Evidence grows on the link between adolescents’ mental health and viral suppression

26 January 2021

A study among teenagers living with HIV in Johannesburg finds 9% have a mental health issue – and are more likely to be virally unsuppressed than others

Young people hands up

A study among adolescents living with HIV on treatment in Johannesburg has found that those with mental health issues are more likely than others to be virally unsuppressed.

South Africa’s national HIV treatment guidelines recommend routine mental health screening as part of adherence support, but it is not always available in public sector antiretroviral treatment (ART) programmes. Despite growing evidence that mental health plays a part in people’s ability to adhere to treatment, the vast majority of people on ART who are living with mental health issues remain undiagnosed and untreated.

To examine the extent to which mental health affects adolescents’ likelihood of viral suppression, researchers carried out mental health screening of ART patients aged 10 to 19 attending Rahima Moosa Hospital in Johannesburg, South Africa between 2018 and 2020.

Around 1,000 of the 1,200 adolescents who went to the ART clinic were asked a set of pre-screening questions during each visit. Of these, just over a third (35%) gave answers that suggested they would benefit from full mental health screening, with older adolescents more likely to qualify.

Around 9% of those who were fully screened during the 2-year study had a mental health issue. This rate rose to almost one in five (19%) among 16 to 19-year-olds. In comparison, just 2% of those aged 10 to 12 had a mental health issue.

Depression was the most common issue, affecting around 4% of adolescents. Around 3% had suicidal thoughts, 3% had post-traumatic stress disorder (PTSD), 2% had anxiety, and just over 1% misused substances.

Three‐quarters of adolescents who had full mental health screening also had a viral load test. Just over one‐third (34%) had an unsuppressed viral load, compared to 17% of adolescents who were fully screened for mental health issues but did not have any.

Having depression or PTSD or engaging in substance misuse were particularly linked with having an unsuppressed viral load.

Having multiple conditions was common. For example, 45% of adolescents with depression also had anxiety, and 41% with depression also had PTSD.

There were no gender differences in the odds of having depression, suicidal thoughts, anxiety or PTSD, but adolescent girls were far less likely to misuse substances than adolescent boys.

Experiencing physical violence was associated with having suicidal thoughts, anxiety and PTSD. Experiencing household conflict was associated with depression.

All the adolescents who screened positive for a mental health issue were assessed by a senior doctor and a social worker. Of these, 16% received psychiatry, 28% were seen by a clinical psychologist, 41% went to peer support clubs, and 19% attended family-support meetings.

The study used screening tools that have not been specifically validated for use with adolescents living with HIV. This, and the fact that the rate of mental health issues found was relatively low, suggests some adolescents with mental health issues may have been missed.

Despite this, the findings provide further evidence of the link between good mental health and viral suppression. It also shows that mental health screening is possible in a public sector ART clinic in South Africa and that this a feasible approach for identifying and referring adolescents with mental health issues to a range of support services to meet their needs. 

Written by Hester Phillips