Prevalence and predictors of posttraumatic stress disorder and depression in HIV-infected and at-risk Rwandan women

Burnout Among Service Providers for People Living with HIV: Factors Related to Coping and Resilience

Individuals who provide services for people living with HIV (PLWH) face numerous work-related challenges, including psychosocial and structural factors affecting the quality of care that they provide. Little is known about the factors that relate to burnout among service providers for PLWH. The current study seeks to examine the factors associated with burnout and the role of resilience and coping in the context of burnout. Via convenience sampling, data was collected from 28 professionals (e.g., peer counselors, HIV testers, case managers/case workers, group facilitators, or social workers) serving PLWH in the USA. Participants completed quantitative measures on sociodemographics, organizational factors, discrimination, trauma, depression, and burnout. A sub-sample of 19 participants provided in-depth qualitative data via semi-structured interviews on burnout, coping, and resilience as a buffer against the effects of burnout. Thematic content analysis revealed themes on the factors related to burnout (e.g., discrimination, limited financial and housing resources, and COVID-19), rejuvenating factors, coping with burnout, and intervention strategies. Additionally, Pearson's product moment correlations revealed significant associations between mental health variables such as depressive and posttraumatic stress disorder symptomology with (a) discrimination and microaggressions and (b) burnout. The current study highlights challenges to providing HIV care, including structural barriers and discrimination that are doubly impactful to the professionals in this sample who share identities with the PLWH whom they serve. These findings may inform the development of an intervention targeting burnout among individuals providing services to PLWH and motivate change to remove structural barriers and improve quality of care for PLWH.

The psychological impact of genocide on the Yazidis

Background

The genocide against the Yazidis by the Islamic State of Iraq and Al-Sham (ISIS) in the Sinjar area of Northern Iraq has costed many lives and has also caused a psychological long-term impact in this minority. This impact can be seen among individual survivors. Additionally, there is a large number of direct and indirect victims and for this reason, the impact can also be observed on the level of the group and society in this region at large.

Methodology

The research examines three different population groups (Yazidis members who had been exposed to violence by terrorist group actions, those not exposed to this experience as they were living in an area not directly exposed to ISIS violence, and a control group of non – Yazidi general population members). In total, 425 participants (age range 15–78) took part in the study and participated in interviews using standard scales to measure general physical and mental health.

Results

The results demonstrate that psychological stress and suicidality are higher among the Yazidis survivors of violence than in the other Yazidi participants.

Conclusion

Psychological disorders after a genocide and war in post-conflict populations should receive more attention in the planning of mental health care and prevention and should be seen as a major problem, especially in camp settings and displaced persons besides the usual increased prevalence of posttraumatic stress and other disorders covered by research so far in this context.

Mapping the availability of translated versions of posttraumatic stress disorder screening questionnaires for adults: A scoping review

Background: The most used questionnaires for PTSD screening in adults were developed in English. Although many of these questionnaires were translated into other languages, the procedures used to translate them and to evaluate their reliability and validity have not been consistently documented. This comprehensive scoping review aimed to compile the currently available translated and evaluated questionnaires used for PTSD screening, and highlight important gaps in the literature.Objective: This review aimed to map the availability of translated and evaluated screening questionnaires for posttraumatic stress disorder (PTSD) for adults.Methods: All peer-reviewed studies in which a PTSD screening questionnaire for adults was translated, and which reported at least one result of a qualitative and /or quantitative evaluation procedure were included. The literature was searched using Embase, MEDLINE, and APA PsycInfo, citation searches and contributions from study team members. There were no restrictions regarding the target languages of the translations. Data on the translation procedure, the qualitative evaluation, the quantitative evaluation (dimensionality of the questionnaire, reliability, and performance), and open access were extracted.Results: A total of 866 studies were screened, of which 126 were included. Collectively, 128 translations of 12 different questionnaires were found. Out of these, 105 (83.3%) studies used a forward and backward translation procedure, 120 (95.2%) assessed the reliability of the translated questionnaire, 60 (47.6%) the dimensionality, 49 (38.9%) the performance, and 42 (33.3%) used qualitative evaluation procedures. Thirty-four questionnaires (27.0%) were either freely available or accessible on request.Conclusions: The analyses conducted and the description of the methods and results varied substantially, making a quality assessment impractical. Translations into languages spoken in middle- or low-income countries were underrepresented. In addition, only a small proportion of all translated questionnaires were available. Given the need for freely accessible translations, an online repository was developed.HIGHLIGHTS We mapped the availability of translated PTSD screening questionnaires.The quality of the translation and validation processes is very heterogenous.We created a repository for translated, validated PTSD screening questionnaires.

Transgenerational trauma in Rwandan genocidal rape survivors and their children: A culturally enhanced bioecological approach

Multiple theories, including attachment, family systems, and epigenetics, among many others, have been invoked to explain the mechanisms through which trauma is transmitted from one generation to the next. To move toward integration of extant theories and, thus, acknowledgement of multiple pathways for transmission of trauma, the authors explore the potential of applying a culturally enhanced bioecological theory to transgenerational trauma (TGT). Data from in-depth qualitative interviews in Rwanda more than two decades after the genocide, with 44 mothers of children born of genocidal rape, and in-depth interviews and focus groups with a total of 60 youth born of genocidal rape, were analyzed according to the processes of culturally enhanced bioecological theory. The findings from a hybrid inductive and deductive thematic analysis suggest that a culturally enhanced bioecological theory of human development allows for an integrated, multi-dimensional analysis of individual, family, cultural, and societal factors of transmission of TGT. Some facets of the data, however, are not accounted for in the theory, specifically, how some mothers were able to create and sustain a positive bond with their children born of genocidal rape, despite societal and family pressure to abandon or abort them. Nonetheless, the findings demonstrate how a culturally enhanced bioecological theory can be an important overarching framework for developing policies and practices to help interrupt or mitigate TGT, strengthen resilience, and facilitate healing for children born of genocidal rape, their mothers, and their families.

Prevalence of depression and associated factors among people living with HIV/AIDS in public hospitals of Southeast Ethiopia

BACKGROUND

Depression is the most frequent mental health condition among human immune deficiency virus or acquired immune deficiency syndrome (HIV/AIDS) patients. It has been related to negative health outcomes. This could lead to hospitalization and an increase in medical expenses. This study aimed to assess the prevalence of depression and associated factors among HIV/AIDS patients in public hospitals Bale Zone, Southeast Ethiopia.

METHODS

A hospital-based cross-sectional study design was randomly employed among 554 study participants. A systematic random sampling technique was used to select the study subjects. A structured Patients Health Questionnaires- 9 was used to measure the depression status of HIV/AIDS patients. Data were collected using a pretested interviewer administered structured questionnaire as well as review of patients medical charts or records. Descriptive statistics were computed. Multivariable logistic regression analyses were conducted identify factors associated with the prevalence of depression. Adjusted odds ratio (AOR), along with a 95% confidence interval (CI), was used to estimate the strength of the association. A p-value of < 0.05 was considered statistically significant.

RESULTS

The prevalence of depression among the study participants was found to be 44.9% (95% CI: 40.79%, 49.1%). Perceived HIV related stigma is the single most dominant predictor of depression [(AOR = 8.2, 95% CI: (4.96, 13.68)], low income level [(AOR = 3.1, 95% CI: (1.59, 6.22)] Experiencing any form of a side effect of highly active anti-retroviral therapy (HAART) [(AOR = 1.5, 95% CI: (1.04, 2.56)], having normal BMI [(AOR = 0.49, 95% CI: (0.29, 0.8)] being HIV patients at WHO clinical stage II [(AOR = 0.44, 95% CI: (0.22, 0.9)], were significantly associated with prevalence of depression.

CONCLUSION

The study revealed that the prevalence of depression among people living with HIV in the study settings was high, almost two out of every five HIV patients were depressed. Low income level, side effect to HAART, and having HIV related stigma were more likely to suffer from depression.

Post-Traumatic Stress Disorder and Coping Strategies Among People with HIV in Lira District, Uganda: A Cross-Sectional Study

Background

Post-traumatic stress disorder (PTSD) is the most commonly reported mental health consequence following traumatic events. However, little is known about how people with HIV cope with the PTSD burden in Lira city, northern Uganda.

