Mental health disorders such as psychological distress, as measured by depressive and anxiety symptoms, represent a growing public health challenge and are more prevalent in people living with HIV (PLHIV) than in the general population (1, 2). Globally, the pooled prevalence of psychological distress among PLHIV was estimated to be 28%, and between 10 and 34% in Sub-Saharan Africa (2). In South Africa, previous estimates of psychological distress among PLHIV vary substantially with higher rates ranging between 20 and 30% (2–4). These estimates highlight the significant impact of mental health challenges on PLWH.

Several studies have suggested a complex and bidirectional relationship between HIV infection and psychological distress. HIV infection can be a consequence of risky behaviors that are associated with poor mental health, or pre-existing mental illness that alters one’s behaviors (2–4). HIV diagnosis can also be unbearable leading to emotional and mental stress experienced due to shock, shame, fear and worry (2, 4–8). In addition, stigma, discrimination, and negative attitudes experienced by PLHIV contribute to psychological distress in this population group (5–8).

Despite significant advances that have been made in HIV treatment, coping with the reality of living long with a chronic illness like HIV remains a challenge (9). Psychological distress has been associated with treatment interruptions and sub-optimal adherence to ART, increasing the potential for virological failure, poor disease outcomes, and further spread of HIV (8, 9). Consequently, the goal of ending the HIV epidemic may not be achieved without addressing the significant mental health challenge among PLHIV (9). The general challenge is that a substantial proportion of PLHIV have existing mental disorders that are likely to go undetected and therefore untreated (7, 10).

PLHIV who are vulnerable to mental health conditions often face individual, structural, and social challenges to accessing and adhering to HIV prevention and treatment modalities (8). Evidence shows that increased vulnerability to poor mental health outcomes among PLHIV vary with socio-demographic and structural factors such as age, race, sex, poverty, low education, and unemployment (7, 8). Comorbid communicable diseases and noncommunicable diseases also contribute to poorer physical and mental health outcomes among PLHIV (8, 9). Experiences of enacted, perceived and internalized stigma among PLHIV contribute to psychological distress and exacerbate barriers to accessing adequate and sustained healthcare (5–8).

Evidence shows that contextual forces intersect with demographic, social, and structural factors in vulnerable communities to shape mental health outcomes among PLHIV (7–9, 11, 12). However, gaps in national level evidence and heterogeneous findings perpetuates an unintegrated health care system in many countries in sub-Saharan Africa (13). Consequently, this study is premised on linkages between persistent health disparities and multiple risk factors across varied contexts (14, 15). Guided by the theory of fundamental causes which recognizes multiple disease outcomes to a health condition; the influence of multiple risk factors; that resources can be used to avoid risks or to minimize the consequences of disease; and that the association between a fundamental cause and health are reproduced over time in the absence of intervening mechanism (16). This theoretical framework guided the analysis of the inter-relationships between HIV and psychological distress and associated background and socio-demographic factors.

Large-scale population-based studies are also needed especially in a high HIV-prevalence country like South Africa to influence policy change, and designing of service delivery models for implementation of integrated strategy at national level. This study investigated the prevalence of psychological distress and associated factors among HIV-positive and HIV-negative youth and adults 15 years and older who are aware of their serostatus using 2017 nationally representative population-based household survey.

This nationally representative survey revealed that the prevalence of psychological distress was considerably higher among HIV-positive youth and adults 15 years older who knew their status compared to their HIV-negative counterparts who also knew their status. A meta-analysis of studies comparing HIV-positive and HIV-negative samples showed that major depressive disorder occurred nearly twice as often among HIV-positive than HIV-negative patients (21). This is similar to global estimates and within the range of prevalence reported in sub-Saharan Africa among PLHIV (1, 3, 22). Overall, 24.7% levels of psychological distress were reported among PLHIV in this study. This is lower than 34.7 and 32.6% reported in other studies in South Africa (3, 4, 22). In other studies, heterogeneity in the prevalence of psychological distress has been partially attributed to different sampling methods, differences in the timing of the studies assessment tools and partly due to different population characteristics (1, 3, 22).

