Common mental health outcomes and access to support services among adolescents living with HIV in sub-Saharan Africa: a protocol for a systematic review

Abstract

Introduction

The prevalence of HIV in adolescents is a major global health concern, and research into the influence of HIV on mental health outcomes in this demographic is ongoing. We will conduct a comprehensive systematic review of common mental health outcomes in adolescents with HIV infection (aged 10–24 years). Recognising the specific psychosocial issues that adolescents living with HIV infection are confronted with, this review aims to integrate existing research on the prevalence, risk factors and protective factors related to both positive and negative mental health outcomes in this population.

Methods and analysis

The following electronic databases will be searched for publications from 1959 up to December 2025: PubMed, PsycINFO, Global Health, Embase, African Journals OnLine and African Index Medicus. The review will focus on both positive and negative mental health outcomes: positive outcomes include resilience, subjective happiness and post-traumatic growth, whereas the negative outcomes include depression, anxiety, post-traumatic stress disorder, substance use disorder and suicidality. Peer-reviewed primary observational studies that report prevalence rates for common mental health outcomes outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, and the International Classification of Diseases, 11th Edition, their associated factors, as well as barriers to and facilitators of use of mental health support services among this population, will be included in the review. Google Scholar and ProQuest Dissertations & Theses Global as well as Electronic Theses and Dissertations from Ghana, South Africa, Uganda and Kenya, will also be searched for grey literature. The review will be limited to publications in English or French. To assess the methodological rigour of the selected studies, the Joanna Briggs Critical Appraisal Tools will be used. The synthesis will include a narrative summary and, if applicable, a meta-analysis of quantitative data depending on the extent of heterogeneity observed in the included studies. Subgroup analyses will be conducted to investigate differences in mental health outcomes by age, sex and socioeconomic position, where applicable. This systematic review will be reported in accordance with the PRISMA statement.

Ethics and dissemination

This review will use secondary data and does not require ethical approval. The findings will be shared through peer-reviewed publications and conference presentations. The emphasis will be on translating research findings into practical mental health interventions and HIV-specific support services for adolescents.

PROSPERO registration number

CRD42024568512.

Strengths and limitations of this study.

• The protocol closely adheres to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) Protocols reporting criteria, and PRISMA will be used to report the results, ensuring a systematic and transparent approach to study selection, data extraction and quality assessment.

• The addition of subgroup analyses based on age, sex and socio-economic position improves the study’s ability to investigate potential differences in mental health outcomes among adolescents living with HIV.

• This review aims to synthesise evidence not only on adverse mental health outcomes but also on positive outcomes.

• There may be a risk of publication bias, as studies with significant results are more likely to be published.

• Heterogeneity in study designs and differing methodological rigour among included studies may result in the inability to pool the results by meta-analysis.

Introduction

Sub-Saharan Africa remains the most affected by the HIV epidemic since its emergence over the past three decades because approximately 67% of people living with HIV reside in the sub-region.^{1 2} This highly significant prevalence of HIV is worsened by its disproportionate effect on adolescents. The term ‘adolescence’ refers to a transitional phase between childhood and adulthood, commonly marked by physiological, cognitive, emotional and social changes, including the development of individual identities, educational pursuits and career decisions and the formation of interpersonal relationships. Typically, it is the period between puberty and early adulthood (10–24 years) when individuals begin to assume adult roles and responsibilities.³ Adolescents living with HIV account for 4% of the global prevalence of HIV, with 85% of this number living in sub-Saharan Africa.¹ Almost half of all new HIV infections are among adolescents aged 10–24 years.⁴ Globally, approximately 38 million people live with HIV, and 3.4 million are adolescents.^{5 6}