Materials and Methods

This study was carried out in Lira District Health Centre IVs from February 10, 2022, to March 10, 2022. A facility-based cross-sectional study was employed among 390 people with HIV attending Lira Health Centre IVs. A consecutive sampling technique was used to select the sample size. Questionnaires were used to collect data. A binary logistic regression model was fitted to identify factors associated with independent variables, and AOR was employed to estimate the strength of association between independent and dependent variables.

Results

Results show that the estimated prevalence of PTSD was 254 (65.1%) and was higher among the females 191 (75.2%), those with no formal education 143 (56.3%), aged 40 years and above 121 (47.6%), and married 127 (50.0%). Results indicate that male respondents had a 51% reduced odds of developing PTSD burden compared to female respondents (AOR: 0.49; 95% CI: 0.30–0.81; P = 0.005). Individuals who did not use planning activities as a coping strategy had more than 2-fold increased odds of experiencing PTSD compared to those who planned activities (AOR: 2.43; 1.26–4.70; P = 0.008). Participants who did not have emotional support had close to 3-fold increased chances of developing PTSD compared to those who had emotional support (AOR: 2.94; 1.74–4.98; P ≤ 0.001). Participants who indicated they were not taking recourse to spirituality had more than 4-fold increased odds of experiencing PTSD compared to those who had spirituality (AOR: 4.40; 1.83–10.46; P = 0.001).

Conclusion

A considerable burden of PTSD among HIV clients attending health centre IVs in Lira District was notably higher and was associated with gender, planning activities, emotional support and spirituality. Early screening of PTSD among HIV clients is needed to alleviate the burden. There is also a need to include PTSD treatment services in the treatment programme of HIV care services in health centre IVs in Lira District.

Transactional sex work and HIV among women in conflict-affected Northeastern Uganda: a population-based study

BACKGROUND

Armed conflict and the HIV pandemic are significant global health issues. Evidence of the association between armed conflict and HIV infection has been conflicting. Our objective was to examine the role of mediating risk factors, such as engagement in transactional sex work, to elucidate the relation between armed conflict and HIV infection.

METHODS

We used multistage sampling across three Northeastern Ugandan districts to randomly select 605 women aged 13 to 49 to answer cross-sectional surveys from January to May of 2016. We used multivariate logistic regression model with R 4.0.3 to examine if exposure to armed conflict has an indirect effect on reporting having an HIV-positive serostatus through engagement in transactional sex work. Age and district residence were included as covariates.

RESULTS

Exposure to armed conflict β = .16, SE = .04, p < .05, OR = 1.17, 95% [CI .08, .23] was significantly associated with reporting a HIV-positive serostatus. For each 1-unit increase in exposure to armed conflict (i.e., additional type of armed conflict exposure), there was a 17% increase in the odds of reporting a HIV-positive serostatus. Engagement in transactional sex work was not associated with reporting a HIV-positive serostatus β = .04, SE = .05, p = .37, 95% [CI - .051, .138]. We found district of residence, age, and interaction effects.

CONCLUSIONS

Although exposure to armed was associated with reporting an HIV-positive serostatus, this relationship was not mediated by engagement in transactional sex. Further research is needed on risk factors that mediate this relationship. The likelihood of reporting a HIV-positive serostatus increased with each additional type of exposure to armed conflict. Thus, screening for exposure to multiple traumatic stressors should occur in HIV prevention settings. Healthcare services that are trauma-informed and consider mental distress would likely improve HIV outcomes.

Development of a Questionnaire to Measure the Perceived Injustice of People Who Have Experienced Violence in War and Conflict Areas: Perceived Injustice Questionnaire (PIQ)

Objectives: The primary aim of this research was to develop a questionnaire that assesses perceived injustice among survivors of war and trauma in conflict areas and to evaluate its psychometric properties. This paper presents the first preliminary validation. Furthermore, the assumption that the general perception of injustice correlates with one’s own experiences of injustice and violence was tested. Methods: The 24-item Perceived Injustice Questionnaire (PIQ) was administered partly online and partly in a paper–pencil version to 89 students of the University of Dohuk in Northern Iraq, an area that has been affected by crisis and war for many years. Principal component analysis was used for factor extraction and internal consistency was determined. The Mann–Whitney-U test was used to calculate the group differences between people with and without experience of physical violence and strong experiences of injustice because Kolmogorov–Smirnov tests showed that the data are not normally distributed. Results: Principal component analysis yielded a four-component solution with eigenvalues being the greater one. Cronbach’s alpha for each scale was acceptable to satisfactory. Significant results of the Mann–Whitney U tests supported our assumptions of between-group differences on each of the subscales (emotional and cognitive consequences, injustice perception, injustice experience, revenge, and forgiveness). Discussion: The findings of this study support the construct validity and the reliability of the PIQ. For this reason, it can be seen as a useful addition to the psychological assessment in psychotherapeutic settings of survivors of war and violence. In conclusion, and based on the PIQ, we suggest the development of a new set of therapy modules with worksheets, focusing on the perception, dealing, and understanding of feeling of injustice as an addition to the existing trauma therapy manual for therapy in war and conflict areas.

Likely clinical depression and HIV-related decline in antiretroviral therapy untreated women who seroconverted during participation in microbicide trials in sub-Saharan Africa

Depression worsens HIV outcomes in populations treated with antiretroviral therapy (ART) medications. Data are limited on the relationship between depression and HIV in untreated populations in sub-Saharan Africa. We aimed to identify associations between likely clinical depression, alcohol use, social support by partners, and HIV viral load (VL) among ART untreated women who recently became HIV positive and enrolled in the Microbicide Trials Network (MTN)-015 study. Analyses used cross-sectional data collected at baseline in MTN-015. Participants in this analysis (N = 190) enrolled from other MTN trials were not receiving ART and provided data on their HIV disclosure status to their husband or male partner and alcohol use behavior. The dependent variable, VL, was categorized as: low (≤400 RNA copies/mL; 9.1% of participants), medium (401-20,000 RNA copies/mL; 48.8%), and high (>20,000 RNA copies/mL; 42.0%). Depression was assessed using eight items from Hopkins Symptom Checklist; a cutoff of ≥1.75 indicated likely clinical depression. Independent variables with a significance of p ≤ 0.05 in unadjusted regressions were included in a regression adjusted for age, education, and time since seroconversion. Depressive symptoms were positively associated with high VL, in the adjusted regression (OR = 1.80; 95% CI = 1.07-3.01). Results suggest that likely having clinical depression may have a biological relationship with HIV disease progression.

Psychosocial Factors, Condomless Sex, and Detectable Viral Load in HIV-Positive Women in Serodiscordant Couples in Nairobi, Kenya

This prospective study of HIV-positive Kenyan women in serodiscordant couples examined relationships between psychosocial factors, viral suppression, and condomless sex. Participants were screened for alcohol use disorders and intimate partner violence (IPV) annually and depressive symptoms every 6 months. Prostate specific antigen (PSA) detection was used as a marker for condomless sex. A total of 151 participants contributed 349 person-years of follow-up. Hazardous/harmful alcohol use was associated with increased risk of detecting PSA in vaginal secretions (aRR 1.99, 95%CI 1.08-3.66, χ2 = 4.85 (1)), while IPV and depression were not. Events representing HIV transmission potential, where there was biological evidence of condomless sex at a visit with a detectable plasma viral load, were observed at 2% of visits. The high prevalence of IPV and association between alcohol use and sexual risk suggest the need for monitoring and support for these conditions as part of comprehensive HIV care for women.

Positive psychotherapy in the treatment of traumatised Yezidi survivors of sexualised violence and genocide

So far, the psychotherapeutic treatment of patients with trauma spectrum disorders has most commonly been based on a disease model in which the normal reaction to trauma results in negative emotions, cognitions and behaviour which, in turn, cause a pathological state of mind or disorder. Here, trauma is associated with distress. This model focuses on identification, classification and treatment of the pathological and maladaptive modulations of the stress response that lead to psychological and social suffering and disability. In contrast to that, recent models in the Psychotherapy of the sequels of extreme life experiences, such as Positive Psychotherapy, have rather focussed on the building of competence, resilience and posttraumatic growth. In this article we summarise our experience in treating Yazidi women for their complex psychological traumata resulting from their experience of ISIS terror. We will use a short summary of published secondary data and reviews and use case examples from our work as primary data to discuss possible individual and collective resources that can help them to recover and to maintain a positive perspective on their person and the world, in spite of their terrible traumatic experiences. Original models of Positive Psychology already paid considerable attention to strength and resilience. The new approach of 'second wave' Positive Psychology expands on this, suggesting that negative emotions as well cultural factors must also be integrated. This approach appears to be particularly helpful in the treatment of this group of Yazidi women. Likewise, it seems to be promising when treating similar groups of people who survived extreme terror and were continuously exposed to genocidal environments.

