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Abstract
Introduction Adolescents living with HIV/AIDS in sub-Saharan Africa have heightened risk for mental health and psychosocial burden owing to their exposure to a multiplicity of adverse conditions such as stigma and discrimination. However, there is no comprehensive evidence synthesis and evaluation of the effectiveness of mental health interventions for adolescents living with HIV/AIDS in this region. We aim to conduct a systematic review to synthesise the literature on existing mental health interventions for adolescents living with HIV/AIDS in sub-Saharan Africa.
Methods and analysis This review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses reporting guidelines. Eligible studies will include those investigating the effectiveness of psychosocial, psychological or other forms of interventions on mental health outcomes, conducted in sub-Saharan African countries and involving adolescents (aged 10–19 years) living with HIV/AIDS. Comprehensive searches will be conducted in electronic databases (PubMed, MEDLINE, CINAHL, Scopus and PsycINFO) and grey literature sources. The search will be restricted to studies published from 2004 onwards and in the English language. Study authors will be contacted, and reference lists of retrieved articles will be reviewed for additional papers. Study selection and data extraction will be performed by two independent reviewers, with any disagreements resolved by consensus or involving a third party. A narrative synthesis will be conducted, and if possible, meta-analyses will be performed to estimate the overall effect sizes of interventions on mental health outcomes. Eligible studies will undergo quality assessment using standardised criteria appropriate for each respective study design.
Ethics and dissemination No primary data collection will be undertaken; therefore, no ethical approval is required. The findings of this review will be disseminated through publication in a peer-reviewed journal and presented at relevant conferences.
PROSPERO registration number CRD42024538975
- Adolescents
- Depression & mood disorders
- Anxiety disorders
- Suicide & self-harm
- MENTAL HEALTH
- HIV & AIDS
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The review includes a comprehensive search strategy across multiple databases and grey literature sources.
The review will employ a systematic study selection and data extraction process with two independent reviewers.
The reporting will follow appropriate Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, ensuring transparency, reproducibility and compliance with systematic review standards.
There is potential for substantial heterogeneity among the studies, due to varied settings, interventions and study designs.
Inclusion is limited to studies reported in English.
Introduction
The HIV/AIDS epidemic continues to be a significant public health challenge in sub-Saharan Africa (SSA), disproportionately affecting vulnerable populations, including adolescents. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), approximately 4.8 million young people aged 10–24 years were living with HIV in 2021, with over 80% residing in SSA.1 Adolescents living with HIV (ALHIV) experience a high prevalence of mental health challenges, such as anxiety, depression and suicidal ideation, underscoring the urgent need for mental health support across the SSA region.2–5 A systematic review of studies conducted in SSA reported that 25% of ALHIV screened positive for psychiatric disorders, with 30%–50% exhibiting emotional or behavioural difficulties or significant psychological distress.3 Notably, the distribution of mental health burden varies across the SSA region. For instance, in South Africa, Woollett et al 6 found that among ALHIV aged 10–19 years receiving HIV treatment in Johannesburg, 27% had symptoms of depression, and 12% experienced anxiety. In Botswana, 15.0% of ALHIV reported suicidal ideation, with a higher prevalence among females.7 In Ethiopia, Abebe et al 8 reported a 35.5% prevalence of depression among young adults living with HIV, particularly among those aged 20–24 years, with contributing factors including opportunistic infections, low social support and stigma. Similarly, Musisi and Kinyanda9 found that among Ugandan adolescents aged 12–17 years, the prevalence of depression was 19.8%, while anxiety disorders affected 8.9% of the participants. This epidemiological data highlight both the widespread nature and the variability of mental health needs among ALHIV, emphasising the importance of tailored, regionally relevant interventions.
The mental health burden of ALHIV is exacerbated by various factors, including stigma, discrimination, poverty, limited access to healthcare services and the challenges of coping with a chronic and stigmatised condition.10 11 These mental health issues can have far-reaching consequences, including poor treatment adherence, increased risk-taking behaviours, impaired social and academic functioning and overall well-being of ALHIV.2 12 13 Despite the evident need for mental health support, access to appropriate services and interventions is limited in many resource-constrained settings in SSA.