Many factors contribute to the high prevalence of HIV among adolescents in sub-Saharan Africa. Studies have shown that substance use, particularly heroin consumption, is linked to increased vulnerability to HIV transmission among adolescents.^{7 8} Although injection drug use is less prevalent among African adolescents, the indirect effect—such as impaired judgement leading to unprotected sex—poses a significant risk to increased incidence.⁹ Additionally, sexual coercion is a critical factor in HIV transmission, as adolescent girls who experience coercion or intimate partner violence are more likely to engage in unprotected sex and have multiple sexual partners, exacerbating their vulnerability due to gender power imbalances.¹⁰ Risky sexual behaviours, including multiple sexual partnerships, early sexual debut and inconsistent condom use, further contribute to the high prevalence of HIV among adolescents.^{11 12} Factors such as peer pressure, socioeconomic vulnerability and inadequate sexual education increase the likelihood of high-risk behaviours.^{13 14} Research in South Africa indicates that adolescents from socioeconomically disadvantaged backgrounds are more prone to engaging in transactional sex, heightening their risk of HIV acquisition.^{15 16}

The response to adolescent HIV treatment and prevention has been multifaceted. A key component of this response involves promoting early access to HIV testing and treatment. Early diagnosis is crucial, as it enables adolescents to initiate antiretroviral therapy (ART) promptly, which does not only improve their long-term health outcomes but also reduces the risk of transmitting the virus to others. Other measures to address the unique challenges adolescents living with HIV face include encouraging disclosure,¹⁷ stigma prevention,¹⁸ promoting education on HIV, addressing mental health issues such as anxiety and depression,¹⁹ enhancing access to support services and the introduction of pre-exposure prophylaxis (PrEP).²⁰

Although PrEP is an effective biomedical intervention for HIV prevention, its accessibility among African adolescents remains limited because of financial, structural and socio-cultural barriers.^{17 21} In South Africa, for instance, adolescents can access PrEP without parental consent, yet stigma and low retention rates hinder its uptake.²² Other factors influencing PrEP uptake include transportation costs and challenges to healthcare access.²³ Misinformation, stigma and concerns about confidentiality further prevent adolescents from seeking PrEP services.^{24 25}

Adolescents living with HIV also encountered substantial challenges as a result of the convergence of the COVID-19 pandemic and the HIV epidemic, which involved difficulties in accessing healthcare, mental health issues and education. The shutdown of clinics restricted transportation options, and fears about exposure to the virus posed challenges to accessing healthcare services.^{26 27} This disruption hindered adherence to therapy and attempts at viral suppression, hence increasing the likelihood of disease progression and transmission. The COVID-19 pandemic disrupted therapy, viral suppression and mental health for adolescents living with HIV. Lockdown measures intensified anxiety, hopelessness and social isolation.^{26 28} School shutdowns and restrictions on social gatherings hampered academic progress and social development. Economic challenges further exacerbated inequities, limiting access to online resources and worsening health outcomes.²⁹

Aside from the effect of COVID-19, many adolescents living with HIV have experienced traumatic events, including the loss of parents due to HIV/AIDS, exposure to sexual or physical abuse and social discrimination.³⁰ Trauma exposure results in poor mental health outcomes,³¹ yet research on the intersection of trauma and mental health in this population remains fragmented.

Although governments and international organisations have attempted to tackle the physical health aspect of HIV infection, there is an increasing acknowledgement of the mental health difficulties experienced by adolescents living with HIV within the sub-region.^{20 32} Adolescents living with HIV encounter distinct barriers and challenges that go beyond the physiological dimensions of the infection. The burden of living with a chronic ailment,³³ possibility of facing social disapproval and stigma^{19 34} and task of manoeuvring through complex healthcare systems can significantly affect their psychological well-being.^{35 36} Studies have shown the higher occurrence of mental health illnesses among adolescents living with HIV, highlighting the significance of managing their mental well-being.^{20 31 37} Mellins and Malee³⁸ underscored the heightened susceptibility to depression and anxiety among adolescents living with HIV. Betancourt et al ³⁹ also pointed out that psychosocial stressors might worsen mental health difficulties in adolescents living with HIV. These psychosocial stressors affect treatment adherence and mental health outcomes in adolescents with HIV infection, with studies showing a direct correlation between mental health conditions and ART compliance.40,42 Poor mental well-being can contribute to suboptimal adherence, resulting in higher viral load and probable risk of transmission.²⁶ Addressing the mental health needs of adolescents living with HIV is crucial for their immediate welfare, long-term health, well-being and quality of life.^{37 38}

