Background
Methods
Definition of terms
Search strategy
Data extraction and management
Results
Primary author and Year | Country | Study design | Sampling strategy | Sample size and participation rate | Participant characteristics |
---|---|---|---|---|---|
Mental health and HIV serostatus/HIV-related outcomes | |||||
Adedimeji et al., 2015 | Rwanda | Cross-sectional Baseline data from 2005 RWISA prospective cohort | Non random selection HIV+ and HIV- women approximately 50% of whom experienced rape during the genocide | N = 928 99% of N = 936 included | Women over age 15 who experienced the 1994 genocide, 76% HIV+ 20.5% < 30 years 48.4% 30–40 years 31.1% 40+ years 100% female |
Adler et al., 2011 | USA | Time-series Time 1: 4 months after return from deployment Time 2: 4 months later | Non random selection Part of a larger study on post deployment transition | N = 647 39% of N = 1651 included who completed both assessments | Active duty USA soldiers in a brigade combat team who had returned from a 15-month deployment in Iraq Age not reported 96% male 4% female |
Kinyanda et al., 2012 | Uganda | Cross-sectional Nested in study on HIV-related psychiatric & psychosocial vulnerabilities in war-affected community | Random selection Multistage sampling to include vulnerable and non-vulnerable individuals | N = 1560 98.5% of N = 1584 included who completed the interview | Vulnerable (widows, orphans, single mothers) and non-vulnerable individuals in a war-affected community Aged 15 years and older 56% were aged between 18 and 44 years 43% male 57% female |
Kinyanda et al., 2016 | Uganda | Cross-sectional Nested in study addressing HIV-related psychiatric and psychosocial vulnerabilities in the war-affected community | Random sampling Multistage sampling for representative sample of vulnerable and non-vulnerable individuals | N = 1110 71.2% with complete data included of N = 1560 | Vulnerable (widowed, divorced, orphan, suffered torture, mental illness, etc.) and non-vulnerable individuals in a war-affected community Aged 15 years and older 56% were aged between 18 and 44 years 43% male 57% female |
Malamba et al., 2016 | Uganda | Cross-sectional Baseline data from a longitudinal cohort study to determine HIV prevalence and risk factors to inform program development | Random selection Two-stage stratified sampling for representative sample | N = 2388 97.5% who had HIV results included of N = 2449 consenting individuals | Conflict affected individuals aged 13–49 29.1% 13–19 years 20.2% 20–24 years 19.6% 25–29 years 12.4% 30–34 years 18.6% 35+ years 40% male 60% female |
Svetlicky et al., 2010 | Lebanon | Cross-sectional Collected 6 months post-conflict, collected for 4 months. | Non random selection Combat reserve soldiers who sought treatment in the Combat Reaction Unit in the wake of the Second Lebanon War | N = 180 65.7% of N = 274 included who completed questionnaires | Mean age = 29.95 years (SD = 5.82; range = 20 to 54 years). 100% male Most were Israeli-born (82.8%) |
Talbot et al., 2013 | Rwanda | Time-series Collected at baseline, 5, 9, and 12 months | Random selection Orphans selected via random number generation from a list of all eligible orphans enrolled in program | N = 120 95% of N = 120 completed all 4 assessments; all participants were included in analysis | 94% were orphaned from the genocide Mean age = 18 years (range 15–25) Male 47% Female 53% |
B.E. Cohen et al., 2012 | USA | Retrospective cohort From a roster of all USA veterans from 2 operations | Non random selection Separated USA veterans who were new users of Department of Veterans Affairs healthcare | N = 71,504 | Veterans of Operations Enduring and Iraqi Freedom Mean age = 28.5 to 29.5 100% female |
Sexual violence and mental health outcomes | |||||
Amone P’Olak et al., 2013 | Uganda | Cross-sectional Baseline data nested in a before and after study | Random selection War-affected youth who had been abducted and lived in rebel captivity for at least 6 months | N = 539 83% of N = 650 who were invited to the study | Aged between 18 and 25 years 61% male 39% female 86% Acholi ethnic group |
Roberts et al., 2008 | Uganda | Cross-sectional | Random selection Multi-stage cluster sampling of camps, administrative zones, and individuals | N = 1210 | Adults living in camps for internally displaced persons Mean age = 35.3 years 40% male 60% female 91% Acholi ethnic group |
