Intersecting Vulnerabilities: Depression, Suicidality, and HIV Risk Among Young Mothers in South Africa

Abstract

Many African women who are pregnant or parenting face intersecting challenges including intimate partner violence, unplanned pregnancies, and motherhood-related stresses that heighten vulnerability to poor mental health. Depression and suicidal ideation are associated with behaviors that increase HIV risk, yet limited research has explored these relationships in African contexts. This study examined associations between depressive symptoms, suicidal ideation, and sexual risk behaviors among unemployed young women aged 19–24 years in KwaZulu-Natal, South Africa. Baseline data were collected between June-October 2018 from participants who had been sexually active in the past year. Prolonged sadness (≥ 2 weeks) and suicidal ideation in the past year were measured using validated single-item indicators. The composite HIV risk outcome captured transactional sex, partners with unknown HIV/STI status, and substance-influenced sex. Poisson regression models adjusted for age, intimate partner violence, and HIV serostatus; moderation by HIV status was tested. Among 1,026 women (median age 22 years), 8.6% were living with HIV, 34% reported prolonged sadness, and 10% reported suicidal ideation. Both exposures were associated with elevated HIV risk (prolonged sadness: PRR = 1.79, 95% CI 1.41–2.27; suicidal ideation: PRR = 1.67, 95% CI 1.24–2.27). Moderation analysis showed no interaction between depressive symptoms and HIV serostatus but identified a significant interaction for suicidal ideation, with a stronger association among women living with HIV. Findings underscore the burden of depressive symptoms among young mothers and its contribution to HIV vulnerability. Integrating mental health screening and referral within antenatal, postnatal, and HIV care could improve outcomes for both women and their children.

Introduction

Depression and suicide represent major public health challenges in low- and middle-income countries (LMICs), where unmet mental healthcare needs and structural vulnerabilities enhance impact [1–4]. This is especially concerning because behavioral health services in LMICs are critically underfunded, resulting in limited access and large treatment gaps [5]. Without timely and effective care, depression can worsen in severity, underscoring the urgency of developing feasible, contextually relevant services.

Pregnancy and the postpartum period are times of heightened vulnerability to depression and suicidal ideation, driven by biological, psychological, and social changes [6–9]. Perinatal and maternal depression and suicide remain an under-researched and often hidden burden in LMICs, with socioeconomic disadvantage, intimate partner violence (IPV) and unplanned pregnancies exacerbating depression and suicide risk [10–12]. The concept of a syndemic, introduced by Merrill Singer [13], describes the co-occurrence and synergistic interaction of multiple health conditions within populations shaped by adverse social and structural contexts. These interacting conditions produce effects greater than the sum of their parts. In this context, the convergence of poverty, gender-based violence, and depression creates reinforcing pathways that intensify women’s vulnerability to HIV and undermine sustained engagement in prevention and care. In this study, we operationalize a syndemic framework by examining how co-occurring psychosocial (e.g., depression, suicidal ideation) and structural (e.g., economic insecurity, gender-based violence) vulnerabilities jointly influence HIV risk behaviors and engagement in prevention and care among pregnant and parenting young women. For women in sub-Saharan Africa specifically, the risk of depression during pregnancy and motherhood is further complicated by the generalized HIV epidemic which disproportionately burdens women. In fact, while an estimated 1 in 4 women in LMICs experience depression during pregnancy or within the first year postpartum, the estimated prevalence is even higher (35.1%) among pregnant and postpartum women living with HIV [14]. Reducing exposure to maternal depression and suicidal ideation during pregnancy, postpartum, or early motherhood is critical for the health of both mother and child, as it can adversely affect child health and developmental outcomes, leaving an intergenerational footprint [15, 16].

