Discussion
illness, depression, ’ loss of interest, anxiety
DISEASE
Our study compared the prevalence of depression and anxiety among people initiating ART in Tanzania before and during COVID-19, with the goal to better understand and respond to the changing needs of PLHIV in the wake of the COVID-19 pandemic. After adjusting for underlying population differences in selected confounders through inverse probability of treatment weighting, a rigorous quasi-experimental approach, we found that the prevalence of depression and anxiety symptoms among those starting ART in Shinyanga during the pandemic was much higher than in 2018. More specifically, we found significant temporal increases in the prevalence of feeling ‘a lot’ or ‘extreme’ loss of interest in things, hopelessness about the future, and uncontrolled worrying. We also noted substantial increases in the prevalence of depression and anxiety of 38 and 41 percentage points, respectively. Although this analysis cannot definitively rule out the role of chance or bias, including unmeasured confounding, in these findings, our study is an early signal of possible heightened mental health issues among PLHIV beginning lifelong HIV care in Tanzania.Our findings are consistent with other studies that show increased mental health illness among PLHIV during COVID-19. Evidence from three systematic reviews looking at the social and behavioral impacts of the COVID-19 pandemic on PLHIV in primarily high-income countries indicate higher levels of stress, anxiety, depression, and loneliness [This analysis had several notable strengths. The focus on ART initiates provides valuable information about potential COVID-related challenges during a crucial window that can shape an individual’s trajectory for engagement in lifelong HIV care. PLHIV are highly vulnerable at the start of HIV care, often experiencing clinical symptoms of disease, coping with the burden of integrating HIV into their identity and possible stigma, and often economically vulnerable if they have left the labor force [Despite this rigorous approach, we cannot causally attribute the observed decline in mental health status to COVID-19 impacts. Differences in symptoms of depression and/or anxiety could also stem from unmeasured confounders, including potential temporal changes other than COVID-19 affecting ART initiates in Shinyanga region, such as political and social change. However, these results are hypothesis generating and provide justification for future surveillance and cohort studies of mental health among PLHIV. Another limitation of this research was the use of different scales to assess mental health status in each period, and potential sensitivity of our findings to the cutoffs used to classify depression and anxiety according to each scale. For this reason, we focused our analysis on the three individual items that were measured similarly across scales. The consistency of our results using the individual indicators lends credibility to the findings from the overall scales. Furthermore, the cutoff values for depression and anxiety have been used and validated in other East African contexts [A substantial worsening of mental health among PLHIV, regardless of the causal role of COVID-19, is concerning for several reasons. First, mental health conditions like depression and anxiety have significant physical, social, and economic consequences on individuals, families, and communities, independent of HIV. Furthermore, when experienced by PLHIV, these conditions are known to undermine an individual’s ability to initiate HIV care [Fortunately, there are a host of evidence-based interventions to support the mental health of PLHIV. Evidence from low- and middle-income countries (LMIC) broadly support the use of psychological interventions over pharmacological interventions [