Nakimuli-Mpungu et al., 2013 | Uganda | Time series Collected at baseline, 3, and 6 months | Non random selection Analysis included only adults with a history of war-related traumatic experiences | N = 375 59% of N = 631 included who were present for at least 2 visits | Demographic data reported all patients N = 2868, many of whom were not included in the main analysis Mean age adult men = 34.5 Mean age adult women = 37.3 47% male 53% female |
Okello et al., 2007 | Uganda | Case control Cross- sectional, unmatched Cases were formerly abducted youth Controls were non abducted youth | Random selection Systematic recruitment, every 3rd name at 2 sites: a children’s support organization (case) and a mixed boarding school (control) | N = 153 Formerly abducted N = 82 Non-abducted N = 71 | War affected adolescents Boys mean age = 15.5 years Girls mean age = 15.2 years Cases: 64% male; 36% female Controls: 61% male; 39% female 100% of controls in secondary school, 12.2% of cases in secondary school |
Betancourt, Agnew-Blais et al., 2010 | Sierra Leone | Prospective cohort Collected at baseline and time 2 | Non random selection Two stage method: 1) master list of youth in care 2) Invited youth between ages 10–18 with contact information | N = 152 60% of N = 260 interviewed at both times | Former child soldiers Mean age = 17.4 years 89% male 11% female |
Betancourt et al., 2011 | Sierra Leone | Cross-sectional Partially nested in a longitudinal study | Non random selection Longitudinal participants from those who participated in one follow up visit, new participants recruited with NGO outreach lists | N = 273 N = 146 from longitudinal study and N = 127 newly recruited for study (50% male, 50% female) | Former child soldiers Mean age = 16.55 (SD 2.61) 71% male 29% female |
Betancourt, Borisova et al., 2010 | Sierra Leone | Prospective cohort Collected at baseline and time 2, approximately 2 years later | Non random selection Two stage method: 1) master list of youth in care 2) Youth aged 10–18 who did not have a severe disability participated | N = 156 60% of N = 260 interviewed at both times | Former child soldiers Mean age = 15.13 years 88% male 12% female |
Betancourt, Brennan et al., 2010 | Sierra Leone | Prospective cohort Collected at baseline (2002), time 2 (2004), and time 3 (2008) | Non random selection Sample from a master list of youth assisted by program. Youth aged 10–17 with contact information invited to participate. | N = 260 56.5% (N = 147) assessed at time 2 68.8% (N = 179) assessed at time 3 | Former child soldiers Mean age at time 1 = 15.13 (SD = 2.22) 89% male 11% female |
Johnson et al., 2008 | Liberia | Cross-sectional | Random selection Population based multi stage random cluster of households | N = 1666 98.2% of N = 1696 attempted interviews | Adults in Liberia; 1/3 were former combatants Mean age = 41 years 47.2% male 52.8% female |
Johnson et al., 2010 | Democratic Republic of Congo | Cross-sectional | Non random selection Accessible population based cluster (some originally selected villages were inaccessible due to weather and security concerns) | N = 998 98.9% of N = 1005 households surveyed | Adults in conflict-affected provinces and districts Mean age = 40.1 years 40.6% male 59.4% female |
Johnson et al., 2014 | Kenya | Cross-sectional | Random sampling Systematic sampling of 90 villages and 10 households to assess election-related violence | N = 916 95.8% of N = 956 households samples | Adults in Kenya Mean age = 37.3 years 40% male 60% female |
Cardozo et al., 2000 | Kosovo | Cross-sectional | Random selection Two-stage cluster sampling | N = 1358 Only women included in relevant analysis, N = 825 | Kosovar ethnic Albanians aged 15+ years 45.3% 15–34 34.1% 35–54 10.9% 55–64 9.7% 65+ 37.7% male 62.3% female |
Sabin et al., 2003 | Guatemalan refugees living in Mexico | Cross-sectional | Non random selection Convenience sample of 5 camps; all households sampled in 4 camps, every 3rd house in 1 camp | N = 170 93% of N = 183 households | Adults and children in Mayan refugee camps Mean age = 37.9 years 42% male 58% female |
Wolfe et al., 1998 | USA | Retrospective cohort Nested in longitudinal study. Baseline within 5 days of return from deployment, time 2 18–24 months later. | Non random selection Included women who completed the mailed sexual harassment questionnaire | N = 160 66.7% of N = 240 women assessed at baseline | Returned veterans of the Persian Gulf War Mean age = 28.2 years (SD = 6.8) 100% female |
