A recent study by researchers from the University of Cape Town (UCT) and Linköping University in Sweden showed that people living with HIV face an elevated risk of suicide due to a combination of stigma, fear of disclosure, mental health challenges and gaps in primary healthcare services, highlighting the urgent need to integrate mental health support into routine HIV care.
The study, published in the AIDS Care journal, explored healthcare workers’ perspectives on risk factors, barriers to care and prevention needs in primary healthcare settings. The team conducted interviews with 13 healthcare workers from three primary healthcare clinics in Khayelitsha.
Associate Professor Stephan Rabie, a chief research officer in UCT’s Department of Psychiatry and Mental Health and the study’s principal investigator, says: “Suicide disproportionately affects people living with HIV. The reasons for this elevated risk are complex and multifaceted. There isn’t one specific causal pathway that can explain why people with HIV are particularly vulnerable to die by suicide. Rather, people with HIV are confronted by a combination of situational stressors that compromise their mental health and increase their risk for suicide.
“The elevated risk for mental illness and related suicide outcomes has far-reaching implications across the HIV care continuum, including delays in treatment initiation, poor HIV care engagement and reduced life expectancy.”
Previous research showed that individuals who die by suicide often visit a healthcare setting 12 months before their death. In South Africa, where most people living with HIV receive care in public sector facilities, opportunities to screen for and prevent suicide amongst individuals seeking HIV care in community-based healthcare remain underutilised.
“Our findings showed that among people with HIV, suicidal ideation and behaviour are driven by a confluence of stressors such as experiencing rejection after disclosing HIV status, and general social stressors, like unemployment and financial deprivation,” says Associate Professor Rabie.
Unlike high-income countries, where psychiatric disorders are predominant in driving suicide, Rabie said that low-resource settings like South Africa show that socioeconomic challenges such as unemployment and food insecurity significantly contribute to suicidal behaviour. “These findings were resonated in the current study,” he adds.
One of the study participants asserted: “Because sometimes you will find out it is not HIV [that is] the problem. There is something else other than HIV, such as poverty at home, a lack of education, and now the burden of medication, or there is family violence at home.”
Rabie and his colleagues found that one of the main barriers to preventing suicide was the lack of routine screening for suicide and limited training in suicide risk assessment among primary care workers.
“Providing opportunities for training in suicide risk assessment that are accessible and not burdensome to healthcare workers will be an important first step in addressing the syndemic of suicide in South Africa,” says Rabie.
The study identified two additional strategies to improve suicide prevention among people living with HIV. Firstly, the authors call for integration of mental healthcare in HIV clinical settings.
Considering the multimorbidity of psychiatric disorders, suicide and HIV, Rabie said that integrating mental healthcare into routine HIV care could serve as a crucial point of prevention and identify individuals in need of additional support.
Secondly, Rabie says the findings showed the need for brief interventions to support primary healthcare workers to address the multifaceted factors that influence suicide among people with HIV, such as counselling programmes focused on psychoeducation on suicide risk factors.
“The findings from this study will inform the development of a brief intervention that introduces brief safety planning to reduce suicide risk and training in adaptive coping skills to manage the stress that drives suicidal ideation and behaviour. In partnership with the City of Cape Town and Western Cape Department of Health and Wellness, this intervention will be pilot tested in primary healthcare facilities in the Cape Metro in 2026,” he says.
The study was supported by the Fogarty International Centre and National Institutes of Mental Health in the USA.