The effect of multi-level HIV prevention interventions on common mental disorders among adolescents and young adults in rural South Africa

This study evaluated the effect of multi-level HIV prevention interventions delivered through DREAMS (Determined, Resilient, Empowered, AIDS-free, Motivated, and Safe) program on common mental disorders (CMD) among adolescents and young adults (AYA) in rural South Africa. We used longitudinal data from two cohorts of AYA aged 13-35 years (N = 2184 for cohort 1 and N = 3067 for cohort 2), recruited between May 2017 and December 2018, with data collected at baseline and follow-up surveys until 2019. Retention rates exceeded 75% in both cohorts. Multi-level HIV prevention interventions included individual-level services like HIV testing and counselling, and post-violence care, and community-level interventions such as social asset building, social protection, and school-based HIV education. Probable CMD was measured using a 14-item Shona Symptoms Questionnaire, with a score of ≥9 indicating CMD. We used inverse probability of treatment weighting adjusting for socio-demographics, food insecurity, experienced violence, sexual behaviour, HIV status and baseline CMD, to estimate the average effect of multi-level interventions on CMD, quantified as a risk difference (RD). Of the 3944 participants, 519 received no intervention, 1060 received community-level interventions, 814 received individual-level interventions and 1551 received multi-level interventions. The prevalence of CMD increased with age, reaching 27% among those aged <25 years. In the causal analysis, exposure to multi-level interventions relative to no intervention was estimated to increase CMD (RD = 4.59, 95% confidence interval (CI):1.61-7.78). Additionally, when comparing multi-level interventions to community-level interventions alone, community-level interventions were found to be protective against CMD among adolescent girls and young women in Cohort 1 (RD = 5.45, 95% CI:1.54-8.92), indicating a higher CMD risk in the multi-level intervention group. These findings suggest that multi-level HIV prevention interventions as currently delivered, may not meet mental health needs in vulnerable AYA. Mental health screening and care should be integrated into HIV services for early diagnosis and treatment of CMD.