Washington et al., 2013 | USA | Cross-sectional Pertinent result presented as case (PTSD) control (no PTSD) | Random selection Population-based stratified sample Included those who completed the PTSD screener | N = 3598 99.6% of N = 3611 | Veterans who had been called to duty Mean age = 46.8 (SD = 17.3) for PTSD positive and 57.4 (SD = 17.0) for PTSD negative women 100% female |
Kang et al., 2005 | USA | Case control Nested data from a population based survey Cases: PTSD Controls: did not meet criteria for PTSD | Random selection Stratified sample to include each subgroup of military personnel | N = 11,441 76.3% of N = 15,000 sampled | Gulf War veterans Mean age: Females: with PTSD = 39.1; without PTSD = 38.1 Males: with PTSD 40.4; without PTSD 39.6 81.4% male 18.6% female |
HIV acquisition/disease progression and mental health outcomes | |||||
Epino et al., 2012 | Rwanda | Cross-sectional From a prospective cohort | Non random selection Patients from clinics | N = 610 | HIV-positive adults who initiated lifelong ART Mean age = 38 (SD = 10) 38% male 62% female Mean CD4 count =214 (SD = 92) |
Mugisha, Muyinda, Wandiembe et al., 2015 | Uganda | Cross-sectional Baseline data from a project delivering a kinship intervention for post-conflict mental health | Random selection Two-stage cluster sample stratified at the sub-county | N = 2361 98% with complete data of N = 2406 | Adult residents of 3 of the most war affected districts 23.5% 18–24 years 27.3% 25–34 years 20.8% 35–44 years 28.5% 45–54 years 37.5% male 62.5% female |
Mugisha, Muyinda, Malamba et al., 2015 | Uganda | Cross-sectional Nested in project delivering a kinship intervention for post-conflict mental health | Random selection Multistage sampling for a representative sample from 3 districts | N = 2361 98% who had complete data included of N = 2406 | Adult residents of 3 of the most war affected districts 23.8% 18–24 years 27.1% 25–34 years 20.7% 35–44 years 28.4% 45+ years 37.5% male 62.5% female |
Muldoon et al., 2014 | Uganda | Cross-sectional From a larger community-based study of sex workers | Non random selection Recruited through peer/sex worker led outreach in bars and hotels, and community-led outreach to former IDP camps | N = 129 | Formerly abducted by the Lords Resistance Army Median age = 22 years (IQR:20–26) 100% female 96.1% from Acholi tribe |
M.H. Cohen et al., 2009 | Rwanda | Cross-sectional Baseline data from a prospective cohort study | Non random selection Mainly recruited by Rwandan women’s associations | N = 850 91% of N = 936 with available mental health data | HIV-positive and HIV-negative women About half of each group experienced genocidal rape Mean age = 36.4 100% female |
M.H. Cohen et al., 2011 | Rwanda | Prospective cohort Baseline, 6, 12, and 18 months later | Non random selection Recruited from Rwandan women’s associations and HIV clinics in Kigali | N = 698 74.6% of N = 936 who completed baseline HTQ and at least 1 post-baseline HTQ | HIV-positive and HIV-negative women 50% of each group experienced genocidal rape Mean age = 36.7 (SD = 8.3) 100% female |
Other associations between mental health and HIV acquisition and disease progression | |||||
Gard et al., 2013 | Rwanda | Cross-sectional Baseline data nested in a prospective cohort study | Non random selection Recruited Rwandan women’s associations and clinical sites for HIV patients | N = 922 98.5% of N = 936 women who completed the Health-Related Quality of Life measure | HIV-positive and HIV-negative women 50% of each group experienced genocidal rape 20.8% under 30 years 48.4% aged 30–40 years 30.8% over 40 years 100% female |
Kohli et al., 2014 | Democratic Republic of Congo | Cross-sectional Baseline data from a randomized community trial | Non random selection Included if provided family rejection information and had experienced at least 1 traumatic event in the past 10 years | N = 315 | Conflict-affected adult women 1.9% 16–19 years 14.6% 20–24 years 28.25% 25–34 years 22.54% 35–44 years 29.52% 45–60 years 3.17% over 60 years 100% female |
Sinayobye et al., 2015 | Rwanda | Cross-sectional Baseline data from 2005 RWISA prospective cohort | Non random selection HIV+ women, approximately 50% of whom experienced rape during the genocide | N = 710 | HIV+ women over age 15, ART naïve Mean age = 34.9 ± 7.0 100% female |
