Clinical Scorecard: Impact of Mental Health and Substance Use on Tuberculosis Preventive Therapy Adherence Among Individuals With HIV

At a Glance

Key Highlights

• Depression symptoms were common (36%) and independently associated with 9% lower TPT adherence and reduced completion odds (OR 0.48).
• Anxiety symptoms, unhealthy alcohol use (34%), and tobacco use (27%) were prevalent but not independently linked to TPT adherence or completion.
• Participant narratives emphasized the negative impact of mental health on adherence and the need for integrated social and psychological support.

Guideline-Based Recommendations

Diagnosis

• Screen PWHIV initiating TPT for depression using PHQ-9 and anxiety using GAD-7.
• Assess alcohol use with AUDIT-C and substance use with ASSIST.

Management

• Refer patients with moderate to severe depression (PHQ-9 ≥10), anxiety (GAD-7 ≥10), or suicidality to social workers and psychologists for support.
• Implement integrated mental health and substance use interventions alongside TPT.

Monitoring & Follow-up

• Use electronic medication-event reminder monitors (MERM) to objectively measure TPT adherence.
• Regularly reassess mental health and substance use symptoms during TPT.

Risks

• Depression significantly increases risk of TPT nonadherence and noncompletion.
• Unhealthy alcohol and tobacco use are common but require further study for direct impact on TPT outcomes.

Patient & Prescribing Data

224 PWHIV on ART initiating 3HP TPT in South Africa

Only 50% completed TPT; depression symptoms were the strongest predictor of lower adherence and completion.

Clinical Best Practices

• Incorporate routine mental health and substance use screening into TPT initiation protocols.
• Provide targeted psychological and social support to patients with depression to improve TPT adherence.
• Utilize electronic adherence monitoring to identify and address nonadherence early.
• Recognize the high prevalence of mental health and substance use disorders among PWHIV and address these comorbidities holistically.

References

• World Health Organization End TB Strategy
• South Africa 2023 HIV and TB Guidelines
• Patient Health Questionnaire-9 (PHQ-9)
• Generalized Anxiety Disorder 7-item (GAD-7) Scale
• Alcohol Use Disorders Identification Test–Consumption (AUDIT-C)
• Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)