Life-years lost associated with mental disorders in people with HIV: a cohort study in South Africa, Canada and the United States

Abstract

Introduction: People with HIV (PWH) have a high burden of mental health disorders, which contribute to increased mortality due to elevated rates of physical illness, suicide or fatal accidents. Additionally, mental health disorders can adversely affect antiretroviral therapy (ART) adherence, leading to increased HIV-related mortality. This study aims to quantify the difference in mortality between PWH who have a mental health disorder and PWH without mental health disorders in South Africa (SA) and North America (NA).

Methods: This cohort study includes PWH aged 18 years or older who initiated ART between 2000 and 2021 at a national private-sector HIV programme in SA and 13 programmes in the United States and Canada. Mental health disorders were diagnosed according to ICD-10 codes F10-F99, which include psychotic disorders, bipolar disorders, depression, anxiety and substance use disorders. We estimated life-years lost (LYL) associated with mental health disorders, quantifying the average difference in remaining life expectancy between individuals diagnosed with a mental health disorder and those without such diagnoses.

Results: The study included 119,785 participants from SA (57.4% female, median age 39 years) and 142,044 from NA (85.0% male, median age 43 years). In SA, 57,999 (48.4%) were diagnosed with a mental health disorder, compared with 93,518 (65.8%) in NA. In SA, the LYL associated with any mental health disorder were 3.42 years (95% CI 2.42-4.28) in males and 2.95 years (0.67-5.95) in females. Corresponding figures for NA were 4.16 years (3.71-4.59) in males and 4.64 years (2.93-6.05) in females. In both regions, LYL were higher for psychotic and substance use disorders than for depression and anxiety. Losses were primarily due to natural deaths at CD4 counts ≥200 cells/µl, with considerable contributions at CD4 counts <200 cells/µl. Unnatural causes also contributed to the loss of life-years in males from SA and males and females from NA.

Conclusions: PWH affected by mental health disorders experience higher mortality, primarily from natural causes. LYL were associated with both immunosuppression and higher CD4 levels. Improved management of HIV and physical comorbidities among PWH affected by mental health disorders may enhance their prognosis.

Keywords: Canada; South Africa; USA; mental health disorders; mortality; substance use disorders.

Figure 1

Life‐years lost associated with mental health diagnoses. Note: Data are stratified by region and sex. The error bars represent 95% confidence intervals. Confidence limits with negative values are truncated at 0 in the figure.

Figure 2

Life‐years lost (LYL) due to specific causes of death associated with mental health diagnoses. Note: Data are stratified by region and sex. Negative LYL signify a longer lifetime among those with mental health diagnoses compared with those without. Data from North America are restricted to the study population with available cause of death data.

Figure 3

Life‐years lost (LYL) due to natural deaths associated with mental health diagnoses. Note: Data are stratified by sex, and the estimates are further disaggregated into four causes of natural death, based on the last CD4 cell count within a year of death. Negative LYL signify a longer lifespan among those with mental health diagnoses compared with those without. Data from North America are restricted to the study population with available cause of death data.