The study team, led by Kwame Shanaube and colleagues, recruited participants from the hospital’s adolescent and young adult antiretroviral therapy cohort between September 2023 and May 2024. Of the 583 young people registered in care during the study period, 416 agreed to take part, an enrollment rate of 71.4 percent. The cohort was predominantly female, with 268 participants, or 64.4 percent, being women, and the median age was 20 years, with an interquartile range of 18 to 23. This demographic profile mirrors the broader epidemiology of pediatric and perinatal HIV transmission in the region, where children born with the virus are now surviving into adolescence and young adulthood in large numbers thanks to two decades of expanded antiretroviral treatment programs.

Methodologically, the researchers opted for a tablet-based questionnaire administered by trained research assistants rather than self-completed paper forms, a design choice that matters in a setting where literacy levels vary and sensitive topics can be difficult to discuss. The instrument incorporated validated screening tools for four conditions: depression, anxiety, post-traumatic stress disorder, and substance use. Screening tools do not deliver clinical diagnoses on their own, but they are the standard first step in identifying people who need fuller assessment, and their use in this study allowed the team to capture a snapshot of psychological morbidity across an entire clinic population rather than only among those who volunteer distress during routine consultations.

The headline numbers are stark. Depression emerged as the most prevalent condition, with 279 of 416 participants, or 67.1 percent, screening positive. Anxiety followed at 35.3 percent, affecting 147 participants. Because many young people screened positive for more than one condition, the overall proportion with at least one disorder, 71.4 percent, reflects substantial comorbidity. For clinicians, the implication is that mental distress in this population is not an occasional complication but the statistical norm, and that a young person attending an HIV clinic in Lusaka is more likely than not to be experiencing depression at a level that would warrant further evaluation.

To understand who was most at risk, the team used logistic regression, a statistical technique that estimates the odds of an outcome while adjusting for other variables in the model. The clearest signal was stigma. Young people who reported feeling stigmatised because of their HIV status had nearly twice the odds of screening positive for at least one mental health disorder compared with those who did not, with an adjusted odds ratio of 1.99 and a 95 percent confidence interval of 1.10 to 3.63, a statistically significant association with a p-value of 0.024. This finding aligns with a large body of international literature linking enacted and perceived stigma to depression and anxiety among people living with HIV, but it is particularly consequential in a cohort of young people who must navigate disclosure, dating, schooling, and employment while managing a chronic, transmissible condition.

A second association hovered at the edge of statistical significance. Participants with a history of smoking showed markedly higher odds of having at least one disorder, with an adjusted odds ratio of 4.24, but the confidence interval ranged from 0.98 to 18.30 and the p-value of 0.053 fell just short of the conventional threshold. The authors are careful to describe this as borderline evidence rather than a confirmed association. The wide confidence interval reflects the small number of smokers in the cohort, a common limitation in studies of adolescent populations where substance use is less established than in older adults. Still, the direction of the effect is consistent with the well-documented overlap between nicotine use and mental ill health, and it suggests that tobacco screening may be a useful adjunct to psychological screening in this setting.

Perhaps the most counterintuitive finding concerned orphanhood. Compared with participants whose parents were both alive, those who had lost one parent had lower odds of screening positive for a mental health disorder, with an adjusted odds ratio of 0.46, and those who had lost both parents had still lower odds, with an adjusted odds ratio of 0.38. Both associations were statistically significant, with p-values of 0.042 and 0.010 respectively. On its face, this seems to defy expectations, since parental death is a recognized risk factor for psychological distress in young people. The authors do not overinterpret the result, but several explanations are plausible. Orphaned adolescents in HIV care programs may be more likely to be in stable guardian arrangements, to have longer and better-supported engagement with clinic services, or to benefit from peer and community support structures that buffer against distress. Alternatively, the finding could reflect unmeasured confounding, such as differences in socioeconomic circumstances, disclosure experiences, or family dynamics that the survey did not capture. Cross-sectional data of this kind can identify patterns but cannot explain them, and the orphanhood result is best read as a prompt for further research rather than a settled conclusion.

What the study does establish firmly is the scale of unmet need. Mental health disorders among adolescents and young people living with HIV are not merely a quality-of-life issue; they have direct clinical consequences. Depression and anxiety are consistently associated with poorer adherence to antiretroviral therapy, more frequent interruptions in care, and worse virological outcomes. In a cohort where more than two-thirds of patients screen positive for depression, the risk that psychological distress undermines the very treatment keeping them alive is substantial. Yet mental health services in much of sub-Saharan Africa remain scarce, concentrated in urban specialist facilities, and largely separate from the HIV care cascade that these young people already navigate. A teenager may attend the same clinic every three months for years without anyone asking a single structured question about their mood, sleep, trauma history, or substance use.

