As the roll-out of antiretrovirals (ARVs) to people living with HIV/AIDS (PLWHA) continues to increase in South Africa, so too does the need to integrate mental health services into HIV care. In this editorial, we argue that the role of mental health in ARV programmes is central. The prevalence of mental disorders in PLWHA is higher than in the general population, and the impact of these conditions is substantial. Screening tools for mental disorders are both available and feasible. These should be incorporated into routine ARV care, with support from dedicated HIV mental health services.
In PLWHA there is growing evidence of an increased prevalence of mental disorders compared with the general population. For example, in a meta-analysis of 10 studies, major depression was nearly twice as common in PLWHA. (1) Similarly, in the HIV Cost and Services Utilization Study (HCSUS) conducted in the USA, (2) the prevalence of depressive, anxiety and substance use disorders in PLWHA was at least twice that reported in the NCS-R. In the HCSUS, the prevalence of alcohol and substance abuse combined was reported as 50.1%, while neurocognitive disorders affect as many as 30% of PLWHA, particularly in late stages. (3) Mental disorders found to be highly prevalent in a South African ARV clinic include major depression (34.9%), posttraumatic stress disorder (14.8%) and alcohol abuse (10.1%). (4)
In addition to these mental disorders, neurocognitive disorders (NCDs) are emerging as a new challenge in the era of ARVs. They often persist despite the use of ARVs, with consequent neurodegeneration. (5) NCDs, with the typical sub-cortical pattern, are being encountered increasingly in ARV clinic populations. Frank HIV dementia (HIV-D) may be occurring less frequently than before, but as the duration of illness increases with ARVs, it is now recognised that prevalences may actually be increasing. (6) Minor forms of NCD also occur, and with greater frequency than HIV-D. While these forms of neurological disease are less disabling, they nonetheless also result in a significant burden of disease. (5)
While it is known that NCDs are highly prevalent, and that minor forms are often not detected, a unique opportunity exists to address some of these questions. While all patients entering ARV care should be screened for NCD, the issue is whether or not individuals with CD4 counts greater than 200 cells/[micro]l and demonstrable neurocognitive impairment should be commenced on ARVs for their relative neuroprotective effects. How busy primary care clinics integrate this screening into routine care should be discussed and researched.
The impact of mental disorders on outcomes in PLWHA is now undisputed. They affect adherence, mortality and quality of life. (7) In addition, many mental disorders increase the probability of engaging in risk behaviours, (8) and are aggravated by or caused by ARV treatment. (9) In the context of the large numbers of PLWHA in South Africa who are infected and who access ARV care, this burden is substantial. South Africa has the largest number of people infected with HIV worldwide. (10) With South Africa deploying one of the more successful ARV roll-outs in the developing world, more than half of PLWHA in the Western Cape will receive ARVs. (11) These growing numbers of patients accessing HIV care have seen the rates of retention in care falling. Of the cohort commencing ARVs in 2005, 13.8% were no longer in care at 2 years. (11) Of this number, approximately 40% are people lost to follow-up (LTFU). LTFU is a crude proxy measure for poor adherence. Substance abuse and mental disorders are common reasons for poor adherence. (12)
With all of these conditions affecting large numbers of PLWHA, screening programmes for mental illness are increasingly being regarded as essential to HIV care. In South Africa, it is a requirement that patients enrolled onto ARVs receive some form of screening for both depression and alcohol abuse. …