Adolescent girls and young women (AGYW) in sub-Saharan Africa face a combination of biological and contextual factors that place them at increased risk of poor mental health, relative to male peers [17, 18]. Biologically, reproductive health concerns, hormonal changes, unplanned pregnancies, and increased susceptibility to HIV play a critical role. Contextually, school pressures, life stressors, gender-based violence, gendered power dynamics, and lack of financial independence compound these risks. Economic insecurity, caregiving strain, and limited partner support are well-established predictors of both depression and incident and prevalent HIV infection [19, 20]. Within AGYW populations, young motherhood represents a distinct context of vulnerability embedded within broader social and structural determinants of mental health, including economic insecurity, caregiving responsibilities, and social disadvantage, which may increase risk of depression [5]. In South Africa, pregnant AGYW and mothers face further overlapping structural and social vulnerabilities that heighten depression and HIV risk. Economic insecurity also directly raises HIV risk through transactional sex, with these pathways compounded by the competing demands of caregiving and survival [21]. Motherhood, particularly without a supportive partner, often increases financial strain and isolation, while alcohol use as a coping strategy further reduces sexual safety [22]. Broader challenges, such as economic uncertainty, unemployment, and weak social protection, gender inequities, IPV, stigma, and limited autonomy can exacerbate mental distress and limit protective sexual behaviors [23, 24]. These factors do not operate in isolation; rather, they co-occur and reinforce one another, creating synergistic pathways through which mental health challenges, economic vulnerability, and gender inequities jointly elevate HIV risk. For example, more than 75% of new HIV infections among 15–24 year-olds in Africa occur in females, highlighting the disproportionately high risk of HIV acquisition among adolescent girls and young women in this age group [18, 25]. Low contraceptive uptake and a median age at first birth of 19 years [15, 26] further place many AGYW into motherhood during a period of heightened HIV risk [27] and mental health vulnerability [28].

Mental health challenges, particularly depression, are bidirectionally linked with HIV. Depression is associated with increased engagement in behaviors that elevate acquisition risk [29, 30] and undermines adherence to biomedical prevention (PrEP) [31, 32] and treatment (ART) regimens [33, 34]. Depression is also more prevalent among AGYW who are living with HIV in this context than among those who are not [17]. Despite being a priority population for PrEP, uptake and persistence remain suboptimal [35], while adherence among AGYW living with HIV is often poor [36]. These intersecting vulnerabilities underscore the urgent need to integrate mental health services with biomedical HIV prevention and treatment adherence support, particularly during pregnancy and breastfeeding, so that HIV programs for AGYW can be more comprehensive and effective. Figure 1 illustrates the hypothesized syndemic pathways linking structural vulnerabilities, mental health, and HIV risk behaviors among young pregnant women and mothers in South Africa.

Fig. 1.

Syndemic conceptual framework underpinning the present study

Despite evidence linking depression, suicidal ideation, and HIV risk, few studies have examined these intersections specifically among pregnant and parenting young women, a population for whom consequences extend to both mother and child. The present study addresses this gap by exploring these relationships among pregnant women and mothers in two communities that experience a high burden of HIV, with the aim of informing interventions that integrate mental health and HIV prevention within maternal and primary health services. Guided by the syndemic framework, we hypothesised that depressive symptoms and suicidal ideation would each be independently associated with greater engagement in behaviours that increase risk of HIV acquisition/onward transmission among pregnant and parenting young women. We further examine whether these associations differ by HIV status.

Methods

Data Collection

Data were collected as part of the Cash Plus Care (CPC) program evaluation. CPC was an incentivized behavior change intervention for young women, aged 19–24 years in KwaZulu-Natal, South Africa. The program was implemented in King Cetshwayo District (KCD), while uGu District served as the control site; baseline data were collected in both districts. The CPC program has been described previously [37]. In brief, young people who reported currently being unemployed or employed part-time, female, between 19 and 24 years of age and residing in study districts were eligible.

In KCD, participants were recruited using convenience sampling, from “Women of Worth” (WoW), a structured 12-session HIV and sexual health workshop series delivered over one year. Attendance was incentivized with conditional cash transfers. Baseline surveys were conducted from June-October 2018. The intervention was HIV serostatus-neutral, with content addressing both prevention and treatment. In the control site (uGu District), participants were recruited through community structures, with baseline data collected July–September 2018.

The present study utilizes data from the baseline survey in each community, delivered in person by trained research assistants at community venues. Given our interest in depressive symptoms and suicidal ideation among current and expectant mothers, we restricted our analytic sample to women who were currently pregnant or had at least one child and reported sexual activity in the past year. Baseline data collection occurred in the participants’ preferred language (English or isiZulu) and took between 30 and 90 min. Written informed consent was obtained prior to data collection, and participants were reimbursed R60 (US $3) in vouchers for their time at this visit.

Measures

Mental health was assessed through two single-item exposure measures from the U.S. Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Surveillance System (YRBSS) [38, 39], which have been previously validated [40, 41], although not specifically in South Africa.