Hence, synthesis of the literature on mental health outcomes among adolescents living with HIV in sub-Saharan Africa is crucial for developing evidence-based interventions to address their unique needs. Mental health outcomes are the measurable consequences of an individual’s mental health state over time,²⁸ which can be either positive or negative. Positive mental health outcomes promote growth and well-being, whereas negative outcomes result in adverse psychological, emotional or behavioural conditions. Limited synthesised data exists on common mental health outcomes among adolescents with HIV in sub-Saharan Africa. In recent years, however, a handful of reviews have attempted to synthesise available data on the mental health burdens and problems common among adolescents living with HIV in the sub-region.43,45

For instance, the review by Dessauvagie et al ⁴⁴ synthesised available evidence on the prevalence and associated risk factors of mental health problems among adolescents living with HIV in sub-Saharan Africa. Similarly, Too et al ⁴⁵ assessed the prevalence and associations of depression and anxiety disorders among adolescents living with HIV in sub-Saharan Africa. Recently, Boakye et al⁴³ synthesised published evidence on the prevalence and related risk and protective factors of depression and anxiety among women living with HIV in the same sub-region. Again, a recent review found a high prevalence of mental health problems—particularly depression, anxiety, psychological distress, suicidality and post-traumatic stress disorder (PTSD) across the HIV care continuum for adolescents in sub-Saharan Africa.⁴⁶ However, these reviews were limited to specific periods and searched only globally accessible records, limiting the number of studies included.^{44 45} The reviews also included studies published exclusively in English, which may have led to a selection bias.43,45 These reviews again focused on mental health challenges in adolescents living with HIV, neglecting positive mental health outcomes and factors affecting access to support services, such as resilience and post-traumatic growth. To provide a more nuanced perspective, this review systematically examines common mental health outcomes in adolescents living with HIV, focusing on positive and negative outcomes.

This review focuses on three key positive mental health outcomes: resilience, subjective well-being and post-traumatic growth. Resilience enables individuals to recover from stress and trauma,⁴⁷ and subjective happiness evaluates life satisfaction and emotional well-being.⁴⁸ Post-traumatic growth, a positive psychological transformation, arises from challenging life circumstances, resulting in increased strength, improved relationships and a deeper appreciation for life.⁴⁹

Conversely, four adverse mental health outcomes, including depression, anxiety, PTSD, substance use disorder and suicidality, will be assessed in this review. Depression is characterised by persistent sadness, loss of interest in activities and feelings of worthlessness, often impairing daily life.⁵⁰ Anxiety involves excessive fear or worry, which may be generalised or triggered by specific situations, usually leading to avoidance behaviours.⁵¹ PTSD occurs following exposure to traumatic events. It includes symptoms such as flashbacks, hyperarousal and emotional numbness,⁵² and substance use disorder refers to the harmful or dependent use of drugs or alcohol.⁵³ Suicidality includes suicidal behaviours such as suicidal thoughts, plans or attempts and reflects a critical and urgent mental health crisis.⁵⁴ This review will also describe the associated determinants of these common mental health outcomes, organised in a multilevel manner according to the socio-ecological model. Again, it identifies the facilitators and barriers to mental health support services that can inform intervention efforts and programmes for this young population.

Objectives

The primary objective of this systematic review is to synthesise the available and accessible literature on the common mental health outcomes in adolescents (aged 10–24 years) living with HIV in sub-Saharan Africa. Specifically, this review seeks to describe the following:

1. Reported prevalence estimates of (both positive and negative) common mental health outcomes among adolescents living with HIV in sub-Saharan Africa.

2. Factors associated with these positive and negative common mental health outcomes and

3. Barriers and facilitators to accessing mental health support services.

Methods and analysis

This protocol was developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocol guidelines.⁵⁵ After completing the review, the PRISMA guidelines will be used to inform the reporting of the results.⁵⁶ Key information about this systematic review, including those relating to the design and methodology, has been registered on the PROSPERO database (CRD42024568512).

