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

BackgroundMental disorders are common in people living with HIV (PLWH) but often remain untreated. We aimed to explore the gap in access to treatment (treatment gap) for mental disorders in adults followed-up in antiretroviral therapy (ART) programs in South Africa and disparities in access to mental health services. MethodsWe conducted a cohort study using ART program data and linked pharmacy and hospitalization data to estimate the 12-month prevalence of treatment for mental disorders (pharmacological or inpatient) and to examine factors associated with the rate of treatment for mental disorders among adults, aged 15-49 years, followed-up from January 1, 2012 to December 31, 2017 at one private care, two pubic primary care, and one public tertiary care ART programs in South Africa. We calculated the treatment gap for mental disorders as the discrepancy between the 12-month prevalence of mental disorders in PLWH (aged 15-49 years) in South Africa (estimated based on data from the Global Burden of Disease study) and the 12-month prevalence of treatment for mental disorders in ART programs. We calculated adjusted rate ratios (aRR) for factors associated with the rate of treatment of mental disorders using Poisson regression. Results182,285 ART patients were followed-up over 405,153 person-years. In 2017, the estimated treatment gap for mental disorders was 40.5% (95% CI 19.5%-52.9%) for patients followed-up in private care, 96.5% (95% CI 95.0%-97.5%) for patients followed-up in public primary care, and 65.0% (95% CI 36.5%-85.1%) for patients followed-up in public tertiary-care ART programs. Rates of treatment with antidepressants, anxiolytics and antipsychotics were 17 (aRR 0.06, 95% CI 0.06-0.07), 50 (aRR 0.02 95% CI 0.01-0.03), and 2.6 (aRR 0.39, 95% CI 0.35-0.43) times lower in public primary-care programs than in the private-sector ART program. InterpretationThere is a large treatment gap for mental disorders in PLWH in South Africa and substantial disparities in access to mental health service between patients receiving ART in the public vs. the private sector. In the public sector and especially in public primary care, PLWH with common mental disorders remain largely untreated.