1. Prolonged sadness (described in the results and discussion as “depressive symptoms”) was assessed with the following question: “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?” (Dichotomized as yes vs. no).

2. Suicidal ideation was assessed with the question: “During the past 12 months, did you ever seriously consider attempting suicide?” (Dichotomized as yes vs. no).

The primary outcome was a composite HIV risk behavior variable, defined as self-reported engagement in any of the following behaviors. These variables were identified a priori from the literature as prevalent among young women in South Africa and associated with elevated risk of HIV acquisition. The variable was operationalized as a count variable with participants having engaged in none, 1, 2 or all 3 behaviors:

• Transactional sex: “In the last 12 months, did you enter into a sexual relationship with a man mainly in order to get things that you need, money, gifts, or other things that are important to you?” (Dichotomized as yes vs. no).

• Sexual partnerships with individuals of unknown HIV/STI status: “How many partners (that you know of) have you had sex with who have not been tested for STIs/HIV?” (Dichotomized as any vs. none).

• Substance-influenced sex: “How many times have you or your partner used alcohol or drugs before or during sex?” (Dichotomized as ever vs. never).

Additional variables of interest included self-reported age, employment status (both current employment and actively seeking work), pregnancy status, IPV (yes/no to a single item question, “In the past 12 months, a partner has hit me (with a fist or slap or something else that could hurt me))”, whether the pregnancy was planned, and whether the father lived in the same household.

Ethical considerations

Ethical approval for the study was obtained from the Human Sciences Research Ethics Committee (REC 6/28/03/18a, b and c).

Analysis

Descriptive analyses were conducted to characterize the study sample. Following descriptive analyses, unadjusted regression models were first conducted to examine the relationship between each primary exposure (prolonged sadness and suicidal ideation) and the HIV risk composite variable. Poisson regression with robust standard errors was implemented using PROC GENMOD in SAS Studio to account for potential overdispersion and provide more accurate variance estimates. Model fit was assessed using Akaike Information Criterion (AIC). Poisson regression with a log link function was used to estimate crude and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). Separate models were constructed to assess the associations between each primary exposure (prolonged sadness and suicidal ideation) and HIV risk behavior.

Potential confounders were identified a priori using directed acyclic graphs (DAGs) to account for possible bias in the associations of interest. Based on these conceptual models, all regression models adjusted for intimate partner violence and HIV serostatus.

Most of our sample was not living with HIV but given potential differences in HIV risk behavior by HIV serostatus, in addition to running models where we controlled for potential confounding by HIV status, we also assessed moderation on the multiplicative scale by including interaction terms between HIV serostatus and each mental health exposure (prolonged sadness and suicidal ideation). To ease interpretation of moderation findings, we excluded those with unknown status from these models. To further understand findings, from the moderation analysis, HIV serostatus stratified models were also run. Statistical significance for all models was set at p < 0.05.

Results

Our analytic sample contained 1,026 women (full sample size prior to applying our eligibility criteria was 3,076). The median age was 22 years (IQR: 21–23). On average, participants had one child (86%, n = 881) and 2% (n = 17) of the sample were pregnant at the time of the study. Nearly all (96.7%, n = 992) reported their most recent pregnancy was unplanned. Most (98.3%, n = 1009) were not employed and more than half of those (56.2%, n = 577) were currently seeking work. Overall, 8.7% (n = 87) were living with HIV at study baseline, and 9.1% (n = 93) reported experiencing past year physical violence (see Table 1).

Table 1.

Descriptive characteristics of the study sample

		N (%)
Median Age [IQR]		22 [21–23]
Past year IPV
	Yes	93 (9.1%)
	No	933 (90.9%)
Currently employed
	Yes	17 (1.7%)
	No	1009 (98.3%)
Looking for work
	Yes	577 (56.2%)
	No	448 (43.7%)
	Refused to answer	1 (0.10%)
Currently pregnant
	Yes	17 (1.7%)
	No	1009 (98.3%)
Currently a mother (includes women who are pregnant as long as they have at least one child already)
	Yes	1014 (98.8%)
	No	12 (1.2%)
Last/current pregnancy planned?
	Yes	34 (3.3%)
	No	992 (96.7%)
Father lives in same household? (n = 502)
	Yes	192 (38.3%)
	No	310 (61.8%)
Student status (n = 1024)
	Regular school full time	296 (28.9%)
	Regular school part time	17 (1.7%)
	College or university, full time	75 (7.3%)
	College or university, part time	30 (2.9%)
	Not a current student	606 (59.2%)
HIV Status (n = 1026)
	Negative	919 (89.6%)
	Positive	87 (8.5%)
	Unknown	20 (2%)
Transactional Sex in past 12 months
	Yes	82 (8.0%)
	No	944 (92%)
>=1 partner who has not been tested for HIV/STI
	Yes	150 (14.6%)
	No	876 (85.4%)
You or partner engaged in substance use before sex in past year
	Yes	64 (6.2%)
	No	962 (93.8%)
Alcohol use in past month
	Yes	66 (6.4%)
	No	960 (93.6%)
Prevalence of HIV risk behaviors
	None	797 (77.7%)
	1 risk behavior	176 (17.2%)
	2 risk behaviors	39 (3.8%)
	3 risk behaviors	14 (1.4%)

