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Table 2 Study outcomes for association between mental health and HIV risk

From: A scoping review of the associations between mental health and factors related to HIV acquisition and disease progression in conflict-affected populations

First author & Year Mental health disorders Mental health scales HIV risk measures Results
Mental health and HIV serostatus/HIV-related outcomes
Adedimeji et al., 2015 Rwanda Depression
PTSD
Center for Epidemiologic Studies Depression Scale (CES-D)
Harvard Trauma Questionnaire (HTQ)
HIV serostatus
Had sex last 6 months
Condom use at least 50% of time last 6 months
History of ever exchanging sex for cash or help
History of a non-HIV STI
Depression (p < 0.001) but not PTSD (p = 0.06) was related to HIV serostatus
Depression (p = 0.002) but not PTSD (p = 0.09) was related to sex in the last 6 months; women who had sex did not have different odds of depression scores between 16 and 26 (OR = 0.88, CI 0.64, 1.22) but had decreased odds of depression scores 27+ (OR = 0.57, CI 0.04, 0.81) and no different odds of symptomatic PTSD (OR = 0.78, CI 0.60, 1.03)
Depression (p = 0.04) and PTSD (p = 0.006) were related to 50% condom use in the last 6 months; women who used condoms had greater odds of depression scores between 16 and 26 (OR = 1.84, CI 1.20, 2.82) but not scores 27+ (OR = 1.36, CI 0.87, 2.54) and decreased odds of symptomatic PTSD (OR = 0.60, CI 0.42, 0.86)
Depression (p = 0.02) and PTSD (p = 0.003) were related to exchange sex; women who had exchanged sex had greater odds of depression scores between 16 and 26 (OR = 1.82, CI 1.19, 2.77) and 27+ (OR = 1.74, CI 1.10, 2.76) and greater odds of being symptomatic for PTSD (OR = 1.68, CI 1.19, 2.36)
Depression (p = 0.04) but not PTSD (p = 0.74) related to history of a non-HIV STI; women with a non-HIV STI had greater odds of depression scores between 16 and 26 (OR = 2.02, CI 1.39, 3.09; AOR = 1.64, CI 1.01, 2.65) but not depression scores of 27+ (OR = 1.50, CI 0.94, 2.41; AOR = 1.11, CI 0.65, 1.89) nor symptomatic PTSD (OR = 1.07, CI 0.77, 1.50)
Adler et al., 2011 USA PTSD PTSD Checklist (PCL) Risked STD by having unprotected sex PTSD at time 1 predicted sex without a condom four months later (OR = 1.57, CI 1.20, 2.04)
Kinyanda et al., 2012 Uganda Depression Hopkins Symptom Checklist (HSCL-15) High risk sexual behaviors:
sex outside marriage;
sex in exchange for gifts;
sex in exchange for money;
sex in exchange for protection;
sex with an older person;
sex with someone known for less than a day;
sex with uniformed personnel;
sex with more than one partner
High-risk sexual behavior was marginally related to MDD amongst males in univariate analysis (OR = 1.61, 95% CI 0.99–2.62, p = 0.06) but not females (OR = 1.17, 95% CI 0.68–2.01, p = 0.57).
High-risk sexual behavior was related to MDD amongst males (OR = 1.70, 95% CI 1.01–2.86, p = 0.05) in multivariable analysis but not females (OR = 1.03, 95% CI 0.59–1.80, p = 0.91).
Kinyanda et al., 2016 Uganda Depression HSCL-25 Sexual intimate partner violence (IPV) (‘force you to have sex when you don’t want to’) Females who experienced sexual IPV had greater odds of probable MDD (AOR = 4.20, CI 1.54, 11.46)
Malamba et al., 2016 Uganda Depression
PTSD
HSCL-25
HTQ
HIV serostatus Those with MDD symptoms had greater odd of testing positive for HIV (UOR = 2.70, CI 1.95, 3.75; AOR = 1.89, CI 1.28, 2.80)
Those with PTSD symptoms had greater odds of testing positive for HIV (UOR = 1.90, CI 1.30, 2.78; AOR = 1.44, CI 1.06, 1.96)
Svetlicky et al., 2010 Lebanon PTSD PTSD Inventory Risky sexual activities (3 items including sex without protection against sexually transmitted diseases) No relationship was found between PTSD and risky sexual activitiesa
Talbot et al., 2013 Rwanda PTSD PCL Laboratory STI testing
HIV risk taking behavior:
Exchanging sex for drugs, money, or favors;
Having sex with an HIV-infected or status unknown partner;
Having two or more sexual partners within the past 3 months
Rates of STI were too low to evaluate associations with PTSD make any conclusions.
