article · Journal of the International AIDS Society
Depression frequently undermines HIV care and prevention across eastern, central and southern Africa, but mental healthcare remains difficult to access. A mathematical modelling study adapted a validated transmission model for western Kenya to evaluate the health impact and cost-effectiveness of integrating depression screening and psychotherapy into healthcare services. Four approaches were tested: universal adult screening, co-screening alongside HIV testing, screening all antiretroviral therapy recipients, and screening only those on antiretroviral therapy with unsuppressed viral loads. Between 2025 and 2035, universal screening prevented the greatest burden of depression, new HIV infections and HIV deaths, costing 1,291 US dollars per disability-adjusted life-year averted. However, screening all antiretroviral therapy clients proved the most cost-effective option at 744 US dollars per disability-adjusted life-year averted, closely followed by screening patients with unsuppressed viral loads. Staged implementation focusing first on clinic-based HIV recipients offers an efficient pathway for improving health outcomes.
Depression significantly impedes adherence to HIV treatment and worsens health outcomes across sub-Saharan Africa. By establishing which depression screening strategies offer the greatest value for money, this research provides healthcare planners and funders with clear guidance on how to allocate limited budgets effectively, demonstrating that integrating mental healthcare into existing HIV programmes can alleviate both mental health and infectious disease burdens.
This modelling study informs public health programmes, healthcare providers and donor organisations planning integrated mental health and HIV services. While it does not introduce a commercial product, the evidence supports decision-making tools and phased service delivery frameworks for clinics in low-resource settings. The findings represent applied health economics research that is ready to guide health policy, clinical implementation guidelines and funding allocation for screening and psychotherapy programmes in public healthcare systems.
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INTRODUCTION: In eastern, central and southern Africa, HIV is a leading cause of mortality, and both HIV and depression contribute substantially to morbidity. Depression can impede effective HIV treatment and prevention, yet access to depression treatment remains limited. We estimated the impact and cost-effectiveness of scaling up depression screening and treatment to different population segments in western Kenya . METHODS: We adapted a previously validated HIV transmission model for western Kenya (EMOD-HIV) to include age- and sex-specific depression incidence, remission and recurrence. The model incorporated depression's effects on HIV risk; HIV testing and linkage to care; antiretroviral therapy (ART) adherence; and ART retention. We evaluated four depression screening and treatment scale-up strategies for adults aged 15+ years: (1) universal screening/treatment for all adults; (2) co-administering depression and HIV screening; (3) screening ART recipients; and (4) screening ART recipients with unsuppressed viral load. We assumed 62% depression treatment efficacy and calculated costs from the provider perspective, including US$3.35 for depression screening and US$20.32 per person for psychotherapy; future costs were discounted at 3%, and costs were varied in sensitivity analyses. We calculated incremental cost-effectiveness ratios as the cost (2024 USD) of depression screening and treatment per overall and HIV-related disability-adjusted life-year (DALY) averted. RESULTS: Without depression treatment, we projected 129,000 new HIV infections, 95,900 HIV-related deaths and 1.83 M depression episodes between 2025 and 2035. Universal screening had the highest impact, averting 29.3% (95% CI 29.2%-29.3%) of person-years lived with depression, 2.8% (95% CI 2.6%-3.1%) of HIV acquisitions and 1.4% (95% CI 1.3%-1.6%) of HIV deaths. The cost-effectiveness of universal screening and treatment was US$1291 per DALY averted (95% CI: $1288-1296). Screening ART clients was most cost-effective at $744 per DALY averted (95% CI: $730-760), followed by screening ART clients with unsuppressed viral load at $752 per DALY averted (95% CI: $710-799). Co-administering HIV and depression was dominated by other strategies. CONCLUSIONS: Integrating depression interventions into HIV care could substantially reduce both depression and HIV burden. Cost-effective scale-up could initially focus on individuals with unsuppressed viral load, then to all ART recipients, and finally expand to communities.
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DOI: 10.1002/jia2.70186
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