Severe mental illness at ART initiation is associated with worse retention in care among HIV-infected Ugandan adults

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. Method 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 KaplanMeier 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 [2840] vs. 35 [3040], P = 0.03), sex (36% vs. 35% female, P = 0.86) and baseline CD4+ T-cell count (112 [54175] vs. 120 [48187] cells/mm3, P = 0.86). At 12 months after ART initiation, KaplanMeier estimates of continuous retention in care were 65% (95% confidence interval, CI: 3139%) among patients without SMI, vs. 47% (95% CI: 3955%) 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.