Higher PTSD symptoms correlated with increased HIV risk-taking behavior (r = 0.24, p = 0.006) at baseline.
PTSD symptoms were related to baseline HIV risk (0.01, p = 0.002) in a growth model; for each 1 point increase of trauma symptoms there was a 0.01 unit increase in baseline HIV risk
B.E. Cohen et al., 2012 USA Depression
PTSD
Comorbid depression and PTSD
ICD-9-CM diagnostic codes Sexually transmitted infections: cervical dysplasia;
genital herpes;
genital warts;
chlamydia;
gonorrhea;
trichomonas;
and other STIs
All STIs except chlamydia were associated with PTSD.
Cervical dysplasia AOR = 1.86 (CI 1.61–2.16),
Genital herpes AOR = 1.69 (CI 1.36–2.08),
Genital warts AOR = 1.83 (CI 1.45–2.31),
Chlamydia AOR = 1.66 (CI 0.93–2.96),
Gonorrhea AOR = 3.12 (CI 1.51–6.44),
Trichomonas AOR = 1.60 (CI 1.08–2.39),
Other STIs AOR = 1.83 (CI 1.52–2.21)
All STIs were associated with depression.
Cervical dysplasia AOR = 2.35 (CI 2.12–2.59),
Genital herpes AOR = 2.51 (CI 2.20–2.87),
Genital warts AOR = 2.44 (CI 2.09–2.86),
Chlamydia AOR = 2.21 (CI 1.49–3.27),
Gonorrhea AOR = 3.99 (CI 2.38–6.71),
Trichomonas AOR = 2.38 (CI 1.85–3.06),
Other STIs AOR = 2.21 (CI 1.95–2.53)
All STIs were most strongly associated with comorbid PTSD and depression.
Cervical dysplasia AOR = 2.65 (CI 2.41–2.91),
Genital herpes AOR = 2.55 (CI 2.24–2.91),
Genital warts AOR = 2.97 (CI 2.56–3.43),
Chlamydia AOR = 2.58 (CI 1.80–3.70),
Gonorrhea AOR = 4.74 (CI 2.91–7.71),
Trichomonas AOR = 3.75 (CI 3.01–4.66),
Other STIs AOR = 2.92 (CI 2.59–3.28)
Sexual violence and mental health outcomes
Amone-P’olak et al., 2013 Uganda Depression and anxiety Acholi Psychosocial Assessment Instrument (APAI) Sexual abuse measured by one item in the War Trauma Screening scale Sexual abuse (β = 0.32, SE = 0.16, p < 0.001) predicted symptoms of depression and anxiety for female but not male youths in multivariate analysis.
Roberts et al., 2008 Uganda PTSD HTQ Rape or sexual abuse Those who reported rape or sexual abuse had greater odds of PTSD symptoms (AOR = 1.76, CI 1.01, 2.75) but not depression symptoms (NR)
Nakimuli-Mpungu et al., 2013 Uganda Depression
PTSD
Self- reporting questionnaire (SRQ-20)
HTQ
Experienced sexual violence
HIV serostatus
Experiencing sexual violence was significantly related to PTSD symptom scores (β = 3.75, SE = 1.01, p < 0.05) but not depression symptom scores (β = 0.54, SE = 0.45).
Being HIV-positive was not significantly related to depression (β = 0.51, SE = 0.43) or PTSD (β = −1.41, SE = 0.94) scores.
Okello et al., 2007 Uganda Depression
Anxiety
PTSD
MINI-KID Sexual torture (undefined)
Being forced to marry
Quantitative results not presented in a table, but the stated that no trauma event (including sexual torture and being forced to marry) showed any significant relationship with any diagnosis of PTSD, major depression and generalized anxiety disorder.a
Betancourt, Agnew-Blais, et al., 2010 Sierra Leone Depression and anxiety A measure developed by the Oxford Refugee Studies Program for use among former child soldiers includes a subscale for anxiety, depression, and hostility Rape as part of Child War Trauma Questionnaire Surviving rape predicted an increase in depression over time (b = 2.58, p = 0.01) after controlling for demographic and war-related experiences. When perceived discrimination was included, the strength of the relationship between rape and depression is reduced, (b = 1.65, p = 0.08). When protective factors were added, there was no longer a relationship between rape and depression.