Eligibility criteria

Broadly, the Population, Exposure of Interest and Outcome format will be adopted to delineate the inclusion criteria for this review.⁵⁷ Table 1 gives a detailed description of the inclusion and exclusion criteria to be used to determine the eligibility of studies for this systematic review.

Table 1. Summary of eligibility criteria.

	Include	Exclude
Settings	Primary studies conducted in clinical and non-clinical settings in any of the 47 WHO member states in Sub-Saharan Africa. Additionally, cross-national studies that involve African and non-African countries, but separate data for African countries will be included.	Primary studies conducted in clinical and non-clinical settings outside the Sub-Saharan Africa. Global, regional or sub-regional studies of which Sub-Saharan African countries have been included but in which results have not been disaggregated. Cross-national studies that do not include disaggregate data for African countries will be excluded.
Population/ participants	Participants sampled are adolescents (aged 10–24 years) living with HIV. Only studies that collect data from adolescents (aged 10–24 years) living with HIV themselves will be included. Participants residing in any of the 47 WHO member states in sub–Saharan Africa. Participants who have reported any of the following common mental health outcomes to be examined (depression, anxiety, PTSD, substance use disorder, suicidality, resilience, subjective happiness and post-traumatic growth).	Studies with adolescents living with HIV who have not reported any of the mental health outcomes to be examined (depression, anxiety, PTSD, substance use disorder, suicidality, resilience, subjective happiness and posttraumatic growth). Studies that collect data on adolescents through their parents, primary caregivers or significant other adults.
Exposure	Two main exposures will be included in this review: Protective or promotive factors Risk factors These exposures will be organised according to the five levels of the socio-ecological model of health: Individual level Interpersonal level Institutional level Community level Policy level	Exposures that are neither protective nor risk factors will be excluded.
Study designs	Primary studies in which quantitative approaches were used (observational designs, eg, cross-sectional, case–control and cohort/longitudinal designs) or qualitative methods (eg, phenomenology and narrative studies) and addressed any of the objectives of this review. Primary studies that reported on any of the three objectives of this systematic review. Reports and publications written in the English language and French. Peer-reviewed papers and master’s and PhD dissertation reports from global and regional organisations based on data.	Any study not written in the English Language or French. Systematic (including umbrella) reviews Any study using the same dataset in a paper that was already included in this review. Any study whose full text is unavailable even after the authors are contacted. Any ‘grey literature’, including editorials, commentaries, opinion pieces and write-ups not based on primary data
Prevalence estimates	Studies that indicate the period prevalence estimate (eg, lifetime, 6-month or 12-month prevalence estimate)	Studies in which it is impossible to determine when the prevalence estimates were made, even after contacting the authors.
Outcome (definition and measurement)	Studies that have clear definitions or descriptions of the outcomes under study will be included in the review. The definitions or descriptions of the outcomes (depression, anxiety, PSTD, substance use disorders and suicidality) should align with descriptions by the DSM-5-TR or ICD-11 Studies that provide precise descriptions of how the outcomes were measured and assessed. Studies that used standardised self-reported and clinically assessed or reported estimates of the outcomes under study will be included in the review.	Studies that lack a clear definition of the outcomes measured and those not aligned with the DSM-5-TR or ICD-11 criteria for the mental health outcomes under study. Studies that do not use standardised or self-reported measures of the outcomes under study

DSM-5-TR, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; ICD-11, International Classification of Diseases 11th Revision; PTSD, post-traumatic stress disorder.

Outcomes

All eligible studies should either report the prevalence of at least one of the mental health outcomes listed above, report factors associated with these outcomes or report on the barriers and facilitators to HIV support services in Sub-Saharan Africa. Eligible studies should have reported evidence addressing at least one of the objectives of this systematic review. Hence, eligible studies should have either estimated the period prevalence of at least one of the common mental health outcomes identified above in Sub-Saharan Africa, described the factors (risk or protective factors) associated with these mental health outcomes or identified the barriers and facilitators to accessing mental health support services. Eligible studies that aim to estimate the prevalence of the outcomes stated above must have provided explicit details regarding the duration of prevalence, as well as the methods by which they were assessed. Additionally, prevalence studies that meet the inclusion criteria will be evaluated based on whether they provide explicit details regarding the sample size and population. In studies where these details are not available in the main text, supplementary materials will be accessed for additional information. Where details are unavailable in the supplementary materials, authors will be contacted to provide further information, clarification or data that were not included in the published paper. However, studies whose details are not made available after consulting supplementary materials and authors will be excluded.