Potential trauma events and the psychological consequences for Yazidi women after ISIS captivity

BACKGROUND

Traumatic war experiences, like the ones the Yazidi had to undergo due to the attack of the so-called Islamic State (ISIS) in August 2014, are often followed by psychological consequences such as posttraumatic stress disorder (PTSD) and depression. A more detailed analysis of such specific survivor groups is needed, to develop and implement appropriate reparation and support measures.

METHODS

In this study, 194 Yazidi women were examined. PTSD was assessed using the Essen Trauma Inventory (ETI) and depression using Beck's Depression Inventory (BDI-II). The potential traumatic event (PTE) and further influential factors were compared between participants with PTSD and those with PTSD and depression, using inferential statistics.

RESULTS

Panticipants showed high rates in prevalence and comorbidity for PTSD and depression. Those diagnosed with comorbid PTSD and depression experienced a higher number of PTEs and had been captured more often and for longer compared to those with PTSD. The number of PTEs experienced was then used to predict comorbid PTSD and depression.

CONCLUSION

Further research should consider the specific situation and the cultural expression of the Yazidi.

A cross-sectional study of the prevalence and factors associated with symptoms of perinatal depression and anxiety in Rwanda

Background

Perinatal depression and anxiety are increasingly recognized as important public health issues in low and middle-income countries such as Rwanda and may have negative consequences for both mothers and their infants. Maternal mental health may be particularly challenged in Rwanda because of the prevalence of risk factors such as poverty, low education levels, negative life events and marital problems. However, there are limited data about perinatal depression and anxiety symptoms in Rwanda. This study thus aimed to explore the prevalence of symptoms of perinatal depression and anxiety in Rwanda, and factors associated with them.

Methods

A sample of 165 women in the perinatal period (second and third trimester of pregnancy, up to 1 year postnatal) were interviewed individually over 1 month in October 2013. Women were interviewed at 5 of 14 health centres in the Eastern Province or the affiliated district hospital. Participants answered socio-demographic questions and scales measuring symptoms of perinatal depression (EPDS: Edinburgh Postnatal Depression Scale) and anxiety (SAS: Zung Self-rating Anxiety Scale).

Results

Among women in the antenatal period (N = 85), 37.6% had symptoms indicating possible depression (EPDS ≥10) and 28.2% had symptoms associated with clinical levels of anxiety (SAS > 45). Among women within the postnatal period (N = 77), 63.6% had symptoms of possible depression, whereas 48,1% had symptoms of probable anxiety. Logistic regression showed that symptoms of postnatal depression were higher for respondents who had four or more living children relative to those having their first child (Odds Ratio: 0.07, C.I. = 0.01–0.42), and for those with a poor relationship with their partner (Odds Ratio: .09, C.I. =0.03–0.25). Any lifetime exposure to stressful events was the only predictor of symptoms of postnatal anxiety (Odds Ratio = 0.20, C.I. = 0.09–0.44).

Conclusions

Symptoms of postnatal depression and anxiety were prevalent in this Rwandan sample and most strongly predicted by interpersonal and social factors, suggesting that social interventions may be a successful strategy to protect against maternal mental health problems in the Rwandan context.

The Significance of Justice in the Psychotherapeutic Treatment of Traumatized People After War and Crises

In the aftermath of crimes against humanity, human rights violations, and genocide, the question arises whether and how justice can be restored. A lack of social justice and continuing injustice in post-conflict areas prevent survivors from processing their traumatic experiences. As a consequence, the individuals and often their families, their community, and the whole society are changed in a lasting way. The trauma can even be passed on over generations. Yet, if war has a negative impact on health, then, programs that focus on achieving justice, peace, and stability should be able to offset or reduce this negative impact. For this reason, the importance of psychosocial well-being and mental health for the reconstruction of societies is acknowledged. Various political, legal, and social programs, like transitional justice, are being implemented in post-war regions to develop justice. Developing or restoring justice also requires good psychosocial care, like a treatment that supports individuals when coping with injustice and gaining a new sense of justice. Such a psychological treatment can make an important contribution when it comes to building new trust and improving mental health. Ethical standards in coping with trauma and developing or restoring justice in post-conflict regions are indispensable to enable long-term peace. The course for new social justice can be set, through a just health system. Thereby, only programs and legal processes, which try to do justice to the survivors and take their needs into account, are ethically justifiable. Human rights and health cannot be separated in psychotherapy with survivors of war and terror. Based on ethical principles, new approaches must be generated for psychotherapy in war regions and with survivors of war and terror. The aim will be to make an important contribution to the mental and social reconstruction of countries after mass violence.

Epidemiology of depressive disorders in people living with HIV in Africa: a systematic review and meta-analysis: Burden of depression in HIV in Africa

OBJECTIVE

The burden of HIV infection is higher in Africa where 70% of people living with HIV (PLHIV) resides. Since depression can negatively impact the course of HIV infection, it is therefore important to accurately estimate its burden among PLHIV in the continent.

METHODS

We searched multiple databases to identify articles published between January 2000 and February 2018, reporting the prevalence of (major) depressive disorders in PLHIV residing in Africa. We used a random-effects meta-analysis model to pool studies.

RESULTS

Overall, 118 studies (60,476 participants, 19 countries) were included. There was no publication bias. The overall prevalence estimates of depressive disorders and probable major depressive disorders were 36.5% (95% CI 32.3-41.0; 101 studies) and 14.9% (12.1-17.9; 55 studies) respectively. The heterogeneity of the overall prevalence of depressive disorders was significantly explained by screening tool used, period (higher prevalence in recent studies) and distribution in sub-regions. The study setting, site, CD4 cell counts, age, sex, proportion of people with undetectable viral load were not sources of heterogeneity.

CONCLUSIONS

This study shows that more than one third of PLHIV face depressive disorders and half of them having major form, with heterogeneous distribution in the continent. As such, depressive disorders deserve more attention from HIV healthcare providers for improved detection and overall proper management.

Burden of post-traumatic stress disorder acute exacerbations during the commemorations of the genocide against Tutsis in Rwanda: a cross-sectional study

Introduction

Following the 1994 genocide against Tutsis in Rwanda, the prevalence of post-traumatic stress disorder (PTSD) is high. In a period of seven days every year in April, Rwandans gather to mourn the victims of the genocide. During this commemoration period, survivors living with chronic PTSD experience PTSD acute exacerbations (PAE). We assessed factors associated with severe PAE during the annual commemoration period of the genocide against Tutsis in Rwanda.

Methods

We carried out a retrospective cross-sectional study that included people who had PAE during the commemoration week in April 2011 across Huye District in Rwanda. Our outcome measure was PAE categorized into three levels: < 15 minutes, 15-30 minutes, and > 30 minutes. Ordinal logistic regression analyses were performed to identify factors associated with severe PAE.

Results

We enrolled 383 people with PAE, of whom 71.8% were female and 53.5% were aged 20-45 years. All participants reported history of PAE, of which 59.8% had experienced more than two PAE during the previous commemoration periods. 33.2% had PAE that lasted > 30 minutes. History of PAE (> twice) (OR = 1.86; 95% CI = 1.27-2.75) and having lost a partner in genocide (OR = 2.19; 95% CI = 1.01-4.81) were associated with severe PAE, after adjusting for sex and age.

Conclusion

Our findings suggest that PAE is frequent during the commemoration periods. People who reported having more prior PAE and being widow (er) were more likely to have severe PAE. While history of PAE and bereavement status are non-modifiable factors, our findings could help identify and target these people who are at risk for severe PAE.

