Despite recent advances, South Africa remains one of the countries worst affected by the human immunodeficiency virus (HIV) epidemic. The United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 target in 2014, which aimed to diagnose 90% of HIV-positive people, provide antiretroviral therapy (ART) to 90% of diagnosed patients, and achieve viral suppression for 90% of treated patients by last year. Although South Africa has not yet met this target, the country has made significant progress in recent years.

According to UNAIDS, around 85% of people living with HIV (PLHIV) in South Africa are aware of their diagnosis. Despite this, progress on increasing the number of people who initiate ART and achieve viral suppression is lagging behind. A recent study by Truong and colleagues suggested that engagement with HIV treatment is lower among individuals with poor mental health. PLHIV are found to have a higher risk of poor mental health outcomes such as depression. Improving mental health awareness among the HIV-positive community in South Africa is vital to improving ART initiation and adherence, bringing South Africa a step closer to achieving its 90-90-90 target. If there are no efforts to increase awareness of poor mental health among PLHIV, GlobalData epidemiologists expect that the number of diagnosed prevalent cases of HIV on ART will decrease over the next five years.

The prospective cohort study, published in EClinicalMedicine by Truong and colleagues this year, took place in a South African clinic. Individuals attending the clinic between 2013 and 2017 were assessed, answered the Patient Health Questionnaire (PHQ-9) used to diagnose depression, and were subsequently tested for HIV. The 2,379 individuals who were found to be HIV seropositive were followed up for 14 months after diagnosis. Of the individuals who tested positive for HIV, 12.5% were diagnosed with depression. These individuals were less likely to initiate ART and attend clinics. As a result, depressed individuals had a much faster decline in CD4 count over the 14-month period compared to HIV-positive people who were not diagnosed with depression. This suggests that HIV-positive individuals with depression have poorer health outcomes.

In addition, the number of cases of HIV in South Africa’s adolescent population is among the highest in the world, with adolescent women being particularly vulnerable to the disease. A recent study by Roberts and colleagues, published in AIDS and Behavior, investigated the prevalence of mental health disorders among this group. As part of the prospective cohort study in the Eastern Cape Province of South Africa, 723 female adolescents were interviewed. The study found that depression occurred more frequently among HIV-positive adolescents when compared to women without an HIV diagnosis, especially if they were mothers or pregnant. The study also found that these women had increased exposure to poverty and domestic violence, which are risk factors for HIV and depression.

GlobalData epidemiologists forecast that there are more than 6,773,000 diagnosed prevalent cases of HIV and 5,527,000 diagnosed prevalent cases of HIV on ART in South Africa this year, which are expected to increase to 7,374,000 and 6,253,000 respectively by 2029 (as shown in Figure 1). This demonstrates that more than 80% of diagnosed prevalent cases of HIV will be on ART in South Africa by the end of this year. But with the lack of mental health awareness among PLHIV, GlobalData epidemiologists expect that the prevalent cases on ART may fall below current forecast estimates between now and 2029.

The negative outcomes associated with depression among PLHIV emphasise the importance of improving mental health services across South Africa. Although the capacity for mental health treatment across the country is currently limited due to a lack of training and shortages of primary health care workers, it is important that efforts are made to reduce the burden of HIV and depression. Integrating mental health screening into HIV testing protocols and encouraging same-day ART initiation could help improve initiation and retention to HIV care among depressed PLHIV. This would increase overall viral suppression, thereby helping South Africa meet its 90-90-90 target in addition to improving mental health diagnosis and treatment across the region.