The Umeed cohort is one of the first prospective studies to examine the effects of psychological factors upon access to services during the important early stages of the continuum of care for HIV/AIDS. We hypothesised that screening positive for CMD or AUD, and having low scores on test of memory or verbal fluency would independently predict non-attendance for post-test counselling, and non-contact with the ART Centre (among those found to be seropositive for HIV). Those screening positive for any CMD were around half as likely to attend for post-test counselling. We also identified weaker evidence for an association between screening positive for alcohol use disorder and attendance for post-test counselling (AOR = 0 · 69, 0 · 45-1 · 03). CMD and alcohol use disorder had similar effects upon attendance for post-test counselling across HIV-positive and negative groups. Among the smaller sample of HIV-infected participants who had attended for post-test counselling (n = 183), planned analyses revealed no evidence of any association between CMD and attendance at the ART Centre. However, exploratory post-hoc analyses showed that people with symptoms of depression and anxiety were much less likely to attend the ART Centre compared to those with no symptoms. Symptoms of depression and anxiety were not associated with either obtaining a CD4 count or having a low CD4 count (where one was obtained). We found no evidence of any association between cognitive impairment and engagement with HIV services.
Determinants of receipt of diagnosis among those undergoing testing are under-researched. Studies in low and middle income settings have tended to focus upon demographic and HIV-related correlates of attendance [24–27]. The only studies to examine the effects of psychological factors upon attendance for post-test counselling were carried out in high income settings and focused mainly on substance use [28–30]. In a sample of people with severe mental illness no association was found between baseline psychiatric diagnostic category and attendance for post-test counselling .
Our post-hoc analyses suggest that it is important to consider the broader impact of symptoms of anxiety and depression upon access to care for HIV/AIDS beyond the clinically relevant diagnostic categories. Risk for non-attendance for PTC was concentrated among the 5 · 4% with clinically significant CMD, nearly a quarter of whom did not re-attend. However, among those who received a HIV diagnosis, attendance for assessment at the ART was substantially reduced among all groups with any anxiety or depression symptoms. Three-quarters of those referred to the ART Centre had some symptoms and more than a third of those with symptoms did not attend. The mechanism for these different risk thresholds could not be clarified but the impact of receiving a positive test result may be contingent upon pre-test mental state, together with other post-diagnostic factors that might lead to an increase in symptoms in this group, and/or unresolved anger, guilt, loss and denial [31, 32]. These possibilities warrant further investigation. It will also be important to test the effectiveness of targeted intervention during and after post-test counselling with the aim of increasing linkage to care.
Currently, there are few studies with which these post-hoc findings may be compared. In a US sample of people who had recently been diagnosed with HIV, depression was a borderline statistically significant predictor of not attending HIV treatment services within three months of follow-up (AOR = 2 · 00, 95% CI = 0 · 96-4 · 14) . The small amount of research on the relationship between mental health and linkage to care in low income settings has tended to focus on alcohol use rather than common mental disorder. In the STIAL study, a brief measure of psychological distress (the MHI-5), was associated with a small decreased risk in linkage to care (defined as obtaining a CD4 count, conditional upon registering at an ART centre). The threshold applied to the MHI-5 identified 55% of ART attendees as having psychological morbidity, suggesting that many would have been subclinical cases. Therefore, while caution is indicated in making inferences from post-hoc findings, there is some independent evidence that subclinical psychological morbidity may have a negative impact on linkage to care. Also, it should be noted that the associations in the US study and the STIAL study were for different segments of the care pathway; in the current study mental health was measured before diagnosis (the US study baseline assessment was within 90 days of diagnosis). Unlike STIAL, we found no association between depression or anxiety symptoms and obtaining a CD4 count, but, due to progressive attrition these analyses were underpowered.
Non-participation was a possible source of bias in Umeed: although 86% of those who were screened eligible agreed to take part, being Goan, having attained primary school education only and being Christian were all associated with refusal. Ethical considerations meant that it was not possible to obtain outcome data on people who had declined to participate. Although none of the demographic factors found to be associated with participation were associated with attendance outcomes, it cannot be guaranteed that bias did not arise. As clinic attendees who were “missed” for screening for eligibility -(usually at busy times in the clinic when all researchers were engaged with other participants) were likely to be missed at random, we would not expect those “missed” to bias our results.
Another potential limitation of the Umeed study is that the cognitive tests had not previously been used or validated in a younger adult Goan population, and education specific norms were derived from the youngest (60–64 year) age group from a previous study conducted in Goa and other sites in India . The high prevalence of apparent low cognitive functioning among Umeed participants is surprising given their broader and mainly younger age distribution. The test context (environmental distractions, and anxiety regarding the HIV test) may have impaired concentration and hence performance. The higher prevalence of impaired verbal fluency, but not memory impairment, among those who were HIV seropositive  was consistent with previous research  and supports construct validity. The fact that the high levels of cognitive impairment identified in the Umeed sample had no effect upon attendance at post-test counselling or linkage to care may suggest that the deficits identified were not severe enough to impact upon participants’ ability to understand and retain information given at time of testing, or to inhibit their ability to plan and execute their return visit.
The quantitative study design of Umeed and the fact that we measured mental health at a single time-point means that the mechanisms for the relationship between psychological factors and service use outcomes are unclear. Further observational, qualitative research is necessary to explore how mental health fits into the complex networks of concerns (stigma, illness/treatment beliefs etc.) that have been found to influence treatment-related behaviours and outcomes [36, 37].