In the past year, 34% of participants reported experiencing prolonged sadness, while 10% reported suicidal ideation. Additionally, 22.3% reported engaging in at least one behavior that increased susceptibility to HIV, including having engaged in transactional sex in the past year (8%), not knowing their partner’s HIV or STI status (14.6%), and using substances before sex (6.3%).

Overall Models

In our unadjusted models, both prolonged sadness and suicidal ideation in the past year were associated with increased composite HIV risk, with prevalence ratios of 2.11 (95% CI: 1.75–2.52) and 1.98 (95% CI: 1.58–2.47), respectively (see Fig. 2).

Fig. 2.

Adjusted and Unadjusted Prevalence Ratios for Prolonged Sadness and Suicidal Ideation on HIV Risk among Current and Expectant Mothers. Models adjusted for IPV, age and HIV serostatus

Models adjusted for age, IPV, and HIV serostatus showed similar associations with HIV risk PRs of 1.79 (95% CI: 1.41–2.27) for sadness and 1.67 95% CI: 1.24–2.27) for suicidal ideation (Fig. 2).

Moderation Analysis

As shown in Table 2, moderation analysis showed no evidence of interaction between prolonged sadness and HIV serostatus (aPR = 0.90, 95% CI: 0.50–1.62, p = 0.7180). In contrast, a significant interaction was observed for suicidal ideation, with stronger associations between suicidal ideation and HIV risk behaviors among women living with HIV (aPR = 2.14, 95% CI: 1.12–4.06, p = 0.0213).

Table 2.

Stratified prevalence ratios and moderation by HIV serostatus for associations between prolonged sadness, suicidal ideation, and hiv risk behaviors among current and expectant mothers

Exposure	Analysis	Unadjusted PR (95% CI)	P-value	Adjusted PR (95% CI)	P-value
Prolonged sadness	Interaction (n = 1026)	--	--	0.90, (0.50, 1.62)	0.718
	LWH strata (n = 87)	1.72 (1.02, 2.91)	0.0438	1.53(0.90, 2.61)	0.114
	Not LWH strata (n = 909)	1.98 (1.53, 2.57)	< 0.001	1.95 (1.49, 2.54)	< 0.001
Suicidal ideation	Interaction (n = 1026)	--	--	2.14 (1.12, 4.06)	0.0213
	LWH strata (n = 87)	3.23 (1.93, 5.39)	< 0.001	2.47 (1.44, 4.22)	0.001
	Not LWH strata (n = 909)	1.42 (0.96, 2.1)	0.076	1.35 (0.91–2.01)	0.134

HIV Serostatus Stratified Models

Among those living with HIV (n = 87), prolonged sadness was associated with behaviors that increase risk of onward transmission to serodiscordant partners in the unadjusted model (PR = 1.72, 95% CI: 1.02–2.91, p = 0.0438), but the association was attenuated and no longer statistically significant after adjustment (PR = 1.53, 95% CI: 0.90–2.61, p = 0.1125).

In contrast, suicidal ideation showed a strong association with behaviors that increase risk of onward transmission to serodiscordant partners, both in unadjusted and adjusted models (PR = 3.23, 95% CI: 1.93–5.39, p < 0.0001 and PR = 2.47, 95% CI: 1.44–4.22, p = 0.001, respectively).