Surviving rape was significantly associated with higher levels of anxiety (b = 5.35, p < 0.001) even after perceived discrimination and protective factors were controlled for.
Betancourt et al., 2011 Sierra Leone Depression and anxiety HSCL-25 Rape as part of Child War Trauma Questionnaire No significant relationship between rape and depression after controlling for multiple variables b = 2.42 (CI -0.99, 5.84).
Rape was significantly related to anxiety b = 2.85 (CI 0.45, 5.26, p = 0.05).
A smaller percentage of boys experienced rape (5%) compared to girls (44%), but the effect of rape on anxiety was significant among male child soldiers and not for females (b = −6.42, p = 0.05).
Betancourt, Borisova, et al., 2010 Sierra Leone Depression and anxiety Oxford Refugee Studies Program measure for use among former child soldiers Rape as part of Child War Trauma Questionnaire Rape was correlated to depression symptoms (r = 0.24, p ≤ 0.01) and anxiety symptoms (r = 0.38, p ≤ 0.001).
Rape was not predictive of depression at T2, adjusting for all covariates (b = 1.74, CI -0.53, 4.00).
Rape was the strongest predictor of anxiety at T2 controlling for anxiety levels at T1 (b = 4.06, CI 1.49, 6.62, p < 0.05) and adjusting for all other covariates.
Betancourt, Brennan et al., 2010 Sierra Leone Depression and anxiety Oxford Refugee Studies Program measure for use among former child soldiers Rape as part of Child War Trauma Questionnaire Rape was associated with higher baseline levels of internalizing problems (depression/anxiety) (b = 4.60, p < 0.05).
After adjusting for all hardship and protective factors, among time-invariant predictors, only being raped remained significantly related to depression/ anxiety (b = 4.34, p = 0.039).
Johnson et al., 2008 Liberia Depression
PTSD
Patient Health Questionnaire 9
PTSD Symptom Scale Interview (1 month recall)
Sexual violence defined as any violence, physical or psychological, carried out through sexual means or by targeting sexuality and included rape and attempted rape, molestation, sexual slavery, being forced to undress or being stripped of clothing, forced marriage, and insertion of foreign objects into the genital opening or anus, forcing 2 individuals to perform sexual acts on one another or harm one another in a sexual manner, or mutilating a person’s genitals. Adults who experienced sexual violence were more likely to meet criteria for PTSD (69% vs. 38%, p < 0.001) and MDD (57% vs. 37%, p = 0.002) compared to adults who did not experience sexual violence.
The weighted prevalence of PTSD (81% vs. 46%, p < 0.001) and MDD (64% vs.42%, p = 0.003) was higher among male former combatants who had experienced sexual violence compared to those who had not.
The weighted prevalence of PTSD (74% vs. 44%, p = 0.005) was higher but not MDD (63% vs.55%, p = 0.51) among female former combatants who experienced sexual violence compared to those who had not.
Noncombatant sexual violence was not related to MDD (32% vs. 29%, p = 0.73) nor PTSD (39% vs. 36%, p = 0.74) for men nor MDD (48% vs. 36%, p = 0.15) nor PTSD (56% vs.36%, p = 0.09) for women.
Those who experienced lifetime sexual violence had 1.39 (p = 0.04) the odds of MDD and 2.67 (p < 0.001) the odds of PTSD compared to those who did not experience sexual violence.
Johnson et al., 2010 Democratic Republic of Congo Depression
PTSD
Patient Health Questionnaire–9
PTSD Symptom Scale Interview (PSS-I)
Sexual violence – defined above The prevalence of MDD was significantly higher for those who experienced sexual violence (60.4%) compared to those who did not experience sexual violence (30.7%, p < 0.001);
The prevalence of PTSD was significantly higher for those who experienced sexual violence (70.2%) than those who did not experience sexual violence (40.3%, p < 0.001) .
The prevalence of MDD for females who experienced conflict-related sexual violence was significantly higher (67.7%) than for those who did not experience conflict-related sexual violence (30.3, p < 0.001).
The prevalence of PTSD for females who experienced conflict-related sexual violence was significantly higher (75.9%) than for those who did not experience conflict-related sexual violence (44.4%, p < 0.001).
There were no differences in the prevalence of MDD (47.5% vs. 36.3%, p = 0.18) or PTSD (56% vs. 41.7%, p = 0.17) for men who did and did not experience conflict-related sexual violence.
