Antiretroviral therapy (ART) has increased the life expectancy of people living with HIV (PLWH), allowing them to live longer with this chronic medical condition [1, 2]. Consequently, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has established the 90-90-90 treatment targets , among which the second target is for 90% of diagnosed PLWH to be receiving ART. In line with the WHO, China renewed its national ART guidelines in 2016 , and ART coverage increased from 67% in 2015 to 80% in 2017 . After entering the “treat all” era [4, 6], ART coverage and effectiveness has increased sharply across countries [7, 8]. Recently, researchers have shifted their focus toward the next targets following viral suppression. The WHO has stated its vision as “zero new HIV infections, zero HIV-related deaths, and zero discrimination,” in a world where PLWH are able to live long and healthy lives . Ensuring healthy lives and promoting well-being have become additional goals of the existing treatment strategies. As a result, the UNAIDS added a fourth 90 target (i.e., ensuring that 90% of people with viral load suppression have good health-related quality of life) to the existing agenda .
Mental health problems (e.g., depression and anxiety) are among the most commonly reported comorbidities of HIV [11–13], affecting quality of life and wellbeing among PLWH [14, 15]. Unaddressed mental health problems have potentially severe clinical implications for PLWH. Evidence suggests that depression and anxiety are associated with low medical adherence , worse retention in HIV care [17, 18], and poor HIV-related outcomes (e.g., quality of life) [19, 20]. A meta-analysis has shown an overall prevalence of depression and anxiety of 33.6% and 28.4%, respectively, among PLWH on ART . Mental health problems have been found to be more prevalent among PLWH in low-and middle-income countries . In China, the prevalence of depression was reported as about 40% among PLWH on ART [22, 23]. Given these findings, the prevention and treatment of mental health problems may be an important element of HIV treatment and care.
A growing body of literature has demonstrated improved mental health status among PLWH after ART initiation. A longitudinal study in the United States showed that, compared to pre-treatment levels, the prevalence of depression decreased from 30–21% after one year on ART . It is possible that the benefits of ART are mediated via a reduction in inflammatory pathways that affect the risk of depression, such as the kynurenine pathway or tryptophan catabolism . ART may also indirectly affect mental health status among PLWH by reducing internalized stigma, increasing community support and access to primary care and psychological support services, and enhancing control of other comorbidities (e.g., tuberculosis and diabetes) [26, 27]. Previous studies have identified a number of factors that are associated with mental health problems among PLWH on ART, including gender , age , personal income level , marital status [22, 28], living arrangements , insurance , comorbidities , sleep quality , perceived stigma and discrimination [23, 28], and family support . However, most of these studies were cross-sectional and could not identify the predictors of mental health problems after PLWH start taking ART.
ART requires lifelong treatment, which brings both positive and negative experiences for users. On the one hand, ART brings significant clinical benefits for PLWH, such as improving physical health status, facilitating immune system recovery (e.g., higher CD4 cell counts), and slowing disease progression [31, 32]. There is also evidence that viral suppression by ART greatly reduces the risk of transmitting HIV to sexual partners [1, 2], potentially improving relationships between PLWH and their sexual partners. On the other hand, although advances in ART have largely reduced its side effects, recent studies have shown that about 25.0–53.3% of PLWH still experience severe side effects in their first year after ART initiation [33, 34]. Moreover, the daily regimen of ART is inconvenient for PLWH. For example, 25% of PLWH in eight high-income countries agreed that being tied to daily medication limited their day-to-day life, and 29% felt stressed by the need to take their medication at the right time every day . These experiences related to ART may also influence mental health among PLWH. Previous studies found that the side effects of ART, lowered CD4 cell counts, and AIDS-related symptoms after ART initiation were associated with depression and anxiety [22, 29, 30]. However, these studies were limited by their cross-sectional nature and the lack of inclusion of potentially relevant experiences of ART.
As far as we know, no longitudinal study has investigated ART-related experiences and how they predict mental health problems among PLWH. To address these gaps, this prospective cohort study measured ART-related experiences at Month 6 and mental health problems at Month 12 among a sample of PLWH in China who had initiated ART for the first time, and investigated whether ART-related experiences (Month 6) could predict mental health problems (Month 12) after considering potential confounders.