Among women not living with HIV (n = 909), prolonged sadness was significantly associated with HIV risk in both unadjusted (PR = 1.98, 95% CI: 1.53–2.57, p < 0.0001) and adjusted models (PR = 1.95, 95% CI: 1.49–2.54, p < 0.0001). In contrast, suicidal ideation was not associated with HIV risk after adjustment (aPR = 1.35, 95% CI: 0.91–2.01, p = 0.1338) for this cohort.

Discussion

This study examined associations between mental health and engagement in behaviors that increase risk of HIV acquisition and, among women living with HIV, onward transmission among current and expectant mothers in South Africa. In our sample, one-third of women who were either pregnant or were mothers reported prolonged sadness, while one in ten reported suicidal ideation in the past year. Both prolonged sadness and suicidal ideation were significantly associated with engagement in behaviors that increase susceptibility to HIV acquisition and onward transmission. These findings are consistent with syndemic theory [13], which describes the co-occurrence and mutually reinforcing relationships between depressive symptoms, suicidality, and HIV risk behaviors within structurally constrained contexts characterized by poverty, gender inequality, and violence [42, 43]. Sensitivity analyses showed that prolonged sadness was no longer significant among women living with HIV, though the direction of the association remained consistent with the overall sample, likely reflecting limited statistical power in this subgroup (n = 87) and should not be interpreted as evidence of no association. In contrast, suicidal ideation strongly predicted engagement in behaviors that increase risk of onward transmission among women living with HIV but not among women without HIV, indicating that the observed association in the overall sample was largely attributable to the association among women living with HIV. Differences in associations by HIV status should be interpreted cautiously given the relatively small number of women living with HIV and limited precision of stratified estimates. In line with our findings, which emphasize the importance of addressing mental health in this population among both those living with and at risk of HIV, we propose solutions around three priority areas: expanding resources to support mental health services in a constricting funding environment, addressing contextual drivers of poor mental health, and leveraging peer programming that is culturally relevant and stigma responsive.

The prevalence of perinatal depression in Africa is generally high (24.3% [14]), with estimates for South Africa even higher (38.5–47% for perinatal and 31.7–39.6% for postpartum depression [44, 45]), consistent with our findings. Our estimates of suicidal ideation also align with prior meta-analyses, which estimate a 9% past-year prevalence in LMICs, and fall within the previously reported range for the perinatal period in South Africa (7.5–27.5%) [46]. Importantly, the observed associations between reported depressive symptoms, suicidal ideation, and sexual risk, including transactional sex and unknown partner serostatus, build on the limited prior research on this topic [29, 30]. Together, these data underscore the dual vulnerabilities faced by young mothers and highlight the need to prioritize mental health within antenatal and women’s primary care services. Importantly, while our study was not designed to distinguish effects by parity or postpartum status, young motherhood within AGYW populations likely reflects a distinct social context characterized by increased caregiving responsibilities, economic strain, and social disadvantage that may shape mental health risk and warrants further investigation in future research.

Our findings highlight the need for mental health support for pregnant women and mothers, and the intersecting vulnerabilities of pregnant women and mothers in South Africa, where high rates of depression and suicidality coexist with elevated HIV risk. A considerable barrier to supporting mental health of pregnant women and mothers in South Africa is the limited funding for mental health programming. Although the most recent data suggests that 5% of South Africa’s national health budget is allocated to mental health [47], which is consistent with the Global Mental Health Action Network recommendation for LMICs, a substantial financing gap persists. In particular, the overwhelming majority of these funds (86%) support in-patient psychiatric treatment [48]. Further, many mental health services in LMICs, including South Africa, are integrated into HIV care and treatment programs, with substantial reliance on international donors such as PEPFAR and USAID. A recent survey of 131 programs across 32 LMICs estimates that 75% of a million people lost access to mental health care due to these funding cuts and 73% of the mental health workforce serving these programs lost their jobs due to recent funding cuts by the US government [49]. HIV prevention services were also severely impacted with PrEP access among pregnant women in South Africa being disrupted [50]. As health systems adapt to constrained budgets, sustainable models must leverage task-shifting, integrate with existing HIV platforms, and minimize additional system burden. Addressing these overlapping challenges requires innovative, context-specific approaches that extend beyond traditional clinic-based services. Evidence suggests that community-delivered, peer-led, and group-based models are particularly valuable for populations facing sensitive and stigmatized issues such as mental health distress, suicidal ideation, and HIV risk behaviors [51]. These models create safe, trusted spaces where AGYW mothers can share experiences and receive mutual support, mitigating the social isolation that often compounds psychological distress [52]. Group and peer-led interventions have been shown to reduce barriers to disclosure and help normalize conversations around topics that carry stigma, including depression, suicidality and IPV [51, 52].