Over the past two decades, various mental health interventions have been developed and implemented to address the unique needs of ALHIV/AIDS.13 14 These interventions range from social support programmes to evidence-based psychotherapies, such as cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT).15–17 However, most of these interventions have been developed, implemented and evaluated in high-income countries, raising questions about their effectiveness or appropriateness in resource-constrained and sociocultural diverse contexts of SSA.18 Furthermore, existing systematic reviews and meta-analyses on mental health interventions for people living with HIV/AIDS have primarily focused on adult populations, overlooking the unique developmental needs and challenges faced by adolescents.19 20 Systematic reviews focusing on ALHIV have predominantly been conducted within a global context, particularly in low-income and middle-income countries,14 21 22 with a notable lack of emphasis on SSA where the burden of HIV is reportedly high.
Nevertheless, these reviews highlight the need for interventions tailored to the developmental stage, cultural context and lived experiences of ALHIV in SSA. Moreover, while some mental health interventions have been implemented for ALHIV in SSA,23 24 studies are yet to comprehensively synthesise their effectiveness in improving mental health outcomes, such as depression, anxiety and suicide as well as their impact on adherence to antiretroviral therapy (ART), which is often influenced by mental health challenges. To address these gaps, we propose to conduct a systematic review of the literature on existing mental health interventions for ALHIV in SSA. This review aims to synthesise the available evidence on the types, effectiveness, implementation approaches and challenges and cultural relevance of these interventions. The review will also examine the strengths, weaknesses and gaps in the current literature, to help inform future research efforts and the development of innovative, context-specific, and culturally appropriate mental health interventions for this vulnerable population.
The specific objectives of the systematic review are:
Identify and describe the types of mental health interventions that have been developed, implemented and evaluated for ALHIV in SSA.
Assess the effectiveness of these interventions in improving mental health outcomes, such as depression, anxiety and suicide, as well as adherence to ART among ALHIV.
Describe the implementation approaches of these interventions and document the implementation gaps.
Methods and analysis
Design
This systematic review will adhere to the reporting standards outlined in the revised 2020 edition of the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA).25 We refined our review question and criteria for inclusion and exclusion by following the guidelines set forth in the Cochrane Handbook for Systematic Reviews of Interventions.26 The PICO acronym, as developed by the Cochrane Collaboration guidelines, was employed to structure the key concepts for review. Additionally, following the Cochrane Collaboration guideline, the primary outcome measures of interest will be limited to changes in depression, anxiety and suicide score, while the secondary outcome of interest will be limited to adherence to ART.
Review question
What mental health interventions have proven effective in improving the mental health outcomes of ALHIV in SSA (see table 1)?
Review question in PICO format
Eligibility criteria
The eligibility criteria were informed by the PICO acronym and the guidelines outlined in the Cochrane Handbook Collaboration. Additional criteria considered for this review were the types of studies, study setting/context, publication period and language.
Inclusion criteria
Population
Studies involving 10–19 years ALHIV in SSA countries will be considered. This criterion specifies the target population of interest for this systematic review, which is adolescents between the ages of 10 and 19 years who have been diagnosed with HIV/AIDS and reside in SSA countries. The age range of 10–19 years aligns with the WHO’s definition of adolescence27 and captures the unique developmental stage and experiences of this age group. Limiting the population to those living in SSA ensures that the interventions and findings are relevant to the specific sociocultural, economic, and healthcare contexts of this region.
Intervention
Studies evaluating psychosocial or mental health interventions aimed at improving mental health outcomes (depression, anxiety and suicide) for ALHIV will be selected for inclusion in this systematic review. The secondary outcome is adherence to ART. This criterion focuses on interventions that are specifically designed to address mental health issues in ALHIV. These interventions may include CBT, IPT, family-based interventions, peer-support programmes, psychoeducation and stress management techniques. While we aim to include interventions grounded in evidence-based frameworks, we also recognise the importance of emerging or community-informed interventions that may not yet have strong evidence base but are relevant in the SSA context. The primary and secondary outcomes reflect the common challenges faced by ALHIV.28 29
Comparison/control
Studies that include a control group will be eligible for inclusion in the systematic review. A control group typically receives no intervention, a placebo or treatment as usual, and serves as a baseline or reference point for comparison with the intervention group.30 The presence of a control group allows researchers to determine if any observed changes or outcomes are due to the intervention itself,31 rather than other factors. Studies that include a comparison group will also be eligible for inclusion. A comparison group may receive a different intervention, an alternative treatment or a variation of the intervention being studied. Comparing the outcomes between the intervention group and the comparison group can provide insights into the relative effectiveness or superiority of the intervention under investigation. Including studies with control or comparison groups enhances the methodological rigour and internal validity of systematic reviews. In comparing the outcomes between groups that received different conditions (intervention vs control/comparison), the review can more reliably assess the true effects of the mental health interventions being evaluated. This approach also helps account for potential confounding factors and biases that may influence the outcomes, strengthening the conclusions that will be drawn from the review.