Definition and measurement of outcomes

This review will include studies that provide precise definitions or descriptions of the outcomes reported to maintain uniformity in the use of terms and concepts throughout the literature. In this review, all the outcomes of interest must meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5 TR) and the International Classification of Diseases (11th edition) diagnostic criteria for depression, anxiety, PTSD, substance use disorders and suicidality. In addition, we will include all behaviours or symptoms that meet the DSM-5 TR criteria for any of the outcomes related to this review. Additionally, all research papers that specifically asked participants about any of the significant symptoms associated with the outcomes will be included in the review. Again, studies should provide explicit details regarding the assessment or measurement techniques used to identify or assess cases, such as self-report measures or diagnostic instruments. The assessments could either be of the following:

• Done through structured clinical interviews.

• Conducted using a self-report standardised questionnaire consisting of multiple questions, with either accessible or unavailable validation data or psychometric information.

Prevalence studies that rely on data obtained from third-party sources will not be included.

Study types

Primary research employing observational study designs, including cross-sectional, case–control and cohort studies, will be incorporated into this review. The prevalence estimates and their associated factors will be derived primarily from observational studies that meet the inclusion criteria. The inclusion criteria will encompass both qualitative and quantitative studies that use various research methodologies, including interviews, focus groups, objective measurements and numerical data analysis. Systematic and umbrella reviews will not be included in this review. Studies using the same dataset in a paper that has already been included in this review will also be excluded. Additionally, studies not written in English or French, as well as those for which full texts are unavailable even after contacting the authors, will be excluded. Similarly, editorials, commentaries, opinion pieces and write-ups not based on primary data will be excluded.

Exposures

This review will focus on the risk and protective factors associated with the mental health of adolescents living with HIV in Sub-Saharan Africa within the context of the socio-ecological model. The socio-ecological model provides a framework for analysing the interactions of individual, interpersonal, community and societal elements that influence health outcomes. To systematically capture these processes, the inclusion criteria for risk factors would include studies that investigate variables at various levels, such as individual behaviours, social relationships, community features and broader societal impacts. For instance, individual risk factors may include habits such as smoking or a sedentary lifestyle, and community-level factors could include neighbourhood characteristics that affect health, such as stigma. Similarly, the inclusion criteria for protective factors would consist of studies that investigate characteristics at various socio-ecological levels that minimise or buffer against negative mental health consequences.

Studies that include either risk or protective factors at any level will be included in the review. However, those studies that do not report on either risk or protective factors will be excluded. This review aims to shed light not only on the identification of risk variables but also on the comprehension of protective factors, as summarised in table 2. The inclusion and exclusion criteria, informed by the socio-ecological model, aim to capture a comprehensive view of the factors affecting the mental health of adolescents living with HIV.

Table 2. Summary of exposure factors according to the socioecological model.

Levels	Definition	Protective factors	Risk factors
Individual	It focuses on personal characteristics that affect mental health	Resilience, self-regulation, self-efficacy and mental health literacy	Self-stigma, low self-esteem, isolation and poor medication adherence
Interpersonal	It examines social relationships, including interactions with family, friends and peers, which influence mental health.	Social support from Friends Family Partners Significant others	Parental loss, parental divorce/separation, neglect, peer stigma, bullying victimisation and intimate partner violence victimisation
Institutional level	It focuses on formal institutions, such as schools, healthcare facilities and workplaces, that affect adolescents’ mental well-being.	Inclusivity Provision of mental health support services	Stereotypes, discrimination and poor access to mental health services
Community	It explores broader community environments, including neighbourhoods, social services and community norms that impact mental health.	Community-based mental health programmes	Exposure to crime or violence, social stigma
Policy	It focuses on laws, policies and societal norms that shape mental health outcomes. It includes government policies, legal protections and national health initiatives.	Anti-discrimination laws and enforcement Public health campaigns reducing stigma Government policies ensuring ART and mental health service accessibility	Restrictive policies on HIV disclosure and mental health

ART, Antiretroviral therapy.