Given that our findings highlight the role of structural and psychosocial vulnerabilities in shaping HIV risk behaviors, structural interventions may be particularly important. Conditional cash transfers have shown promise in addressing these structural barriers. In South Africa’s HPTN 068 trial, transfers improved school attendance and reduced partner violence among AGYW, although without direct impact on HIV incidence [53, 54]. However, by reducing economic dependence and exposure to partner violence, such transfers may indirectly lower HIV risk. The CPC intervention extended this model by pairing transfers with structured HIV and sexual health workshops, highlighting the potential of “cash plus” approaches [55]. For sustainability, linking such programs to South Africa’s Child Support Grant (CSG), which already reaches millions of mothers could sustain economic benefits while integrating psychosocial components to strengthen mental health outcomes [56–58].

In light of the strong association between mental health and HIV risk behaviors observed in this study, and among persons living with HIV in particular, scalable approaches to delivering integrated support are needed. Peer-delivered and community-based care can further extend access to integrated mental-health and HIV services. The mothers2mothers program demonstrated that Mentor Mothers improved PMTCT knowledge, disclosure, and psychosocial wellbeing [59], with a cluster RCT showing reduced maternal depression and better infant outcomes [51]. Improvements in maternal mental health and disclosure support may also reduce barriers to HIV prevention and treatment adherence. Similarly, Zimbabwe’s Friendship Bench showed that lay counsellors delivering problem-solving therapy reduced depression and suicidal ideation [52]. Digital platforms such as MomConnect [60], which already reaches millions of South African mothers via mobile messaging, could extend the reach of such interventions at low cost, particularly when linked with grant systems and community-based care.

In this study, peer navigators and task shifting among lay health workers represent a promising delivery mechanism for such integrated, evidence-based care. Positioned within communities and often sharing lived experiences with participants, they are uniquely equipped to provide psychosocial support that is empathetic, culturally relevant, and accessible. Evidence from HIV care in South Africa demonstrates the effectiveness of peer-delivered models in improving adherence and retention in care [61]. Extending this framework to include mental health promotion and suicide prevention could increase uptake of services while addressing stigma and mistrust of formal healthcare systems. Peer navigators can bridge AGYW mothers to clinical services while simultaneously offering psychosocial interventions such as problem-solving therapy, behavioral activation, or group interpersonal therapy approaches shown to be feasible in low-resource settings [62].

Our findings underscore the need for holistic models of care that integrate mental health, improved HIV prevention and treatment access and adherence, and social support within community platforms. Interventions designed for AGYW mothers must move beyond siloed service delivery to address the structural and psychosocial dimensions of their lives. Future research should examine how best to operationalize and scale community-based, peer-led approaches in ways that are sustainable and responsive to the needs of young mothers.

This study has several strengths and limitations. Key strengths include our large sample size and focus on an underserved population with high unmet healthcare needs, addressing an important gap in the literature and advancing equity in research. The cross-sectional design (which precludes causal inference and creates temporal ambiguity), use of single-item measures for mental health constructs and potential recall and social desirability bias for self-reported measures are noted limitations. In addition, future research should test the feasibility, acceptability, and effectiveness of community-based, peer-led approaches that integrate mental health with HIV prevention and treatment in routine care settings, including primary, antenatal, and postpartum services. These efforts should include rigorous implementation research and ongoing dialogue with multilevel stakeholders to ensure timely integration into national programming. Finally, the observed moderation suggests that early identification and treatment of depressive symptoms (i.e., before it can progress to suicidal ideation) among expectant and current mothers who are living with HIV may represent an important entry point for integrated HIV prevention strategies. However, the relatively small number of participants living with HIV limited statistical power for subgroup and interaction analyses, and these exploratory findings should therefore be interpreted with caution.

Conclusion

Mental health must be central to strategic planning for not only HIV but maternal health more broadly. Integrated, community-based, and economically supportive approaches (such as cash transfer programs) are urgently needed to address the intersecting social and structural vulnerabilities affecting both mothers and their children. Embedding more active mental health surveillance (along with screening and support for contextual factors associated with depression risk) into antenatal and primary care may promote earlier detection and connection to mental health resources, ideally reducing progression to more severe mental health challenges.

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.