In the present study, the prevalence of psychological distress among HIV-positive individuals was significantly higher for those 50 years and older. This is similar to other studies that revealed that high levels of psychological distress stress were associated with older adults living with HIV (3, 4). Aging is associated with a decline in physical and cognitive abilities, which increases the risk of developing multiple chronic illnesses, including mental health disorders (23–25), and this is of particularly high concern among PLHIV (25). Therefore, older people with HIV need to get linked to HIV care and access mental health and other support services to help them stay healthy and remain engaged in HIV care (26).

The prevalence of psychological distress among HIV-negative individuals was significantly higher among females, Black Africans, the unemployed and those who reported experiences of physical IPV. In other studies, the observed differences have been associated with social stressors linked to gender and racial differences in socioeconomic resources (27). It has also been shown that gender plays an important role in explaining the incidence of intimate partner violence (28, 29). The final model suggests that unemployment was marginally associated with psychological distress in HIV-negative individuals. HIV-negative females remained associated with psychological distress in the final models. These observations suggest a continued need to address resource inequality related to gender, race, and unemployment to reduce mental health disparities among South Africans.

The prevalence of psychological distress among HIV-negative individuals was also higher among high-risk alcohol drinkers, and this variable was also retained in the final model. Alcohol use disorder often co-occurs with other mental health disorders, either simultaneously or sequentially (30). The most common mental health conditions that co-occur with alcohol use disorders are depression and anxiety (31). The findings reiterate the importance of harmful alcohol use as an urgent public health priority in South Africa. This highlights the need for comprehensive interventions targeting co-occurring alcohol use disorders and psychological distress.

Furthermore, those who rated their health as fair or poor had a higher prevalence of psychological distress, regardless of whether they were HIV-positive or HIV-negative. The final model also suggests that self-rated health may be an important predictor of poor mental health outcomes in both HIV-positive and HIV-negative individuals. Self-rated health has been used as a reliable, quick assessment tool for population health monitoring (32, 33). Other findings also suggest that measuring people’s subjective health can be a useful tool for assessing the risk of mental health issues in HIV-related care and support programs (8). However, evaluating this measure for use in such services is important.

In addition, the model suggests that psychological distress is associated with no education or low educational attainment among HIV-positive individuals, as observed in other studies (34, 35). On the contrary others found no association between educational status and general psychological distress (36). Lack of education or low educational attainment are indicators of poverty. Research indicates that those living with HIV in impoverished communities are disproportionately affected by mental health issues (37, 38). These observations underscore the importance of integrated HIV mental health interventions linked with poverty alleviation strategies in resource-limited settings (37, 38).

Furthermore, the final model indicates that psychological distress is significantly associated with living in urban areas among HIV-positive individuals. In South Africa, the HIV burden varies geographically and is highest in urban settings (13, 39). Evidence shows that the high levels of psychological distress may be linked to the persistently high level of HIV prevalence in urban settings (40, 41). This can be attributed to the collective hardship of poverty and unemployment in urban areas, combined with the high burden of HIV, and these factors can lead to increased psychological distress (13, 42). These observations suggest that the government should continue supporting policies that improve situational circumstances and address the unmet social and mental health needs, especially in highly HIV-burdened communities.

The study found that HIV-positive individuals who knew their status were more likely to experience psychological distress compared to those who were HIV-negative. The results showed that increasing age, low educational attainment and residing in urban settings increase the risk of psychological distress among HIV-positive individuals. In addition, psychological distress is influenced by gender and race-based disparities, including unemployment. Maladaptive behaviors such as alcohol abuse and IPV also contribute to psychological distress. Overall, the study emphasizes the importance of addressing alcohol use disorders and socio-structural inequalities like poverty, low educational attainment, and unemployment as critical factors associated with psychological distress in the study population. Based on the current findings appropriate screening and treatment for psychological distress should be considered for comprehensive HIV care. Therefore, integrating mental health services with HIV care and support program is necessary for reducing negative life events associated with psychological distress among PLHIV. Further research is needed on the impact of psychosocial and HIV-related factors on mental health of HIV-seropositive individual especially given the scaling up of ART.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

The studies involving humans were approved by the Human Sciences Research Council Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

NV: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. MM: Conceptualization, Formal analysis, Supervision, Writing – original draft, Writing – review & editing. TG: Writing – original draft, Writing – review & editing. LM: Writing – original draft, Writing – review & editing. SM: Funding acquisition, Writing – original draft, Writing – review & editing. NZ: Funding acquisition, Writing – original draft, Writing – review & editing. OS: Conceptualization, Writing – original draft, Writing – review & editing.