Participants

This review will encompass studies selected from Sub-Saharan Africa that involve adolescents (aged 10 to 24 years), irrespective of sex, sexual orientation, occupational affiliation or religious affiliation. To qualify for inclusion, studies must include participants who have had firsthand experience with the mental health outcomes of interest.

Study settings

This review will cover studies undertaken in any of the 47 geographical nations in Sub-Saharan Africa listed by the WHO. Studies conducted in countries that meet the inclusion requirements should have been undertaken in either clinical or non-clinical settings. No restrictions will be placed on specific healthcare settings or geographic locations within the region.

Information sources

To identify eligible literature, search strategies will be developed to incorporate text phrases and medical subject headings (MeSH) associated with mental health outcomes, adolescents and Sub-Saharan Africa. A thorough search will be performed in six electronic databases, four of which are global in scope (PubMed, PsycINFO, Global Health and Embase) and two of which are region-specific (African Journals OnLine (AJOL)) and African Index Medicus (AIM). To augment the electronic database search, other grey literature sources will be incorporated, including post-graduate dissertations identified through ProQuest Dissertations & Theses Global, Google Scholar searches, as well as Electronic Theses and Dissertations portals in Ghana, South Africa, Uganda and Kenya. The ‘Cited by’ feature on Google Scholar will be used to identify pertinent forward citations of these related and relevant papers. Furthermore, the authors of at least two qualifying papers will be contacted, and a request will be made for unpublished copies of pertinent papers from their archives, which will be screened for eligibility. The ‘Similar articles’ function in PubMed and the ‘Related articles' function in Google Scholar will be used to identify additional records. The search will be limited to studies published in English or French from 1959 (the year in which the earliest case of HIV was reported in Africa)⁵⁸ to December 2025. The review will be completed by around June 2026.

Search strategies and processes

The review team will develop a strategy for the literature search. To meet the specific criteria and appropriateness of each selected database, our search strategy will involve keywords, truncation, Boolean logic operators (AND, OR and NOT), and MeSH terms (such as ‘mental illnesses, mental disorders, posttraumatic growth, adolescents, youth, adolescent, Sub-Saharan Africa, Eastern Africa, Central Africa, Western Africa, Southern Africa, Angola, and Benin’) The geographic search filter would encompass the phrases ‘sub-Saharan Africa’ as well as the names of sub-regions (eg, Western Africa) and the 47 countries or nations within the sub-region. A prototype APA PsycINFO search strategy will be created and completed, after which the subject headings and syntax of the other databases (AJOL, AIM, Global Health, CINAHL and PubMed) will be included in the strategy. The comprehensive search technique for PubMed is outlined in online supplemental appendix A. Our search process will be reported using the PRISMA Statement for Reporting Literature Searches in Systematic Reviews guidelines.⁵⁹ Two members of the review team (DAK and ENBQ) will perform the searches, after which DAK and KOA will remove any duplicate entries from the compiled search results.

Data management

The results of the database queries will be compiled and organised using EndNote (version 9.3.3). EndNote will also be used to remove redundant entries and access the full text of potentially eligible scholarly articles. Although the search will be conducted individually on each of the selected databases, the search results will be combined in EndNote before any duplications are removed. Again, Microsoft Excel (spreadsheets) will be designed by the review team for the title and abstract screening, full-text screening, data extraction and risk of bias assessment purposes.

Selection process

Two members of the research team, namely DAK and MAP, will screen titles and abstracts for eligibility based on the predefined inclusion and exclusion criteria. Full-text articles will be obtained for further assessment. Disagreements will be resolved through discussion or consultation with other members of the research team, with ENB serving as an arbiter.