Longitudinal evaluation of markers of inflammation in HIV-positive and HIV-negative Rwandan women

OBJECTIVES

African women are disproportionately affected by HIV infection and may experience non-AIDS-related complications associated with inflammation. High-sensitivity C-reactive protein (hsCRP), d-dimer and transthyretin have been examined as inflammatory markers elsewhere, but it is unclear how they change over time in HIV-negative or HIV-positive African women with or without antiretroviral therapy (ART) initiation.

METHODS

We examined hsCRP, d-dimer and transthyretin levels at baseline and at follow-up of ≥2 years in 185 HIV-negative and 510 HIV-positive Rwandan women who were ART naïve at study entry. Generalized estimating equations for each marker were used to investigate the association with HIV infection/CD4 count, ART and follow-up time.

RESULTS

Compared with HIV-negative women, HIV-positive women had higher hsCRP and d-dimer and lower transthyretin concentrations, with greater differences at lower CD4 counts. After adjusting for CD4 count and other factors, ART was not significantly associated with log hsCRP (P = 0.36) at follow-up, but was independently associated with lower log d-dimer (P = 0.03) and higher transthyretin (P = 0.0008) concentrations. At ≥ 2 years of follow-up, hsCRP had not significantly changed in any group but log d-dimer had decreased significantly in all groups. Transthyretin declined significantly over time in HIV-negative women and HIV-positive non-ART initiators, but increased significantly in HIV-positive ART initiators.

CONCLUSIONS

HIV infection and advanced immune suppression were associated with higher hsCRP and d-dimer and lower transthyretin concentrations. ART (independently of CD4 changes) was significantly associated with decreases in d-dimer and increases in transthyretin, but, in contrast to other studies, was not associated with decreases in hsCRP. We found no change in hsCRP over time in any group.

A systematic review and meta-analysis of epidemiology of depression in people living with HIV in east Africa

BACKGROUND

Depression is the most prevalent psychiatric disorder among people living with HIV (PLWHIV) and is associated with poor quality of life, additional comorbidities, disability, unemployment, poorer therapeutic outcomes and risky behaviors. The present systematic review and meta-analysis aims to systematically summarize empirical evidence and to formulate recommendations for future research.

METHODS

We searched PubMed, EMBASE, SCOPUS, and relevant literature for possible studies to include. A qualitative and quantitative analysis was undertaken for this systematic review. Subgroup and sensitivity analysis were performed. Cochran's Q- and the I² test were used to assess heterogeneity. The presence of publication bias was evaluated by using Egger's test and visual inspection of the symmetry in funnel plots.

RESULTS

Of 283 titles initially identified, 81 abstracts were eligible for review. Of these, 46 articles qualified for full text review and 19 were retained. In our meta-analysis the pooled prevalence of depression in PLWHIV was 38% (95% CI 29.30-47.54). The pooled prevalence estimates of depression was 49.79% in Ethiopia and 30.88% in Uganda. In addition, the prevalence of depression was 12.40% and 46% as measured by diagnostic and screening instrument respectively. Our qualitative synthesis showed that factors such as having opportunistic infection, perceived stigma, negative life event, WHO clinical staging of disease, hospitalization in the past one month, stressful life events, food insecurity, self-efficacy, missed frequency of clinic visit, frequency of follow-up, older age, low income, urban residence and being government employee were strongly and significantly associated with depression in PLWHIV in east Africa.

CONCLUSION

The pooled prevalence estimates of prevalence of depression in PLWHIV was 38%. The prevalence estimates of depression in PLWHIV in Ethiopia was significantly higher than Uganda. In addition the prevalence of depression was significantly higher in studies conducted by screening than diagnostic instrument. Routine screening and integrated management of depression into the existing HIV care services is warranted. Validation and use of standard instrument to assess depression in PLWHIV is needed. Moreover, longitudinal and community based studies focusing on incidence and determinates of depression in PLWHIV are recommended.

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

The association between poor mental health and factors related to HIV acquisition and disease progression (also referred to as HIV-related factors) may be stronger among conflict-affected populations given elevated rates of mental health disorders. We conducted a scoping review of the literature to identify evidence-based associations between mental health (depression, anxiety, and post-traumatic stress disorder [PTSD]) and factors related to HIV acquisition and progression in conflict-affected populations. Five electronic databases were searched on October 10, 2014 and updated on March 7, 2017 to identify peer-reviewed publications presenting primary data from January 1, 1994 to March 7, 2017. Articles were included if: 1) depression, anxiety, and/or PTSD was assessed using a validated scale, 2) HIV or HIV-related factors were a primary focus, 3) quantitative associations between depression/anxiety/PTSD and HIV or HIV-related factors were assessed, and 4) the study population was conflict-affected and from a conflict-affected setting. Of 714 citations identified, 33 articles covering 110,818 participants were included. Most were from sub-Saharan Africa (n = 25), five were from the USA, and one each was from the Middle East, Europe, and Latin America. There were 23 cross-sectional, 3 time-series, and 7 cohort studies. The search identified that mental health has been quantitatively associated with the following categories of HIV-related factors in conflict-affected populations: markers of HIV risk, HIV-related health status, sexual risk behaviors, and HIV risk exposures (i.e. sexual violence). Further, findings suggest that symptoms of poor mental health are associated with sexual risk behaviors and HIV markers, while HIV risk exposures and health status are associated with symptoms of poor mental health. Results suggest a role for greater integration and referrals across HIV and mental health programs for conflict-affected populations.

Genocide Rape Trauma: A Conceptual Framework for Understanding the Psychological Suffering of Rwandan Survivors

In 1994, the Rwandan genocide claimed the lives of approximately 1 million Tutsi and moderate Hutu citizens. Systematic rape was a strategic component of the Hutu extremist plan to eradicate the Tutsi minority population. This involved collective and repeated sexual assaults with brutal violence, public humiliation, and torture. This article maps the ongoing psychological impact on Rwandan genocide rape survivors and identifies implications for international nursing practice. The research formalizes their narratives, identifying a number of interconnected elements that combine to produce myriad forms of chronic psychological suffering in the Rwandan context. This work in turn reveals the specific needs of these survivors that may be addressed by nursing. It allows nurses, as experts in managing the human responses to health and illness, to develop a more complete understanding of psychological suffering as it pertains to vulnerable populations during and in the wake of extreme social conflict. This clarifies the roles of nurse educators, clinicians, and policy advocates as key agents in providing genocide rape survivors with the resources and expertise needed to effectively manage their ongoing trauma.

Sexual assault victimization and psychopathology: A review and meta-analysis

Sexual assault (SA) is a common and deleterious form of trauma. Over 40years of research on its impact has suggested that SA has particularly severe effects on a variety of forms of psychopathology, and has highlighted unique aspects of SA as a form of trauma that contribute to these outcomes. The goal of this meta-analytic review was to synthesize the empirical literature from 1970 to 2014 (reflecting 497 effect sizes) to understand the degree to which (a) SA confers general risk for psychological dysfunction rather than specific risk for posttraumatic stress, and (b) differences in studies and samples account for variation in observed effects. Results indicate that people who have been sexually assaulted report significantly worse psychopathology than unassaulted comparisons (average Hedges' g=0.61). SA was associated with increased risk for all forms of psychopathology assessed, and relatively stronger associations were observed for posttraumatic stress and suicidality. Effects endured across differences in sample demographics. The use of broader SA operationalizations (e.g., including incapacitated, coerced, or nonpenetrative SA) was not associated with differences in effects, although including attempted SA in operationalizations resulted in lower effects. Larger effects were observed in samples with more assaults involving stranger perpetrators, weapons, or physical injury. In the context of the broader literature, our findings provide evidence that experiencing SA is major risk factor for multiple forms of psychological dysfunction across populations and assault types.