Outcomes of interest
The studies that will be included in this review must report on quantitative measures or scores related to depression, anxiety and suicidal ideation or behaviour. These measures include standardised scales, questionnaires or other validated assessment tools used to evaluate the presence and severity of these mental health conditions. The studies should also report on the changes in these mental health scores from baseline (preintervention) to the last available follow-up timepoint after the intervention was implemented. This allows for the evaluation of the potential impact or effectiveness of the intervention on improving mental health outcomes over time. Furthermore, the studies must have used validated and reliable instruments or tools relevant to our study population and context. For depressive symptoms, these includes Patient Health Questionnaire (PHQ-9), Children’s Depression Inventory (CDI), Hamilton Depression Rating Scale for Children, Beck Depression Inventory (BDI) and Centre for Epidemiologic Studies Depression Scale (CES-D); for anxiety symptoms, these include the Generalised Anxiety Disorder Scale (GAD-7), Multidimensional Anxiety Scale for Children (MASC), Hamilton Anxiety Rating Scale (HAM-A), Beck Anxiety Inventory (BAI) and Child and Adolescent Anxiety Measure (CAAM) and for suicidality, these include the Columbia-Suicide Severity Rating Scale (C-SSRS), Scale for Suicide Ideation (SSI), Suicide Behaviours Questionnaire-Revised (SBQ-R), Ask Suicide-Screening Questions (ASQ) and Suicide Intent Scale (SIS). This ensures that the mental health outcomes are assessed using standardised and psychometrically sound measures, increasing the validity and comparability of the findings. The review will also consider validated culturally adapted versions of these measures for African contexts, and any additional validated measures that emerge during the systematic search process. In addition to mental health outcomes, the studies should also report on measures or indicators, including self-reported adherence scales, pharmacy refill records, electronic monitoring devices and viral load measurements as indirect indicators of adherence to ART among ALHIV. Adherence to ART is a crucial aspect of HIV/AIDS management,32 and mental health interventions may potentially impact treatment adherence, hence the need to focus attention on adherence.
Study designs
This criterion specifies the types of study designs that will be included in the review, focusing on studies that evaluate the effectiveness or feasibility of mental health interventions. Randomised controlled trials (RCTs), quasi-experimental studies, pilot interventions and pre–post studies evaluating mental health interventions will be considered for inclusion. RCTs are considered as the gold standard for evaluating interventions.33 Quasi-experimental studies, pilot interventions and pre–post studies will also be included to capture a broader range of evidence and interventions that may be in earlier stages of development or implementation.
Setting
Only studies conducted in SSA countries will be included in the review. We will define SSA according to the World Bank classification, including Eastern African countries (such as Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe), Western African countries (including Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal and Sierra Leone), Central African countries (such as Cameroon, Central African Republic, Chad, Republic of the Congo, Democratic Republic of the Congo, Equatorial Guinea and Gabon) and Southern African countries (including Angola, Botswana, Eswatini, Lesotho, Namibia and South Africa). This criterion ensures that the included studies are specific to the context of SSA countries, where the HIV/AIDS epidemic has had a significant impact and where resources for mental health interventions are limited.
Language
Studies published in English. This criterion limits the included studies to those published in the English Language due to resource constraints (cost of translation) and the need for consistent data extraction and synthesis. While this may introduce some language bias, English is a commonly used language for academic publications in SSA.
Publication period
This criterion establishes a time frame for the literature search, focusing on studies published from the year 2004 onwards. This time frame captures a significant period of research and intervention development in the field of HIV/AIDS and mental health, particularly in the context of SSA. Including studies from 2004 onwards ensures that the findings and recommendations are relevant to current practices and context.
Exclusion criteria
Studies focusing solely on adults (>19 years) or children (<10 years) living with HIV/AIDS. The rationale for this exclusion is to maintain a clear focus on the unique developmental needs and experiences of adolescents, which may differ from those of adults or younger children.
Studies reporting data on participants with different ages in which it is difficult to separate data on adolescents for analysis.
Studies evaluating solely biomedical or pharmacological interventions without a psychosocial/mental health component. The rationale for this exclusion is to align the review with its primary objective of examining mental health interventions for ALHIV.
Reviews, editorials, commentaries, case reports and qualitative studies without an intervention component.
Studies for which the full text is not available or accessible either through online databases or other means. This exclusion criterion is based on practical considerations related to the systematic review process and to ensure that the reviewers have access to the complete information and details necessary for data extraction and quality assessment.
Search strategy
For this review, we identified the PICO components and cross-referenced them with search terms utilised in comparable previous reviews to ensure completeness.14 21 The authors have developed composite search terms that included controlled vocabulary for the selected databases (eg, Mesh terms for PubMed) and keywords for the population, intervention types and outcomes of interest. To ensure that the search strategy retrieved studies evaluating mental health interventions focused on depression, anxiety and suicidal thoughts/suicide, Mesh terms or the controlled vocabulary for each database and keywords/test words of these mental disorders were infused in the search strategy as shown in table 2.
Sample, search strategy for PubMed using Boolean Operators (OR & AND)
Information sources
Six major Cochrane-recommended electronic databases will be searched using the predetermined customised search strategy: PubMed, Scopus, MEDLINE, CINAHL, PsycINFO and Health Source: Nursing academic edition. To limit the potential risk of publication bias, the reviewers will conduct additional searches in Google Scholar, Library catalogues, Conference Proceedings, Clinical Trials databases, such as ClinicalTrials.gov, dissertation abstracts and institutional databases, such as UNAIDS and WHO reports for additional papers. Hand searches of relevant journals and reference lists of included studies will be conducted to identify potentially relevant studies. Researchers and study authors will be contacted for additional papers.
Data records, management and screening
The search results will be imported into a reference management software, specifically Rayyan, to first identify and remove duplicates. Two independent reviewers will screen the titles and abstracts of the identified records against the inclusion and exclusion criteria. Any disagreements will be resolved through discussion or consultation with a third reviewer. Full-text articles of potentially eligible studies will be retrieved and further assessed for inclusion by two independent reviewers. A third reviewer will be consulted in case of disagreement. The process will be summarised using PRISMA flow diagram.
Data extraction
A standardised data extraction form (online supplemental file) similar to those used in previous systematic reviews14 21 will be used to capture relevant information from the included studies. Two reviewers will conduct a pilot test of the data extraction form, engage in discussions and iteratively refine the form based on their deliberations. Two independent reviewers will conduct data extraction, and any discrepancies will be resolved through discussion and the involvement of a third reviewer. The extracted data will include study characteristics (eg, author, year, country and study design), population details, intervention details, key findings on the effectiveness of the intervention and implementation approaches and challenges.
Supplemental material
Data synthesis
A qualitative content analysis approach34 will be used to collate the extracted data. The data will be categorised and compared for similarities differences, and relationships in respect of the mental health interventions and their impact on mental health outcomes and adherence to ART. The data will be synthesised through the identification of themes and concepts relevant to the review question. The thematic analysis will follow a rigorous seven-stage process. Initially, two independent reviewers will conduct data familiarisation through multiple readings of included studies, documenting key findings, patterns and contextual factors using a standardised extraction form. This will be followed by initial coding, where reviewers will conduct line-by-line coding of relevant findings, develop codes inductively and establish coding consistency through independent review of 20% of studies, resolving discrepancies through consensus. Theme development will involve grouping similar codes into potential themes using concept mapping, with relationships between codes visually mapped and themes reviewed against original data to ensure representativeness. The theme review and refinement stage will involve a two-level review process: examining coded extracts for coherent patterns and reviewing themes against the entire data set. A third reviewer will independently verify themes, with regular team meetings to ensure alignment with research objectives. The final reporting stage will include clear theme definitions, visual representations of theme relationships, detailed description of the analytical process and acknowledgement of limitations and potential biases. If possible, meta-analyses will be performed to estimate the overall effect sizes of interventions on mental health outcomes.
Risk of bias assessment
Eligible studies will undergo quality assessment using standardised criteria appropriate for each respective study design. Two reviewers will independently review each included study for methodological quality. Discrepancies in this assessment will be resolved through discussion among the two reviewers. Where necessary, a third reviewer will be included to make a final judgement of the rating of an included study. RCTs will be appraised using the Cochrane Risk of Bias tool which provides opportunity to examine randomisation, allocation concealment and selective reporting among others as potential sources of bias.35 The modified version of the Newcastle–Ottawa Scale36 will be used to appraise nonrandomised studies. The mixed-method appraisal tool (MMAT) version 201837 will be used to evaluate considerations unique to mixed-methods studies and to appraise article quality. This tool was chosen over other quality appraisal tools because it is explicitly applied to mixed-methods research and makes provision to assess the individual methods (quantitative and qualitative) within the design. When study reports lack adequate information, a judgement of ‘UNCLEAR’ will be assigned to specific risk of bias items within the assessment tools. Following this, each study will be given a final quality rating—classified as ‘low’, ‘moderate’ or ‘high’—based on the comprehensive evaluation of bias risk.
Ethics and dissemination
Since no primary data will be collected, ethical approval is not needed. The review’s findings will be disseminated through publication in a peer-reviewed journal and presented at relevant conferences.
Discussion
While previous reviews have examined mental health interventions for people living with HIV/AIDS,19 20 the proposed review is focused on and unique to ALHIV in SSA. By narrowing the scope to this vulnerable population and geographic region, the review aims to address a critical gap in the existing literature. Furthermore, this protocol incorporates rigorous methodological approaches, such as the use of standardised quality assessment tools (eg, Cochrane Risk of Bias Tool). These methodological considerations align with best practices in conducting systematic reviews and meta-analyses, ensuring a high level of transparency and scientific rigour.
The findings of this systematic review will have significant implications for research, practice and policy related to the mental healthcare of ALHIV in SSA. First, it will identify gaps and limitations in the existing literature that require further investigation and intervention development. This insight can inform future research priorities and funding allocations, ensuring that resources are directed towards addressing the most pressing needs of this vulnerable population. Second, the review will provide evidence-based insights into the effectiveness, feasibility and cultural appropriateness of various mental health interventions in SSA context. This information can guide healthcare practitioners, policymakers and programme implementers in selecting and adapting interventions that are most likely to be effective and sustainable in resource-limited settings.
Second, previous reviews have highlighted the paucity of research on mental health interventions specifically tailored for ALHIV.6 12 This systematic review is likely to corroborate these findings, underscoring the need for more research in this area. Second, existing studies have primarily focused on psychosocial support interventions and CBT for this population.38 39 The review may reveal a limited diversity of intervention types, suggesting the need for exploring alternative or culturally adapted approaches. Finally, previous reviews have identified challenges in implementing mental health interventions in resource-limited settings, such as shortages of trained healthcare professionals, stigma and logistical barriers.14 40 This systematic review may provide further evidence of these challenges and highlight the need for sustainable and scalable intervention models.
The review faces several limitations that may impact its findings. First, the potential for substantial heterogeneity among the included studies, due to diverse settings, interventions and study designs, could limit the feasibility of conducting meta-analyses or drawing robust conclusions. Additionally, the protocol includes only studies published in English, which may result in the exclusion of relevant non-English studies and potentially introduce language bias. Furthermore, mental health interventions for ALHIV/AIDS in SSA represent a rapidly evolving field, meaning new studies and interventions may emerge, quickly rendering the review outdated and necessitating periodic updates. Finally, while the review focuses on SSA, its findings may have limited generalisability to other regions or contexts due to cultural, socioeconomic and healthcare system differences.
Ethics statements
Patient consent for publication
Footnotes
Contributors Conceptualisation of study: SA, DSB, EX, VVA, PKA, YYB, ABF and LKO. Methods and design: SA, DSB, EX, VVA, PKA, YYB, ABF, LKO and CY. Original draft preparation: DSB, EX, VVA, PKA, YYB, ABF, LKO and CY. Review and editing: SA and DSB. All authors have read and agreed to the published version of the protocol. Guarantor author is SA.
Funding The review will be conducted as part of a 2-year POSSIBLE-Africa fellowship (grant no. # POS24-07) awarded to the last author by Science for Africa Foundation.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.