Data collection and data items

To record relevant information obtained from selected studies, a data extraction form will be created. This data extraction form will include specific details such as the authors’ names and publication years, study setting (whether clinical or non-clinical), sampling method and sample size, study design, method of outcome measurement, key findings and study quality score. Data on mental health outcomes outlined above will be extracted. Additionally, data will be extracted on factors associated with these outcomes, as well as barriers and facilitators to mental health support services among this population. Two research team members (DAK and KOA) will independently extract data from the included papers. ENBQ will further authenticate this for comprehensiveness and accuracy. The review team will strive to reach a consensus on addressing any conflicts that may arise during the accuracy verification of the included studies. The team will contact authors of eligible research to obtain supplementary details and, if necessary, verify their accuracy.

Risk of bias in individual studies

Two members of the research team (DAK and KOA) would each employ the Joanna Briggs Critical Appraisal Tools⁶⁰ in assessing the methodological quality of diverse study designs, including quantitative descriptive studies, mixed method studies and qualitative studies. The Joanna Briggs Institute (JBI) provides a collection of critical appraisal tools for systematically assessing the quality of various sorts of research investigations. The JBI checklist for evaluating analytical cross-sectional studies (quantitative studies)⁶¹ addresses critical aspects such as study objective clarity, study design appropriateness, sampling strategy adequacy, validity of exposure and outcome measurements, identification and handling of confounding factors, statistical method appropriateness and clarity of results presentation. In the field of qualitative research, the JBI checklist focuses on the clarity and appropriateness of research questions, suitability of chosen qualitative methodologies, adequacy and appropriateness of data collection methods, appropriateness of data analysis techniques, credibility of findings, transferability of findings to other contexts, and ethical considerations and approvals.⁶²

Data synthesis

Data synthesis will be conducted based on the objectives of this review. To address objective 1, prevalence estimates will be pooled. Summary measures of prevalence will be computed by combining data from individual studies. The summarisation of prevalence estimates may involve either a narrative synthesis, meta-analysis, or combination of the two, contingent on the degree of heterogeneity observed among the observational studies eligible for inclusion in the analysis and report on relationships and prevalence. To assess the degree of heterogeneity among the eligible prevalence and association studies, the I-squared (I²) statistic will be used. A value of 0 signifies the absence of heterogeneity. A value of 25% or less denotes low heterogeneity, whereas a value of 75% or greater signifies high heterogeneity. If heterogeneity is observed to be low, the prevalence estimates will be merged through a meta-analysis using the random effects model available in the Jamovi programming software package (version 1.8.1.1).⁶³ A sensitivity analysis, if deemed necessary, will be performed to assess the likelihood of bias and ascertain potential factors contributing to variation. Subgroup analysis, which may involve the inclusion of sex, research design or age categories, will be conducted if deemed necessary to ensure that comparisons are limited to studies that employ equivalent impact measurements. Furthermore, graphical representations, including forest plots and tables, will be employed to help summarise and visualise the results of individual studies.

To address the second objective of this review, findings on factors associated with common mental health outcomes will be synthesised based on the five levels of the socio-ecological model of health, which include individual, interpersonal, institutional, community and policy level factors. For the third objective, the evidence from studies that meet the criteria will be synthesised using the three-step procedure of narrative synthesis.⁶⁴ These include (1) logically classifying the studies, (2) evaluating the results obtained from each classification and (3) integrating the findings from all the studies that were incorporated. Findings will be integrated using thematic analysis. The thematic analysis enables the construction of a logical storyline from the findings by identifying and synthesising recurring themes or patterns across the included studies.⁶⁵ It also enables the exploration of the underlying meanings and implications of the data, as well as a more comprehensive examination of the studies' content and context.