The authors argue that the practical response is to embed mental health screening and referral pathways directly into adolescent HIV services, rather than waiting for distress to announce itself. The AdoMinds study, within which this survey was nested, is an implementation study, meaning its explicit goal is to test how psychological interventions can be woven into routine care in real-world clinics. The prevalence data collected here serve as the baseline evidence for that effort: they demonstrate that the problem is common enough, and the risk factors identifiable enough, that systematic screening is justified. Because stigma emerged as the one factor clearly associated with higher odds of disorder, interventions that reduce stigma, whether through peer support groups, community education, or clinic-based counseling, may deliver psychological benefits alongside their social ones.

The study’s limitations are worth keeping in view. It was conducted at a single hospital in Lusaka, so the findings may not generalize to rural Zambia or to other countries, and the cross-sectional design means the associations reported cannot establish causation. Screening tools identify probable cases rather than confirmed diagnoses, so the true clinical prevalence could differ from the figures reported. Even so, the consistency of the depression and anxiety findings with earlier research from the region, and the size and completeness of the cohort, lend the results considerable weight. For the 416 young people who took part, and the hundreds of thousands like them across eastern and southern Africa, the message of the study is unambiguous: surviving HIV is no longer the hardest part. The harder task, now measurable and now visible, is ensuring that the minds of a generation raised with the virus are cared for as diligently as their immune systems have been.

Subject of Research: Prevalence and correlates of common mental health disorders among adolescents and young people living with HIV receiving antiretroviral therapy in Lusaka, Zambia

Article Title: Prevalence of common mental health disorders and associated factors among adolescents and young people living with HIV in Lusaka, Zambia

Article References: Shanaube, K., Simwanza, S., Tapisha, B., Ngosa, D., Sigande, L., Mshanga, I., Mulungu, C., Mwenya, O., Mwamba, J. G., Moyo, L. T., Moyo, C., Mbambara, T., Lungu, G., Mbewe, M., Moonga, G., & Maila, B. (2026). Prevalence of common mental health disorders and associated factors among adolescents and young people living with HIV in Lusaka, Zambia. PLOS Mental Health, 3(10), e0000710. https://doi.org/10.1371/journal.pmen.0000710

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000710

Keywords: HIV, mental health, adolescents, Zambia, depression, anxiety, stigma, antiretroviral therapy, cross-sectional study, Lusaka, screening, orphanhood

Depression among adolescents is a formidable global health problem, with roughly one-third of adolescents worldwide estimated to experience depressive symptoms. The burden falls disproportionately on young people in low- and middle-income countries, where prevalence estimates in sub-Saharan Africa range from about 27 percent to more than 70 percent in some studies, compared with roughly 23 percent in North America and Europe. Adolescence is also a sensitive developmental window: depression that begins during these years can disrupt neurodevelopment, undermine social functioning, and increase the risk of suicide, intimate partner violence, and HIV acquisition. Yet despite effective treatments existing, modeling studies suggest treatment alone can avert only a fraction of the total disease burden, making prevention a critical public health priority.

The research team, led by Valerie A. Lucas of the University of North Carolina at Chapel Hill together with colleagues including Audrey Pettifor and Kathleen Kahn, turned to the HPTN 068 trial, a randomized controlled trial conducted from 2011 to 2015 in rural South Africa that had tested whether conditional cash transfers tied to school attendance could reduce HIV risk in adolescent girls and young women. The team conducted a secondary analysis of 2,116 participants who were under 18 at enrollment, with a mean age of 15.1 years. Participants reported on six specific adverse childhood experiences at baseline: double orphanhood, food insecurity, low perceived care from their guardian, physical intimate partner violence, sexual violence, and violence at school. Depressive symptoms were then measured annually during the trial and at two additional follow-up visits in 2016/17 and 2018/19, using the 20-item Center for Epidemiologic Studies Depression scale, a validated screening tool in South African adolescents.

The scale of adversity in the sample was striking. Food insecurity was the most common experience, reported by 33.1 percent of participants in the previous year, followed by school violence at 18.4 percent, physical intimate partner violence at 15.0 percent, sexual violence at 9.6 percent, low guardian care at 5.9 percent, and double orphanhood at 4.7 percent. Nearly 40 percent of participants reported no adversities, but a substantial minority reported two or more. Intriguingly, the adversities were largely independent of one another, with the strongest correlation, between physical partner violence and sexual violence, registering at just 0.207. This statistical independence suggests each type of adversity operates through distinct mechanisms, and it allowed the researchers to estimate each one’s effect separately rather than lumping them into a single additive score, an approach they argue can obscure important differences between experiences.

To move beyond simple association toward causal inference, the team employed g-computation, a form of marginal structural model developed by epidemiologist James Robins. The technique works in two steps: first, a logistic regression model estimates each participant’s probability of depression at each follow-up visit given her actual adversity history and covariates; then, the researchers create counterfactual copies of the dataset in which every participant is set either to have experienced or not experienced a given adversity. Averaging predicted depression probabilities across these counterfactual scenarios yields an estimate of what depression prevalence would have been if the adversity had been completely eliminated, or universally experienced. The difference between the two is the prevalence difference, the estimated causal effect. Standard errors were computed with 500 bootstrap replications that sampled each participant’s full set of visits as a cluster, and the team quantified vulnerability to unmeasured confounding using E-values.

