.001), and other countries showed comparable gains. Viral suppression rates demonstrated similar improvements, with Uganda increasing from 59% to 82% and Zimbabwe from 64% to 88%. Multivariable logistic regression models were used to analyze the impact of depression on adherence and viral suppression among women living with HIV in these nations. Model covariates included distance traveled to clinics, education (completed primary school), urban residence, and household income. Country-specific analyses revealed significant variations: depressed women in Uganda showed 0.26 odds of ART adherence (95% CI 0.07–0.86) compared to non-depressed counterparts, while Malawi (OR 0.23; 95% CI 0.05–1.16) and Tanzania (OR 0.40; 95% CI 0.13–1.23) showed non-significant associations. Depressed women in Tanzania and Zimbabwe had 0.40 (95% CI 0.17–0.93) and 0.60 (95% CI 0.40–0.95) odds of being virally suppressed, respectively, compared to their non-depressed counterparts. Pooled analysis demonstrated that depressed women had 0.40 (95% CI 0.19–0.85) and 0.62 (95% CI 0.45–0.87) odds of adherence and viral suppression, respectively, compared to non-depressed women. Notably, higher education (OR 0.71; 95% CI 0.58–0.86) and urban residence (OR 0.62; 95% CI 0.49–0.78) were associated with reduced viral suppression in the pooled analysis. These findings underscore the need for integrated mental health support in HIV programs to address persistent disparities among women living with HIV, and highlight the complex relationships that exist between mental well-being, socioeconomic and cultural context, and adherence to HIV treatment. In light of new threats to broader prevention program funding, identifying high-risk groups to optimize limited public health resources has never been more crucial. Such measures could accelerate progress toward UNAIDS targets by addressing the mental health-adherence nexus in high-burden populations.