Patient and public involvement

Considering that this is secondary research, no patients will be involved in this systematic review as participants. However, in the light of recent expert and scholarly recommendations,⁶⁰ we engaged the Adolescent and Young Adult Mental Health Research Lab (the AYA Lab) Advisory Team in the Department of Psychology, University of Ghana, to review and provide feedback to strengthen the eligibility criteria, ensure that the pre-selected databases are aligned and relevant and ensure that review objectives and methodological choices including search terms and strategies, and data synthesis approaches apply to the target population, can enhance the interpretation of the review findings and can potentially improve the practical effect and uptake of the key conclusions. The decision to engage the AYA Lab Advisory Team was necessitated by the practical challenge associated with accessing adolescents living with HIV and (or) their families for inclusion as persons with lived (and living) experiences. The AYA Lab Advisory Team comprises a range of mental health professionals with long-standing research interests and professional experience in delivering mental health programmes and interventions to school-going and out-of-school adolescents and young people living with chronic health conditions, who experience psychosocial and behavioural challenges in Ghana and other resource-poor contexts. For this review, the AYA Lab Advisory Team had three research meetings across 3 weeks to discuss the best scope of this review.

Ethics and dissemination

This systematic review will rely exclusively on secondary data obtained from published or publicly accessible sources and will not involve any direct contact with human participants. As such, ethical approval is not required. The study will adhere strictly to established ethical standards in the conduct and reporting of research, including transparency in methodology, proper citation of sources and unbiased synthesis of findings.

The findings of this review will be disseminated through publication in a peer-reviewed journal and presentations at relevant academic and policy-focused conferences. The review team will ensure that the implications of the findings are communicated to researchers, practitioners and policymakers, with a focus on informing interventions and support services for adolescents living with HIV in Sub-Saharan Africa. Emphasis will be placed on translating the findings into practical recommendations for integrated mental health and HIV care.

Although no substantial amendments to this protocol are anticipated, any necessary changes will be documented and justified in detail. These will include the date of the amendment, a clear description of the change and the rationale behind it. All amendments will be updated in the PROSPERO registration and approved by all contributing authors to ensure transparency and consistency throughout the review process.

Discussion

This review aims to provide a thorough, systematic synthesis of the existing evidence on the prevalence and associated factors of both positive and negative mental health outcomes among adolescents living with HIV in Sub-Saharan Africa. The synthesis of findings will be discussed in the context of the current literature, addressing the implications for policy, practice and future research. The outcomes of this review are anticipated to serve as a helpful asset that enhances the existing body of knowledge in buffering up efforts to ensure the holistic health and well-being of adolescents living with HIV in the sub-region.

This review, while grounded in PRISMA guidelines, may face several notable limitations. The review faces potential publication bias, over-reporting of adverse mental health outcomes and heterogeneity in study designs, measurement tools and methodological rigour. Variability in study quality and data collection methods could compromise internal validity, and language bias may occur. Additionally, the uneven geographic and demographic representation, over-representation from certain countries and reliance on self-reported data may pose limitations to the findings. There may also be the risk of under-reporting due to stigma or limited mental health literacy. Given the considerable diversity among the studies incorporated into this review, there may be variability that could hinder the ability to conduct a meta-analysis, which may be attributable to the diverse methodologies employed in the individual studies included in this review. Additionally, the risk of limited eligible studies may result in reduced geographic and demographic representation, as well as restricted generalisability, particularly for underrepresented countries in the sub-region.

Nevertheless, this review is essential because it allows for subgroup analysis that compares differences and similarities in terms of risk and protective factors. The review’s focus on self-reported data from adolescents ensures interventions designed based on the review’s findings reflect the real needs of adolescents living with HIV. By identifying risk and protective factors across multiple levels, the evaluation can inform culturally tailored, multi-level interventions that target these factors. It supports a strengths-based and adolescent-centred approach, promoting adolescent involvement in intervention design and highlighting the need for accessible, integrated mental health services within HIV care.

The evidence this review offers may help identify specific areas and individuals that require further research focus regarding mental health outcomes. For instance, findings may inform targeted funding, legal reforms and policies that are adolescent-friendly. In practice, the review can promote holistic and trauma-informed care by supporting the integration of mental health services into HIV programmes and guiding the refinement of screening and referral systems. For research, it highlights gaps in areas such as resilience, trauma and the impact of COVID-19 and sets methodological standards to guide future research. Overall, the results of this review will be relevant and captivating for stakeholders in academia, research, clinical community and health policymakers in Sub-Saharan Africa.