The results were revealing. At the first follow-up year, when adjusted depression prevalence peaked at 31.9 percent, the two largest single-adversity effects came from low perceived care from a guardian, which raised depression prevalence by 11.1 percentage points, and physical intimate partner violence, which raised it by 10.1 percentage points. Food insecurity added 6.3 percentage points, and school violence 5.2. Most striking of all, young women who had experienced both physical intimate partner violence and sexual violence showed a 15.7 percentage point elevation in depression prevalence, the largest effect of any exposure in the study, an effect that remained substantial at 14.4 percentage points five years after baseline.

Double orphanhood, by contrast, defied expectations. Despite a substantial body of literature linking parental loss to depression among children affected by HIV in sub-Saharan Africa, losing both parents before age 18 produced only a small and statistically insignificant effect of 3.1 percentage points at Year 1, and by Year 7 the estimate had actually turned negative at minus 5.7 percentage points. The researchers suggest a possible explanation rooted in the social fabric of rural South Africa: extended family networks frequently step in to fill the caregiver role for orphaned children. What matters for mental health, the data imply, is not whether the biological parents are alive, but whether a caring adult is present in the young woman’s life. Low perceived guardian care, measured by a single question asking whether the most involved guardian cared about her not at all, proved far more damaging than orphanhood itself.

The trajectory of effects over time also carried important lessons. Depression prevalence in the cohort fell dramatically from 31.9 percent at Year 1 to just 8.8 percent by Year 7, and most adversity effects shrank alongside it. But some persisted with remarkable tenacity. Food insecurity raised depression prevalence by 6.3 to 7.7 percentage points across the first five years of follow-up. School violence, remarkably, continued to elevate depression even after most participants had left secondary school, with a significant 6.4 percentage point effect at Year 5, suggesting that the psychological damage inflicted in unsafe school environments outlasts the exposure itself. Physical partner violence remained significant at Year 5 with an 8.3 percentage point effect. The E-value analysis indicated that an unmeasured confounder would need to be associated with both the exposure and depression by a factor of roughly two to explain away the significant findings, a threshold the authors consider implausible given the weak correlations among adversities in their sample.

The authors are candid about limitations. All exposures and outcomes were self-reported, and current depressive symptoms could color how young women recalled or reported past adversities. The CES-D measures symptoms rather than providing clinical diagnoses, and a sensitivity analysis using a stricter cutoff of 20 or higher produced similar patterns with smaller magnitudes. The study captured adversities only at baseline, ignoring new exposures, severity, and frequency after age 18, and outcome data were missing at some visits, particularly Year 3 when only 38.6 percent of the sample completed the depression assessment, though the imputation approach assumed missingness was random conditional on measured variables. Adversities with low prevalence, such as double orphanhood and sexual violence, also had limited statistical power, producing wider confidence intervals.

Nevertheless, the study’s strengths are considerable: an explicitly causal analytic framework, temporally separated measurement of exposures and outcomes, seven years of follow-up, and extensive sensitivity analyses that consistently supported the main findings. The practical implications are concrete. Supporting caregivers and their engagement in young people’s lives, regardless of orphan status, could buffer depression risk. Consumption-smoothing interventions and income diversification could reduce the food insecurity that affects a third of households. Economic empowerment programs, cash transfers, and trauma-informed care could reduce young women’s exposure to and recovery from partner violence. And school-based interventions targeting violent teachers, unsafe environments, and harassment could yield population-level mental health benefits that persist well beyond graduation. In a country where up to 88 percent of young adults report at least one childhood adversity and 30 percent experience depression, identifying which adversities matter most, and for how long, may be the first step toward breaking the cycle.

Subject of Research: Effects of adverse childhood experiences on depression prevalence in adolescent girls and young women in rural South Africa

Article Title: The effect of adverse childhood experiences on depression prevalence in adolescent girls and young women over time: a secondary analysis of HPTN 068 trial data

Article References: Lucas, V. A., Reyes, L. M., Maselko, J., Stoner, M., Rosenberg, M., DeLong, S. M., Bhushan, N. L., Moffett, B., Beidelman, E. T., Klein, M., Kahn, K., & Pettifor, A. (2026). The effect of adverse childhood experiences on depression prevalence in adolescent girls and young women over time: a secondary analysis of HPTN 068 trial data. SSM – Mental Health, 10, Article 100706. https://doi.org/10.1016/j.ssmmh.2026.100706

Image Credits: AI Generated

DOI: 10.1016/j.ssmmh.2026.100706

Keywords: adverse childhood experiences, depression, adolescent girls, South Africa, food insecurity, intimate partner violence, school violence, orphanhood, g-computation, HPTN 068, global mental health, CES-D