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

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 activities^a

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)

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.

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

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)