Impacts of making sense of adversity on depression, posttraumatic stress disorder, and posttraumatic growth among a sample of mainly newly diagnosed HIV-positive Chinese young homosexual men: the mediating role of resilience

The experience of HIV, as a life-transforming event, might produce both negative and positive outcomes. Guided by the stress appraisal model, the present study investigated the hypothesized pathways in predicting symptomatology and posttraumatic growth (PTG) in a sample of Chinese male patients with HIV (PHIV) who were mainly newly diagnosed, young, and homosexual. In this cross-sectional study, 141 Chinese male PHIV (87.2% of them were homosexual) completed measures of making negative/positive sense of adversity, resilience, depression, posttraumatic stress disorder (PTSD), and PTG. The path analysis results showed that making negative sense of adversity was associated with depression and PTSD, partially mediated by low levels of resilience, whereas making positive sense of adversity was associated with PTG, partially mediated by resilience. The results suggest that negative and positive outcomes of trauma are impacted by making negative and positive sense of adversity, respectively, via two separate pathways, both mediated by resilience. Our findings contribute to an understanding of the cognitive process of symptomatology and PTG in the HIV context. Theoretical considerations, clinical implications, and future directions are discussed.

Depression and key associated factors in female sex workers and women living with HIV/AIDS in the Dominican Republic

Little is known about the mental health of female sex workers and women living with HIV/AIDS in the Dominican Republic, which impedes HIV prevention, testing, and treatment. This project estimates the prevalence of depression and identifies key contributing factors to this outcome in female sex workers, women living with HIV/AIDS, and a comparison group. Participants were female sex workers (N = 349), women living with HIV/AIDS (N = 213), and a comparison group of HIV-negative women who were not sex workers (N = 314) from the Dominican Republic. Participants completed questionnaires assessing demographic characteristics and depression. Female sex workers and women living with HIV/AIDS completed additional questionnaires ascertaining HIV or sex work-related internalized stigma. Depression was prevalent among female sex workers (70.2%), women living with HIV/AIDS (81.1%), and the comparison group (52.2%). Adjusted logistic regressions showed that internalized stigma was associated with depression for female sex workers (OR = 2.73; 95% CI = 1.95-3.84) and women living with HIV/AIDS (OR = 3.06; 95% CI = 1.86-5.05). Permanent income was associated with this outcome for female sex workers (OR = 0.08; 95% CI = 0.01-0.80) and the comparison group (OR = 0.04; 95% CI = 0.00-0.45).

Mental Health Burden Among Impoverished HIV-Positive Patients in Peru

HIV and poor mental health are intricately related. In settings of poverty, both are often rooted in structural factors related to material and social deprivation. We performed a qualitative analysis to understand factors contributing to poor emotional health and its impact among impoverished Peruvian HIV-infected individuals. We conducted focus group discussions with patients and providers consisting of semistructured, open-ended questions. Qualitative analysis provided insight into the profound impact of depression, isolation, stigma, and lack of social support among these patients. Living with HIV contributed significantly to mental health problems experienced by HIV-positive individuals; furthermore, long-standing stressors-such as economic hardship, fragmented family relationships, and substance use-shaped patients' outlooks, and may have contributed not only to current emotional hardship but to risk factors for contracting HIV as well. Once diagnosed with HIV/AIDS, many patients experienced hopelessness, stigma, and socioeconomic marginalization. Patients tended to rely on informal sources of support, including peers and community health workers, and rarely used formal mental health services. In resource-poor settings, the context of mental health problems among HIV-positive individuals must be framed within the larger structural context of poverty and social exclusion. Optimal strategies to address the mental health problems of these individuals should include integrating mental health services into HIV care, task shifting to utilize community health workers where human resources are scarce, and interventions aimed at poverty alleviation.

Traumatic episodes and mental health effects in young men and women in Rwanda, 17 years after the genocide

OBJECTIVES

To investigate mental health effects associated with exposure to trauma in Rwanda during the 1994 genocide period, and over the lifetime, in Rwandan men and women aged 20-35 years.

SETTING

This was a cross-sectional population-based study conducted in the southern province of Rwanda. Data was collected during December 2011 to January 2012.

PARTICIPANTS

A total population of 917 individuals were included, 440 (48%) men and 477 (52%) women aged 20-35 years. Number of households for inclusion in each village was selected proportional to the total number of households in each selected village. The response rate was 99.8%. Face-to-face interviewing was done by experienced and trained clinical psychologists, following a structured questionnaire.

RESULTS

Women were slightly less exposed during the genocide period (women 35.4% and men 37.5%; p=0.537), but more women than men were exposed to traumatic episodes over their lifetime (women 83.6%, n=399; men 73.4%, n=323; p<0.001). Current major depressive episodes (MDE) were twice as prevalent in women as in men. Traumatic episodes experienced in the genocide period severely affected men's current mental health status with relative risk (RR) 3.02 (95% CI 1.59 to 5.37) for MDE past and with RR 2.15 (95% CI 1.21 to 3.64) for suicidality. Women's mental health was also affected by trauma experienced in the genocide period but to an even higher extent, by similar trauma experienced in the lifetime with RR 1.91 (95% CI 1.03 to 3.22) for suicidality and RR 1.90 (95% CI 1.34 to 2.42) for generalised anxiety disorder, taking spousal physical/sexual violence into consideration.

CONCLUSIONS

Depression, post-traumatic stress disorder, anxiety and suicidal attempts are prevalent in Rwanda, with rates twice as high in women compared with men. For women, exposure to physical and sexual abuse was independently associated with all these disorders. Early detection of gender-based violence through homes and community interventions is important.

Life after Genocide: Mental Health, Education, and Social Support of Orphaned Survivors

Thousands of orphaned survivors of the 1994 Rwandan Genocide against the Tutsi were not only exposed to extraordinarily severe forms of violence, but also many of these children took on the responsibility of caring and providing for other child survivors. This study describes the poverty, educational attainment, social support and mental health of orphaned heads of household (OHH) fourteen years after the genocide, and analyzes how violence exposure during the genocide and post-genocide stressors contributed to symptoms of posttraumatic stress disorder (PTSD) and distress. Participants were 61 members of an OHH community organization who were interviewed in 2002 about their genocide experiences and who provided a follow-up assessment of post-genocide risk factors and PTSD and distress symptoms in 2008. Almost all of the OHH in this study reported low social support, high levels of poverty, and high rates of PTSD and distress symptoms. Lower educational attainment predicted PTSD symptoms and partially mediated the association between exposure to genocide violence and PTSD. Distress was predicted by lack of social support and witnessing family members harmed during the genocide. Results suggest that public health and community efforts to improve educational outcomes and to strengthen and expand social support networks may improve mental health outcomes of OHH.

Supportive-Expressive Group Therapy for People Experiencing Collective Traumatic Crisis During the Genocide Commemoration Period in Rwanda: Impact and Implications

In Rwanda, the annual commemorations of the genocide are associated with an increase in the level of collective traumatic crises whereby many people participating in commemoration activities present various symptoms, including emotional distress and re-experiencing traumatic events of the 1994 genocide. These sudden crises normally last between 30 and 120 minutes and can affect hundreds of people at big commemoration events. They are accompanied by a degree of urgency that disturbs the whole assembly. This article briefly presents an overview of these crises and highlights the results of a study on the effects of a supportive-expression group intervention in the post-crisis period for people who experienced these collective traumatic crises. The study compares the therapeutic progress made by a group of people who participated in a supportive-expression group therapy program as compared to those who did not receive the intervention. The study suggests that the supportive group intervention can improve the overall psychological wellbeing of people who experienced collective traumatic crisis even though it was ineffective for some symptoms.

Over-reported peripheral neuropathy symptoms in a cohort of HIV infected and uninfected Rwandan women: the need for validated locally appropriate questionnaires

BACKGROUND

Peripheral neuropathy symptoms (PNS) are commonly manifested in HIV-infected (HIV+) individuals, although data are limited on the prevalence and predictors of PNS in HIV+ patients from sub-Saharan Africa.

OBJECTIVE

To determine the prevalence and predictors of PNS in HIV+ and HIV-uninfected (HIV-) Rwandan women.

METHODS

Data were analysed from 936 (710 HIV+ and 226 HIV-) women from the Rwanda Women Interassociation Study and Assessment (RWISA), an observational prospective cohort study investigating the effectiveness and toxicity of ART in HIV+ women.

RESULTS

Of 936 enrolled, 920 (98.3%) were included in this analysis with 44% of HIV- and 52% of the HIV+ women reporting PNS (p=0.06). CD4+ count was not associated with PNS, although there was a non-significant trend towards higher prevalence in those with lower CD4+ counts. For the HIV- women, only alcohol and co-trimoxazole use were independently associated with PNS. WHO HIV stage IV illness and albumin ≤ 3.5 were associated with PNS in HIV+ women.

CONCLUSIONS

The rate of peripheral neuropathy symptoms reported in this cohort of HIV-infected African women seems implausible, and rather suggests that the screening tool for peripheral neuropathy in culturally diverse African settings be locally validated.

HIV infection and depression

Major depression is highly prevalent among HIV-positive patients (HIVpp). The prevalence of depression ranges between 18% and 81%, depending on the population studied and the methodology of the study. The etiology of depression in HIVpp is likely determined by: (i) biological factors (alterations in the white matter structure, hypothalamic-pituitary-thyroid dysfunction, Tat-protein-induced depressive behavior); (ii) psychosocial factors (HIV stigma, occupational disability, body image changes, isolation and debilitation); (iii) history or comorbidity of psychiatric illness; and (iv) the perinatal period in HIVpp women. Symptomatology of depression differs between HIVpp and HIV-negative patients (HIVnp). Depression may also alter the function of lymphocytes in HIVpp and decrease natural killer cell activity, contributing to the increased mortality in these patients. Selective serotonin re-uptake inhibitors are considered the first-line treatment. Treatment of depression can improve quality of life and lead to a better prognosis of HIV infection.

EMDR Humanitarian Work: Providing Trainings in EMDR Therapy to African Clinicians

This article is a nonexhaustive overview concerning the developments of eye movement desensitization and reprocessing (EMDR) therapy in a humanitarian context in Africa. These efforts aimed to promote psychological healing for people suffering after humanitarian crises, wars, and disasters. This article reflects a summary of the contributions obtained from organizations and people working and teaching EMDR therapy in Africa. In addition to explaining the cultural, political, and socioeconomic outcomes of the African context and the special needs of those suffering from trauma and trauma-related symptoms, this article emphasizes the challenges for humanitarian efforts in offering and in teaching EMDR therapy in Africa. The work in four countries is presented to provide specific examples.

Symptoms of common mental disorder and cognitive associations with seropositivity among a cohort of people coming for testing for HIV/AIDS in Goa, India: a cross-sectional survey

Background

The majority of research on HIV/AIDS and mental health has been carried out among clinical populations: the time of onset of comorbid depression and the mechanisms for this are therefore unclear. Although there is evidence to suggest that asymptomatic people living with HIV/AIDS exhibit some cognitive deficits, the prevalence of poor cognitive functioning among people in low income settings at an early, pre-clinical stage has not yet been investigated.

Methods

We used a cross-sectional survey design to test the hypotheses that symptoms of Common Mental Disorder (CMD) and low scores on cognitive tests would be associated with seropositivity among participants coming for testing for HIV/AIDS. Participants were recruited at the time of coming for testing for HIV/AIDS; voluntary informed consent was sought for participation in research interviews and data linkage with HIV test results. Baseline questionnaires including sociodemographic variables and measures of mental health (PHQ-9, GAD-7, panic disorder questions, AUDIT and delayed word list learning and recall and animal naming test of verbal fluency) were administered by trained interviews. HIV status data was extracted from clinical records.

Results

CMD and scoring below the educational norm on the test of verbal fluency were associated with testing positive for HIV/AIDS in bivariate analysis (OR = 2.26, 1.31-3.93; OR = 1.77, 1.26-2.48, respectively). After controlling for the effects of confounders, the association between CMD and seropositivity was no longer statistically significant (AOR = 1.56, 0.86-2.85). After adjusting for the effects of confounders, the association between low scores on the test of verbal fluency and seropositivity was retained (AOR = 1.77, 1.27-2.48).

Conclusions

Our findings provide tentative evidence to suggest that low cognitive test scores (and possibly depressive symptoms) may be associated with HIV status among people who have yet to receive their HIV test results. Impaired cognitive functioning and depression-like symptoms may be the result of the same underlying neurological damage. CMD and cognitive impairment may overlap to a greater extent than previously assumed. If replicated, this may have implications for the way in which we measure and treat CMD and cognitive functioning among people living with HIV/AIDS.

Two decades later: The resilience and post-traumatic responses of Indigenous Quechua girls and adolescents in the aftermath of the Peruvian armed conflict

OBJECTIVES

In comparison to other traumatic events, the impact of a childhood during war on resilience later in life has been seldom examined. The aim of this study was therefore to examine the long term outcomes of post-traumatic responses and resilience of a sample of adult Indigenous Quechua women, who were girls or adolescents during the Peruvian armed conflict (1980-1995).

METHODS

The study instruments (Harvard trauma questionnaire part I and IV; Connor-Davidson resilience scale; life stress questionnaire) were translated to Quechua and cross-culturally validated. A cross sectional survey design was used in 2010 to collect data from a convenience sample of 75 participants (25-45 years old) in Ayacucho, Peru, the region most affected by the conflict. Data was examined using hierarchical regression analyses.

RESULTS

Participants reported extreme exposure to violence (e.g., sexual violence, torture, combat, death of family members, and forced displacement) during the armed conflict, but surprisingly, only 5.3% reported a current level of symptoms that may indicate a possible post-traumatic stress disorder (PTSD). Resilience scores and number of years exposed to conflict as a child were not associated with PTSD symptoms; instead only the degree of exposure to violence, and current level of stress contributed to the variance of PTSD-related symptoms. Conversely, resilience and current stress contributed to the variance of trauma symptoms when measured by local idioms of distress.

CONCLUSIONS

Findings should be interpreted with caution, due to limitations in the content validity of instruments, risk of inaccurate recall, use of individual explanations of distress (such as PTSD) for collective experiences of violence, use of non-indigenous frameworks to examine Indigenous resilience, and other methodological concerns. The study however highlights the high degree of traumatic exposure of these former war children. While the prevalence of potential PTSD was astonishingly low in this sample, a number of women still suffer from significant distress two decades after the traumatic events. Therefore, post-conflict interventions should renew efforts to foster the resilience of marginalized populations disproportionately targeted by violence and advocate for enhanced protection of women and children in current armed conflicts.

The impact of HIV status, HIV disease progression, and post-traumatic stress symptoms on the health-related quality of life of Rwandan women genocide survivors

PURPOSE

We examined whether established associations between HIV disease and HIV disease progression on worse health-related quality of life (HQOL) were applicable to women with severe trauma histories, in this case Rwandan women genocide survivors, the majority of whom were HIV-infected. Additionally, this study attempted to clarify whether post-traumatic stress symptoms were uniquely associated with HQOL or confounded with depression.

METHODS

The Rwandan Women's Interassociation Study and Assessment was a longitudinal prospective study of HIV-infected and uninfected women. At study entry, 922 women (705 HIV+ and 217 HIV-) completed measures of symptoms of post-traumatic stress and HQOL as well as other demographic, clinical, and behavioral characteristics.

RESULTS

Even after controlling for potential confounders and mediators, HIV+ women, in particular those with the lowest CD4 counts, scored significantly worse on HQOL and overall quality of life (QOL) than did HIV- women. Even after controlling for depression and HIV disease progression, women with more post-traumatic stress symptoms scored worse on HQOL and overall QOL than women with fewer post-traumatic stress symptoms.

CONCLUSIONS

This study demonstrated that post-traumatic stress symptoms were independently associated with HQOL and overall QOL, independent of depression and other confounders or potential mediators. Future research should examine whether the long-term impact of treatment on physical and psychological symptoms of HIV and post-traumatic stress symptoms would generate improvement in HQOL.

Sexual relationship power and depression among HIV-infected women in Rural Uganda

Background

Depression is associated with increased HIV transmission risk, increased morbidity, and higher risk of HIV-related death among HIV-infected women. Low sexual relationship power also contributes to HIV risk, but there is limited understanding of how it relates to mental health among HIV-infected women.

Methods

Participants were 270 HIV-infected women from the Uganda AIDS Rural Treatment Outcomes study, a prospective cohort of individuals initiating antiretroviral therapy (ART) in Mbarara, Uganda. Our primary predictor was baseline sexual relationship power as measured by the Sexual Relationship Power Scale (SRPS). The primary outcome was depression severity, measured with the Hopkins Symptom Checklist (HSCL), and a secondary outcome was a functional scale for mental health status (MHS). Adjusted models controlled for socio-demographic factors, CD4 count, alcohol and tobacco use, baseline WHO stage 4 disease, social support, and duration of ART.

Results

The mean HSCL score was 1.34 and 23.7% of participants had HSCL scores consistent with probable depression (HSCL>1.75). Compared to participants with low SRPS scores, individuals with both moderate (coefficient b = −0.21; 95%CI, −0.36 to −0.07) and high power (b = −0.21; 95%CI, −0.36 to −0.06) reported decreased depressive symptomology. High SRPS scores halved the likelihood of women meeting criteria for probable depression (adjusted odds ratio = 0.44; 95%CI, 0.20 to 0.93). In lagged models, low SRPS predicted subsequent depression severity, but depression did not predict subsequent changes in SPRS. Results were similar for MHS, with lagged models showing SRPS predicts subsequent mental health, but not visa versa. Both Decision-Making Dominance and Relationship Control subscales of SRPS were associated with depression symptom severity.

Conclusions

HIV-infected women with high sexual relationship power had lower depression and higher mental health status than women with low power. Interventions to improve equity in decision-making and control within dyadic partnerships are critical to prevent HIV transmission and to optimize mental health of HIV-infected women.

Differences in the Nonuse of any Contraception and Use of Specific Contraceptive Methods in HIV Positive and HIV Negative Rwandan Women

Contraception can reduce the dual burden of high fertility and high HIV prevalence in sub-Sahara Africa, but significant barriers remain regarding access and use. We describe factors associated with nonuse of contraception and with use of specific contraceptive methods in HIV positive and HIV negative Rwandan women. Data from 395 HIV-positive and 76 HIV-negative women who desired no pregnancy in the previous 6 months were analyzed using univariate and multivariate logistic regression models to identify clinical and demographic characteristics that predict contraceptive use. Differences in contraceptive methods used were dependent on marital/partner status, partner's knowledge of a woman's HIV status, and age. Overall, condoms, abstinence, and hormonal methods were the most used, though differences existed by HIV status. Less than 10% of women both HIV+ and HIV− used no contraception. Important differences exist between HIV-positive and HIV-negative women with regard to contraceptive method use that should be addressed by interventions seeking to improve contraceptive prevalence.

Depression, alcohol use and adherence to antiretroviral therapy in sub-Saharan Africa: a systematic review

This study evaluated estimates of depression symptoms, major depression, alcohol use or disorders and their association with ART adherence in sub-Saharan Africa. Studies published between January 1, 2006 and July 31, 2011 that documented rates of these mental health problems were identified through electronic databases. A pooled analysis of 23 studies reporting rates of depression symptoms and six studies reporting rates of major depression indicated a pooled estimate of 31.2% (95% CI 25.5-38.2%, Tau(2) = 0.23) and 18% (95% CI 12.3-25.8%, Tau(2) = 0.19) respectively. Few studies reported rates of alcohol use or disorders, and so we did not pool their estimates. Likelihood of achieving good adherence was 55% lower among those with depression symptoms compared to those without (pooled OR = 0.45 (95% CI 0.31-0.66, Tau(2) = 0.20, P value = 0.000). Interventions to improve mental health of HIV-positive individuals and to support adherence are desperately needed in sub-Saharan Africa.

Depression and posttraumatic stress disorder among HIV-infected Gambians on antiretroviral therapy

Mood disorders are more frequent among people with HIV infection than among non-HIV-infected individuals of the same age, socioeconomic status, and HIV risks. They have been associated with worse adherence and clinical outcomes, yet remain underdiagnosed and undertreated in sub-Saharan Africa. We explored the relationship between mood disorders using the 10-item depression scale of the Centers for Epidemiological Studies (CES-D10) and the 22-item Impact of Events Scale-Revised (IES-R) for posttraumatic stress disorder, and a range of demographic and HIV-related variables among 252 consecutive subjects on antiretroviral therapy (ART). The study was conducted in the Genito-Urinary Medicine Clinic of the Medical Research Council's Gambia Unit. These screening tests were positive in 7% and 30%, respectively, of the patients, with higher scores (more depression or more post-traumatic stress) associated with female gender, more advanced WHO clinical stage, and lower Karnofsky Perfomance Scale rating. Higher CES-D10 scores were also seen among those on their second ART regimen. No relationship was seen with age, time on ART, viral load, or CD4 cell count. Compared to an earlier study at the same site in subjects prior to starting ART, the prevalence of depression in those stabilized on ART was dramatically reduced (by 34%, from 41%) while that of PTSD dropped less (by 13%, from 43%). Integrating the CES-D10 or a similar instrument into patient preparation for ART is recommended in order to identify those who may benefit from further mental health investigations, specific therapy, or closer follow-up during early ART.

'I think my future will be better than my past': examining support group influence on the mental health of HIV-infected Rwandan women

Urgent need exists for improved psychological services among HIV-infected women in post-genocide Rwanda. Psychological problems associated with trauma and sexual violence (i.e., depression, posttraumatic stress disorder [PTSD]) place women at increased risk for sexual risk behaviour, low health-seeking behaviour, delay of antiretroviral therapy (ART) and reduced ART adherence. We explored experiences of HIV-infected Rwandan women attending psychosocial support groups and their narratives about how participation affected their mental health and HIV treatment. Focus group discussions examined participants' reasons for support group attendance, perceived psychological benefit of support groups, influence on ART adherence, and other influences on health behaviors and attitudes. Rwandan women (aged 18-65) were randomly selected from 10 health clinic-facilitated support groups for HIV-infected trauma survivors in Kigali. Results identified positive psychological and physical changes as well as behaviour changes in relationships with men, which participants attributed to support group attendance. Data showed significant improvement in mental health, ART adherence and HIV serostatus disclosure resulting from group attendance. Participants acknowledged limitations of support groups with respect to addressing poverty and hunger. Implementing psychosocial support groups may leverage clinical outcomes and rejuvenate the well-being of HIV-infected women with interpersonal trauma and/or PTSD and depressive symptoms, particularly those from post-conflict countries.

Structural determinants of food insufficiency, low dietary diversity and BMI: a cross-sectional study of HIV-infected and HIV-negative Rwandan women

OBJECTIVES

In Sub-Saharan Africa, the overlapping epidemics of undernutrition and HIV infection affect over 200 and 23 million people, respectively, and little is known about the combined prevalence and nutritional effects. The authors sought to determine which structural factors are associated with food insufficiency, low dietary diversity and low body mass index (BMI) in HIV-negative and HIV-infected Sub-Saharan women.

STUDY DESIGN

Cross-sectional analysis of a longitudinal cohort.

SETTING

Community-based women's organisations.

PARTICIPANTS

161 HIV-negative and 514 HIV-infected Rwandan women.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes included food insufficiency (reporting 'usually not' or 'never' to 'Do you have enough food?'), low household dietary diversity (Household Dietary Diversity Score ≤3) and BMI <18.5 (kg/m(2)). The authors also measured structural and behavioural factors including: income, household size, literacy and alcohol use.

RESULTS

Food insufficiency was prevalent (46%) as was low dietary diversity (43%) and low BMI (15%). Food insufficiency and dietary diversity were associated with low income (adjusted odds ratio (aOR)=2.14 (95% CI 1.30 to 3.52) p<0.01), (aOR=6.51 (95% CI 3.66 to 11.57) p<0.001), respectfully and illiteracy (aOR=2.00 (95% CI 1.31 to 3.04) p<0.01), (aOR=2.10 (95% CI 1.37 to 3.23) p<0.001), respectfully and were not associated with HIV infection. Alcohol use was strongly associated with food insufficiency (aOR=3.23 (95% CI 1.99 to 5.24) p<0.001). Low BMI was inversely associated with HIV infection (aOR≈0.5) and was not correlated with food insufficiency or dietary diversity.

CONCLUSIONS

Rwandan women experienced high rates of food insufficiency and low dietary diversity. Extreme poverty, illiteracy and alcohol use, not HIV infection alone, may contribute to food insufficiency in Rwandan women. Food insufficiency, dietary diversity and low BMI do not correlate with one another; therefore, low BMI may not be an adequate screening tool for food insufficiency. Further studies are needed to understand the health effects of not having enough food, low food diversity and low weight in both HIV-negative and HIV-infected women.

Cross-cultural adaptation and validation of the self-reporting questionnaire among HIV+ individuals in a rural ART program in southern Uganda

BACKGROUND

HIV treatment programs are in need of brief, valid instruments to identify common mental disorders such as depression.

AIM

To translate and culturally adapt the Self-Reporting Questionnaire (SRQ-20) for use in Uganda and to investigate its psychometric properties in this setting.

METHODS

Following an initial translation of the SRQ-20 from English to Luganda, key informant interviews and focus-group discussions were used to produce a culturally adapted version of the instrument. The adapted SRQ-20 was administered to 200 HIV-positive individuals in a rural antiretroviral therapy program in southern Uganda. All study participants were also evaluated by a psychiatric clinical officer with the Mini International Neuropsychiatric Interview (MINI). Receiver-operating-characteristic analysis was used to examine the sensitivity and specificity of the SRQ-20 compared to the clinical diagnosis generated by the MINI.

RESULTS

The prevalence estimates of any depressive disorder and current depression were 24% (n = 48) and 12% (n = 24), respectively. The SRQ-20 scores discriminated well between subjects with and without current depression based on the MINI, with an area under the curve of 0.92, as well as between subjects with and without any current or past depressive disorder, with an area under the curve of 0.75. A score of 6 or more had 84% sensitivity and 93% specificity for current depression, and 75% sensitivity and 90% specificity for any depressive disorder.

CONCLUSION

The SRQ-20 appears to be a reliable and valid screening measure for depression among rural HIV-positive individuals in southern Uganda. The use of this screening instrument can potentially improve detection and management of depression in this setting.

Caregiver role overload and network support in a sample of predominantly low-income, African-American caregivers of persons living with HIV/AIDS: a structural equation modeling analysis

While informal caregivers play an important role in improving the health of disadvantaged persons living with HIV/AIDS (PLHAs) in the United States, caregiver role overload has the potential for distress. We used latent profile analysis (LPA) to classify caregivers based on their perceived level of support and structural equation modeling (SEM) to examine the relationships among role overload, perceived support, caregiver demographic characteristics, and social network members' characteristics in a sample of 215 predominantly low-income, African-American informal caregivers. The LPA resulted in two classes of caregivers with higher and lower perceived support. The SEM results indicated that caregiver role overload was associated with being in the less supported class, younger age, and limited physical functioning, while social support class was associated with being female and being HIV seropositive in addition to support network characteristics. Interventions should address the support needs of HIV caregivers to reduce their potential for distress.

Association of pre-treatment nutritional status with change in CD4 count after antiretroviral therapy at 6, 12, and 24 months in Rwandan women

BACKGROUND

Body mass index (BMI) independently predicts mortality in studies of HIV infected patients initiating antiretroviral therapy (ART). We hypothesized that poorer nutritional status would be associated with smaller gains in CD4 count in Rwandan women initiating ART.

METHODS AND FINDINGS

The Rwandan Women's Interassociation Study and Assessment, enrolled 710 ART-naïve HIV-positive and 226 HIV-negative women in 2005 with follow-up every 6 months. The outcome assessed in this study was change in CD4 count at 6, 12, and 24 months after ART initiation. Nutritional status measures taken prior to ART initiation were BMI; height adjusted fat free mass (FFMI); height adjusted fat mass (FMI), and sum of skinfold measurements. 475 women initiated ART. Mean (within 6 months) pre-ART CD4 count was 216 cells/µL. Prior to ART initiation, the mean (±SD) BMI was 21.6 (±3.78) kg/m(2) (18.3% malnourished with BMI<18.5); and among women for whom the following were measured, mean FFMI was 17.10 (±1.76) kg/m(2); FMI 4.7 (±3.5) kg/m(2) and sum of skinfold measurements 4.9 (±2.7) cm. FFMI was significantly associated with a smaller change in CD4 count at 6 months in univariate analysis (-6.7 cells/uL per kg/m(2), p=0.03) only. In multivariate analysis after adjustment for covariates, no nutritional variable was associated with change in CD4 count at any follow up visit.

CONCLUSION

In this cohort of African women initiating ART, no measure of malnutrition prior to ART was consistently associated with change in CD4 count at 6, 12, and 24 months of follow up, suggesting that poorer pre-treatment nutritional status does not prevent an excellent response to ART.

Improvement in posttraumatic stress disorder in postconflict Rwandan women

BACKGROUND

Depression and posttraumatic stress disorder (PTSD) are common in developing and postconflict countries. The purpose of this study is to examine longitudinal changes in PTSD in HIV-infected and uninfected Rwandan women who experienced the 1994 genocide.

METHODS

Five hundred thirty-five HIV-positive and 163 HIV-negative Rwandan women in an observational cohort study were followed for 18 months. Data on PTSD symptoms were collected longitudinally by the Harvard Trauma Questionnaire (HTQ) and analyzed in relationship to demographics, HIV status, antiretroviral treatment (ART), and depression. PTSD was defined as a score on the HTQ of ≥2.

RESULTS

There was a continuing reduction in HTQ scores at each follow-up visit. The prevalence of PTSD symptoms changed significantly, with 61% of the cohort having PTSD at baseline vs. 24% after 18 months. Women with higher HTQ score were most likely to have improvement in PTSD symptoms (p<0.0001). Higher rate of baseline depressive symptoms (p<0.0001) was associated with less improvement in PTSD symptoms. HIV infection and ART were not found to be consistently related to PTSD improvement.

CONCLUSIONS

HIV care settings can become an important venue for the identification and treatment of psychiatric problems affecting women with HIV in postconflict and developing countries. Providing opportunities for women with PTSD symptoms to share their history of trauma to trained counselors and addressing depression, poverty, and ongoing violence may contribute to reducing symptoms.

Using Mixed-Methods Research to Adapt and Evaluate a Family Strengthening Intervention in Rwanda

INTRODUCTION

Research in several international settings indicates that children and adolescents affected by HIV and other compounded adversities are at increased risk for a range of mental health problems including depression, anxiety, and social withdrawal. More intervention research is needed to develop valid measurement and intervention tools to address child mental health in such settings.

OBJECTIVE

This article presents a collaborative mixed-methods approach to designing and evaluating a mental health intervention to assist families facing multiple adversities in Rwanda.

METHODS

Qualitative methods were used to gain knowledge of culturally-relevant mental health problems in children and adolescents, individual, family and community resources, and contextual dynamics among HIV-affected families. This data was used to guide the selection and adaptation of mental health measures to assess intervention outcomes. Measures were subjected to a quantitative validation exercise. Qualitative data and community advisory board input also informed the selection and adaptation of a family-based preventive intervention to reduce the risk for mental health problems among children in families affected by HIV.. Community-based participatory methods were used to ensure that the intervention targeted relevant problems manifest in Rwandan children and families and built on local strengths.

RESULTS

Qualitative data on culturally-appropriate practices for building resilience in vulnerable families has enriched the development of a Family-Strengthening Intervention (FSI). Input from community partners has also contributed to creating a feasible and culturally-relevant intervention. Mental health measures demonstrate strong performance in this population.

CONCLUSION

The mixed-methods model discussed represents a refined, multi-phase protocol for incorporating qualitative data and community input in the development and evaluation of feasible, culturally-sound quantitative assessments and intervention models. The mixed-methods approach may be applied to research in other parts of sub-Saharan Africa and beyond.

Challenges in addressing depression in HIV research: assessment, cultural context, and methods

Depression is one of the most common co-morbidities of HIV infection. It negatively impacts self-care, quality of life, and biomedical outcomes among people living with HIV (PLWH) and may interfere with their ability to benefit from health promotion interventions. State-of-the-science research among PLWH, therefore, must address depression. To guide researchers, we describe the main diagnostic, screening, and symptom-rating measures of depression, offering suggestions for selecting the most appropriate instrument. We also address cultural considerations in the assessment of depression among PLWH, emphasizing the need to consider measurement equivalence and offering strategies for developing measures that are valid cross-culturally. Finally, acknowledging the high prevalence of depression among PLWH, we provide guidance to researchers on incorporating depression into the theoretical framework of their studies and employing procedures that account for participants with depression.