Retention in care and asoociated factors among adults living with HIV and severe mental illness at Butabika Hospital and Mulago ISS Clinic.

Abstract

Introduction; Uganda has made significant achievements along the HIV care cascade. However, for these gains to be sustained, there is need to tailor services to the different subpopulations of people living with HIV (PLWHIV) who may have unique needs. An estimated one in every 10 PLWHIV in Uganda has had a diagnosis of severe mental illness (SMI). Quality HIV services for this vulnerable group can be achieved through improved long-term retention in HIV care. This study sought to determine the proportion of retention in care and associated factors among PLWHIV with a known diagnosis of severe mental illness at Butabika National referral hospital and Mulago ISS clinic. Methods; A retrospective cohort mixed methods study was conducted on PLWHIV who attended Butabika National referral Hospital HIV care clinic and Mulago ISS clinic between 2017 to 2020 and had a documented diagnosis of SMI defined as any clinically diagnosed bipolar disorders, major depressive disorder, psychotic disorders, schizophrenia spectrum disorders & severe forms other non-substance abuse-related mental disorders. Data on sociodemographic and clinical aspects of the patients at ART initiation were collected by abstracting information from patient clinic charts to determine the proportion of retention in care. These data were augmented by in￾depth interviews (IDI) with stable PLWHIV with a history of SMI and key informant interviews (KII) with the health care providers for these patients to explore factors influencing retention in HIV care and reasons for Loss to follow up (LTFU) at six and twelve months after ART initiation. Multilevel mixed effects Poisson regression model and inductive thematic analysis were used to analyze quantitative and qualitative data respectively. Results; From November 2021 to January 2022, we abstracted data for 328 PLWHIV and SMI (177 from Butabika HIV clinic, 151 from Mulago ISS). Majority were female (68.6%), median age was 36 years (IQR=17), about three quarters were Christians (73.5 %) and almost half lived in Kampala district (49.1%). Most of the patients were in WHO clinical stage III (53.4%), were diagnosed with psychotic disorders (40.6%) and had no signs and symptoms of TB (70.7%) at ART initiation. Higher retention of 43.3% (95% CI: 38.0- 48.7) was observed at six months compared to 35.7% (95% CI: 30.7-41.0) at 12 months follow up in the two clinics. Having unsuppressed HIV viral load (>/=1000copies/ml) after six months of antiretroviral therapy (ART) (IRR=1.23, P=0.02) ,being aged 36 years and below (IRR=0.97, P<0.01), initial presentation through outpatient department (IRR=0.72, P=0.02), having signs and symptoms TB at baseline (IRR=0.97, P=0.03), staying in a radius of more than 30 Km from the clinic (IRR=0.91, P=0.02), having a documented clinical diagnosis of Bipolar disorder (IRR=0.96, P<0.01), or other mental disorders (Anxiety disorder and epilepsy) (IRR=0.90, P<0.01) as well as being in lower WHO clinical stage (stages II&II) (IRR=1.08, P=0.01) at ART initiation were significantly associated with retention in care at six (6) and twelve (12) months. Lack of social support, long waiting hours at the clinic, perceived stigma and discrimination, competing life activities like work and family, being of low socioeconomic status and poor adherence to mental health drugs were identified as psychosocial factors that influence retention in care. Conclusion; In this study only one third of PLWHV and SMI (35.7%) were retained in care at 12 months compared to the WHO set target of 90%. Low retention in care was associated with factors like age, place of residence, functional status, having signs and symptoms of TB and documented SMI diagnosis. On other hand, high retention in care was associated with factors like lower WHO clinical stage (I&II) and unsuppressed viral load. Addressing critical but feasible barriers such as poor social support, long waiting hours at the clinic, stigma and discrimination as part of integrated HIV and mental health care will go a long way in improving retention among PLWHIV and SMI as we target HIV epidemic control.