title: Severe mental illness at ART initiation is associated with worse retention in care among HIV-infected Ugandan adults.
abstract: OBJECTIVE
  The impact of severe mental illness (SMI) on retention in HIV care remains uncertain. We aimed to measure the association between SMI at antiretroviral therapy (ART) initiation and subsequent retention in care in HIV-infected Ugandan adults.
  
  
  METHODS
  We conducted cohort study of 773 patients who initiated ART between January 2005 and July 2009 at the Butabika HIV clinic in Kampala, Uganda. SMI was defined as any clinically diagnosed organic brain syndrome, affective disorder or psychotic disorder. We used Kaplan-Meier and Cox proportional hazards analysis to evaluate the association between SMI and retention in care.
  
  
  RESULTS
  The prevalence of SMI at ART initiation was 23%. Patients with SMI at baseline were similar to those without SMI in terms of age (median [IQR]: 35 [28-40] vs. 35 [30-40], P = 0.03), sex (36% vs. 35% female, P = 0.86) and baseline CD4+ T-cell count (112 [54-175] vs. 120 [48-187] cells/mm3, P = 0.86). At 12 months after ART initiation, Kaplan-Meier estimates of continuous retention in care were 65% (95% confidence interval, CI: 31-39%) among patients without SMI, vs. 47% (95% CI: 39-55%) among those with SMI (P < 0.001). All-cause mortality in the two groups was similar: 1.2% vs. 2.0% (P > 0.05). In multivariable analysis, the only baseline variable independently associated with breakage of continuous care was SMI (HR = 1.58, 95% CI: 1.06─2.33).
  
  
  CONCLUSIONS
  Severe mental illness at ART initiation is associated with worse retention in HIV care in this urban Ugandan referral hospital. As ART is scaled up across sub-Saharan Africa, greater attention must be paid to the burden of mental illness and its impact on retention in care.
authors.affiliation: Department of Medicine and Centre for Infectious Diseases, Stellenbosch University, Cape Town, South Africa. jnachega@jhsph.edu
authors.forename: Jean B
authors.initials: JB
authors.lastname: Nachega
authors.forename: Brian
authors.initials: B
authors.lastname: Mutamba
authors.forename: David
authors.initials: D
authors.lastname: Basangwa
authors.forename: Hoang
authors.initials: H
authors.lastname: Nguyen
authors.forename: David W
authors.initials: DW
authors.lastname: Dowdy
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Mills
authors.forename: Elly
authors.initials: E
authors.lastname: Katabira
authors.forename: Ethel
authors.initials: E
authors.lastname: Nakimuli-Mpungu
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D000367:Age Factors; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes; D002423:Cause of Death; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000401:mortality / Q000523:psychology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D055118:Medication Adherence / Q000523:psychology*; D001523:Mental Disorders / Q000150:complications* / Q000453:epidemiology; D019964:Mood Disorders / Q000150:complications / Q000453:epidemiology; D015999:Multivariate Analysis; D010352:Patient Dropouts / Q000523:psychology*; D015995:Prevalence; D016016:Proportional Hazards Models; D011618:Psychotic Disorders / Q000150:complications / Q000453:epidemiology; D012720:Severity of Illness Index; D012737:Sex Factors; D014454:Uganda / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents