• "In the Women's Interagency HIV Study prospective cohort (N = 848), chronic depressive symptoms were associated with over three times the hazard of mortality, among women on cART, and over seven times the hazard of mortality, among women not on cART, compared with women on cART with no depression
 
• Depression has been shown to increase the risk of mortality among PLWH.
 
• And among 765 HIV+ women at four US sites followed for up to 7 years, women with chronic depressive symptoms were twice as likely to die as women with limited or no depressive symptoms, even after adjusting for predictors of mortality (i.e., CD4+ cell count, cART duration, age)
 
• Biological factors, including comorbid communicable diseases (e.g. tuberculosis, hepatitis) and noncommunicable diseases (e.g. diabetes, heart, and bone disease), as well as chronic immune activation, contribute to poorer physical and mental health outcomes"
 
• In a US multisite study with over 2800 PLWH, 36% had major depression and 15.8% had generalized anxiety disorder [36], compared with only 6.7 and 2.1%, respectively, in the general population
 
• Prevalence of substance use disorders also tend to be higher among PLWH than in the general poulation ranging from 21 to 71% [44,54], as do rates of neurocognitive impairment - about 50% of PLWH, even those who are virally suppressed
 

• Biological factors, including comorbid communicable diseases (e.g. tuberculosis, hepatitis) and noncommunicable diseases (e.g. diabetes, heart, and bone disease), as well as chronic immune activation, contribute to poorer physical and mental health outcomes [61,62]. Intersecting social stigmas, and criminalization in some contexts (e.g. sex work, drug use, and same-gender sex) present additional challenges to key populations that are highly affected by HIV, including MSM, transgender women, sex-workers, people who use drugs (including PWID), and racial and ethnic minorities. These groups experience perceived and internalized stigma as well as enacted stigma (e.g. discrimination) that negatively affect mental health, and this relationship is further compounded by the unfortunate stigma of mental illness in society and among patients and providers [63-65].
 
• And among 765 HIV+ women at four US sites followed for up to 7 years, women with chronic depressive symptoms were twice as likely to die as women with limited or no depressive symptoms, even after adjusting for predictors of mortality (i.e., CD4+ cell count, cART duration, age)
 
• Mental disorders can present a substantial barrier to adequate engagement and retention in HIV primary care. Research has established links between the presence of psychiatric illness and poor rates of HIV care linkage and retention.
 
• Lack of HIV diagnosis jeopardizes the health of PLWH by impeding access to the significant health benefits that cART confers. Lack of HIV diagnosis presents a further public health challenge because a substantive proportion of new HIV infections are attributable to persons who are not aware of their HIV status
 
• There is evidence suggesting a bi-directional relationship between depression and the immune system [79-81]. Depression is known to negatively affect the immune system (e.g. CD4+ cell decline) although the underlying mechanisms remain poorly understood. Chronic immune activation and hypothalamic-pituitary-adrenal axis dysregulation [82,83], which HIV infection can exacerbate [84-86], are established factors contributing to developing depression and likely contribute to high rates of depression among PLWH [62]. HIV crosses the blood brain barrier causing immune activation in the brain and the central nervous system [87]. Inflammatory proteins (e.g. C-reactive protein, cytokines) lead to oxidative stress and neuronal injury [88], specifically, the chronic inflammatory response to HIV infection leads to elevated cytokine levels, including IL-6 and TNF-α, which can trigger a chain reaction involving Tryptophan depletion through the activation of Indoleamine 2,3-dioxygenase enzyme
 
• Community advocates have built on this science by advancing a messaging campaign regarding 'U = U' (undetectable = untransmittable), which states that PLWH with sustained HIV viral suppression cannot transmit HIV through sex [133,134]. The campaign holds that the optimistic messaging of U = U will build hope in the community and contribute to a lessening of HIV-related stigma, which in turn can reduce psychological distress among PLWH and their sex partners. Community advocates and anecdotal reports indicate that the U = U message helps many PLWH feel unburdened by the shame and stigma that accompanies HIV infection [133]. There is a need for systematic research on patient understanding of U = U and its potential benefits for mental health and well being among PLWH.
 

1 Mental health problems (ranging from distress to SMI) are elevated among people at-risk for HIV and those living with HIV. This risk is true across populations most affected by the epidemic in different regions of the world.
2 Mental health problems contribute to HIV acquisition and poor outcomes along the HIV treatment continuum.
3 HIV and the resulting chronic immune activation increase the risk to develop mental health problems.
4 We have the necessary assessment (screening) tools and efficacious treatments to treat mental health problems among people living with and at risk for HIV. However, we need to prioritize mental health treatment, especially mental health treatment integrated into HIV care, with appropriate resources to address the current screening and treatment gap. 5 Promising advances have been made integrating mental healthcare into HIV primary care (via task-shifting, stepped-care interventions, and other strategies).
6 Some community and public health driven campaigns regarding HIV treatment and prevention may help reduce stigma and psychological distress.