There were no differences in the prevalence of MDD (50.7% vs. 38.4%, p = 0.38) or PTSD (61.5% vs. 44.1%, p = 0.34) for men nor of MDD (72.9% vs. 40.1%, p = 0.07) or PTSD (83.6% vs. 52.4%, p = 0.06) for women who experienced community based sexual violence.
Johnson et al., 2014 Kenya Depression
PTSD
Patient Health Questionnaire–9
PSS-I
Sexual violence – defined above 31% of those who experienced sexual violence had anxiety and depression before the 2007 election, 45% who experienced sexual violence had anxiety and depression during the election, and 33.7% who experienced sexual violence had anxiety and depression after the 2007 election.
The weighted prevalence of MDD (41.0%, CI 27, 55 vs. 35.0%, CI 29.2, 40.8) and PTSD (40.1%, CI 28.6, 51.6 vs. 30.9%, CI 25, 36.8) were not significantly different between those who reported sexual violence and those who did not report sexual violence.
Cardozo et al., 2000 Kosovo PTSD HTQ Rape Rape was not related to PTSD symptoms:
21.6% or women who reported rape had symptoms of PTSD vs. 16.92% of women who did not report rape, p = 0.49;
AOR = 1.68, CI 0.69, 4.08
Sabin et al., 2003 Guatemalan refugees living in Mexico Depression
Anxiety
PTSD
HSCL-25
HTQ
Sexual abuse or rape reported as traumatic event Sexual abuse or rape was independently associated with anxiety (p = 0.02) but sexual abuse did not remain significant in the full model.
All rape survivors (N = 6, 100%) experienced anxiety.
Sexual abuse or rape was not related to PTSD or depression.a
Wolfe et al., 1998 USA PTSD Mississippi Scale for Combat-related PTSD Sexual assault defined as a sexual experience that was unwanted and involved the use or threat of force (attempted or completed rape) either by strangers or people you knew Women who were sexually assaulted experienced a significant 18.9 point increase in PTSD scores (M = 91.83, SD = 22.69) compared to women with no sexual harassment (M = 71.36, SD = 17.53).
Women who were sexually assaulted had increased risk for PTSD compared to women who were only physically (12.5 point difference) or verbally (15.9 point difference) harassed.
Washington et al., 2013 USA PTSD 7-item screen for DSM IV PTSD History of military sexual assault Women with PTSD were significantly more likely to have had experienced sexual assault in military (43% vs. 5.1%, p < 0.001).
Kang et al., 2005 USA PTSD PCL Sexual assault Among female (AOR = 5.41; 95% CI 3.19, 9.17) and male (AOR = 6.21 CI 2.26, 17.04) veterans, sexual assault was significantly associated with PTSD even while controlling for other covariates.
HIV acquisition/disease progression and mental health outcomes
Epino et al., 2012 Rwanda Depression HSCL-15 CD4 count There was not a significant difference in depression for those with <=200 CD4 cell count (25.5) and > 200 CD4 count (26) (p = 0.58).
Mugisha, Muyinda, Wandiembe et al., 2015 Uganda PTSD Mini-International Neuropsychiatric Interview (MINI) HIV status
Sexual trauma events
Those reporting HIV+ status had greater odds of having PTSD (UOR = 2.09, CI 1.48, 2.95)
Those who experienced 1–2 sexual trauma events had greater odds of having PTSD in the unadjusted (UOR = 2.6, CI = 1.63, 4.15) but not the adjusted (AOR = 1.23, CI 0.73, 2.07) model
Those who experienced 3+ sexual trauma events had greater odds of having PTSD (UOR = 5.65, CI 3.33, 9.61; AOR = 2.02, CI 1.08, 3.76)
Mugisha, Muyinda, Malamba et al., 2015 Uganda Depression MINI HIV status
High risk sexual behaviors
Receiving HIV treatment
HIV+ status was related to MDD (UOR = 2.85, CI 2.04, 3.96), after adjusting for sex and age (AOR = 2.63, CI 1.87, 3.70), and in the multivariate model (OR = 1.83, CI 1.22, 2.74)
High risk sexual behavior was not related to MDD in the unadjusted (UOR = 1.13, CI 0.77, 1.67) or adjusted model (AOR = 1.37, CI 0.91, 2.09)
Receiving HIV treatment was related to MDD in the adjusted model (AOR = 3.22, CI 1.08, 9.57) but not the unadjusted model (UOR = 2.03, CI 0.85, 4.85)
Muldoon et al., 2014 Uganda Depression and anxiety APAI All participants had exchanged sex for money or resources in the previous 30 days For all participants the mean score for the depression sub-scale was 12.84 (SD = 4.79) and the mean score for the anxiety sub-scale was 8.76 (SD = 5.14).
