Depression and the revolving door of HIV care: using multistate approaches to understand complex longitudinal exposure/outcome relationships among a cohort of people entering HIV care in Cameroon from 2019 to 2020.

Introduction: Addressing the mental health needs of people with HIV is critical to ending the HIV epidemic. Yet, empirical evidence on the downstream consequences of poor mental health at entry into HIV care is scant, limiting our ability to deploy appropriate interventions. Multistate methods can provide a nuanced picture of how longitudinal care engagement differs between those with and without mental ill-health. Methods: From June 2019 to March 2020, we enrolled people with HIV aged 21+ entering HIV care at three clinics in Cameroon. We conducted structured interviews to ascertain demographics and depression status (Patient Health Questionnaire-9 scores>9=heightened depressive symptoms) at enrolment and extracted participant clinical record data through 1 January 2022. We estimated the proportion of individuals and time spent in six mutually exclusive and exhaustive care states: linked to clinic; engaged at clinic, prescribed antiretroviral therapy; disengaged from clinic; re-engaged at clinic; known death and known transfer out across the first 18 months following entry. Further, we explored re-engagement patterns among those who disengaged. Estimates were compared for those with vs without heightened depressive symptoms. Results: 420 people contributed 630.1 person-years of follow-up; 20% (n=84) had probable depression. A similar proportion of individuals with and without heightened depressive symptoms failed to return to the clinic after their first visit (~10%). However, those with heightened depressive symptoms were less likely to be continuously engaged in care at month 18 (prevalence difference=-14.3; 95% CI -27.0 to -2.3) and spent an average of ~40 fewer days (95% CI -78.4 to -1.2) engaged in care at their original clinic across follow-up compared with their counterparts. Of the 141 who disengaged from care, those with heightened depressive symptoms were less likely to be re-engaged 6 months later (prevalence difference=-10.2%; 95% CI -25.7 to 5.9). Conclusions: Routine depression screening and sustained support for people with HIV with heightened depressive symptoms are warranted to uphold these individuals' right to health and improve downstream outcomes.