No cut off score is defined for symptomatic for either subscale.
M.H. Cohen et al., 2009 Rwanda Depression
PTSD
CES-D
HTQ
About 50% of participants in each group of HIV-positive and HIV-negative experienced genocidal rape
CD4 cell counts
Women with HIV infection were more likely than HIV-negative women to have clinically significant depression (81% vs. 65%, p < 0.0001) and MDD (31% vs. 23%, p < 0.047).
Women with more advanced HIV, indicated by CD4 cell counts < 200 = mL (OR 4.97, CI 2.93, 8.45), were the most likely to have depressive symptoms.
Women who had experienced genocidal rape were more likely to have PTSD in unadjusted analyses (OR = 1.63, CI 1.23, 2.15).
Depressive symptoms were higher in women who had a history of genocidal rape (OR = 1.56, CI 1.12, 2.16).
M.H. Cohen et al., 2011 Rwanda Depression
PTSD
CES-D
HTQ
About 50% of participants in each group of HIV-positive and HIV-negative experienced genocidal rape HIV-positive status was related to increased symptoms of depression (81.5% vs. 63.8%, p < 0.0001), marginally related to symptoms of PTSD (59.6 vs. 67.5%, p = 0.081), and not related to MDD (29.2% vs. 22.7%, p = 0.11) compared to HIV-negative status at baseline.
There was a continued reduction in PTSD at each follow-up visit for both HIV-positive and HIV-negative groups (6 month change = −0.78, p < 0.0001; 12 month change = − 0.9, p < 0.0001; 18 month change = − 0.84, p < 0.0001).
HIV-positive status (b = 0.03, p = 0.38) was not related to PTSD improvement from baseline to 18-month follow up.
All participants had fewer depressive symptoms at 18 months follow up compared to baseline (77% vs. 57%).
In changes from baseline to visit 4, experiencing genocidal rape was significantly associated with reduced PTSD.a
Other associations between mental health and HIV acquisition and disease progression
Gard et al., 2013 Rwanda Depression
PTSD
CES-D
HTQ
About 50% of participants in each group of HIV-positive and HIV-negative experienced genocidal rape HIV-positive women had higher depression scores than HIV-negative participants (23.67, SD = 9.19 vs. 20.79, SD = 9.60, p < 0.001).
More HIV-positive women met criteria for depression than HIV-negative women (81.46% vs.64.58%, p < 0.001).
There was no difference in PTSD scores between HIV-positive and HIV-negative women (2.31, SD = 0.69 vs. 2.4 SD = 0.67, p = 0.09).
A greater percentage of HIV-negative compared to HIV-positive women experienced elevated PTSD scores (65.63% vs. 57.8%, p = 0.05).
Kohli et al., 2014 Democratic Republic of Congo Depression
PTSD
HSCL-15
HTQ
Rape Rape or sexual assault in the past 10 years was related to increased symptoms of PTSD (β = 0.35, p < 0.001) and depression (β = 0.29, p < 0.001) in multivariate regression.
Sinayobye et al., 2015 Rwanda Depression
PTSD
CES-D
HTQ
CD4 count Depression scores were associated with CD4 count (p < 0.001) with:
CD4 counts > 350 having a mean depression score of 22.4 ± 9.3;
CD4 count 200–350 having a mean depression score of 23.0 ± 8.2;
CD4 count < 200 having a mean depression score of 25.8 ± 9.1
PTSD scores were not associated with CD4 count (p = 0.60) with:
CD4 counts > 350 having a median (IQR) PTSD score of 2.1 (1.7–2.7)
CD4 count 200–350 having a median (IQR) PTSD score of 2.1 (1.8–2.8)
CD4 count < 200 having a median (IQR) PTSD score of 2.2 (1.8–2.8)
  1. AOR adjusted odds ratio, ART Antiretroviral therapy, CI confidence interval, MDD major depressive disorder, NR not reported, OR odds ratio, SE Standard Error, SD standard deviation
  2. aEffect size data are reported where available; textual descriptions of results are reported when that was all that the authors present