First author & Year | Mental health disorders | Mental health scales | HIV risk measures | Results |
---|---|---|---|---|
Mental health and HIV serostatus/HIV-related outcomes | ||||
Adedimeji et al., 2015 Rwanda | Depression PTSD | Center for Epidemiologic Studies Depression Scale (CES-D) Harvard Trauma Questionnaire (HTQ) | HIV serostatus Had sex last 6 months Condom use at least 50% of time last 6 months History of ever exchanging sex for cash or help History of a non-HIV STI | Depression (p < 0.001) but not PTSD (p = 0.06) was related to HIV serostatus Depression (p = 0.002) but not PTSD (p = 0.09) was related to sex in the last 6 months; women who had sex did not have different odds of depression scores between 16 and 26 (OR = 0.88, CI 0.64, 1.22) but had decreased odds of depression scores 27+ (OR = 0.57, CI 0.04, 0.81) and no different odds of symptomatic PTSD (OR = 0.78, CI 0.60, 1.03) Depression (p = 0.04) and PTSD (p = 0.006) were related to 50% condom use in the last 6 months; women who used condoms had greater odds of depression scores between 16 and 26 (OR = 1.84, CI 1.20, 2.82) but not scores 27+ (OR = 1.36, CI 0.87, 2.54) and decreased odds of symptomatic PTSD (OR = 0.60, CI 0.42, 0.86) Depression (p = 0.02) and PTSD (p = 0.003) were related to exchange sex; women who had exchanged sex had greater odds of depression scores between 16 and 26 (OR = 1.82, CI 1.19, 2.77) and 27+ (OR = 1.74, CI 1.10, 2.76) and greater odds of being symptomatic for PTSD (OR = 1.68, CI 1.19, 2.36) Depression (p = 0.04) but not PTSD (p = 0.74) related to history of a non-HIV STI; women with a non-HIV STI had greater odds of depression scores between 16 and 26 (OR = 2.02, CI 1.39, 3.09; AOR = 1.64, CI 1.01, 2.65) but not depression scores of 27+ (OR = 1.50, CI 0.94, 2.41; AOR = 1.11, CI 0.65, 1.89) nor symptomatic PTSD (OR = 1.07, CI 0.77, 1.50) |
Adler et al., 2011 USA | PTSD | PTSD Checklist (PCL) | Risked STD by having unprotected sex | PTSD at time 1 predicted sex without a condom four months later (OR = 1.57, CI 1.20, 2.04) |
Kinyanda et al., 2012 Uganda | Depression | Hopkins Symptom Checklist (HSCL-15) | High risk sexual behaviors: sex outside marriage; sex in exchange for gifts; sex in exchange for money; sex in exchange for protection; sex with an older person; sex with someone known for less than a day; sex with uniformed personnel; sex with more than one partner | High-risk sexual behavior was marginally related to MDD amongst males in univariate analysis (OR = 1.61, 95% CI 0.99–2.62, p = 0.06) but not females (OR = 1.17, 95% CI 0.68–2.01, p = 0.57). High-risk sexual behavior was related to MDD amongst males (OR = 1.70, 95% CI 1.01–2.86, p = 0.05) in multivariable analysis but not females (OR = 1.03, 95% CI 0.59–1.80, p = 0.91). |
Kinyanda et al., 2016 Uganda | Depression | HSCL-25 | Sexual intimate partner violence (IPV) (‘force you to have sex when you don’t want to’) | Females who experienced sexual IPV had greater odds of probable MDD (AOR = 4.20, CI 1.54, 11.46) |
Malamba et al., 2016 Uganda | Depression PTSD | HSCL-25 HTQ | HIV serostatus | Those with MDD symptoms had greater odd of testing positive for HIV (UOR = 2.70, CI 1.95, 3.75; AOR = 1.89, CI 1.28, 2.80) Those with PTSD symptoms had greater odds of testing positive for HIV (UOR = 1.90, CI 1.30, 2.78; AOR = 1.44, CI 1.06, 1.96) |
Svetlicky et al., 2010 Lebanon | PTSD | PTSD Inventory | Risky sexual activities (3 items including sex without protection against sexually transmitted diseases) | No relationship was found between PTSD and risky sexual activitiesa |
Talbot et al., 2013 Rwanda | PTSD | PCL | Laboratory STI testing HIV risk taking behavior: Exchanging sex for drugs, money, or favors; Having sex with an HIV-infected or status unknown partner; Having two or more sexual partners within the past 3 months | Rates of STI were too low to evaluate associations with PTSD make any conclusions. Higher PTSD symptoms correlated with increased HIV risk-taking behavior (r = 0.24, p = 0.006) at baseline. PTSD symptoms were related to baseline HIV risk (0.01, p = 0.002) in a growth model; for each 1 point increase of trauma symptoms there was a 0.01 unit increase in baseline HIV risk |
B.E. Cohen et al., 2012 USA | Depression PTSD Comorbid depression and PTSD | ICD-9-CM diagnostic codes | Sexually transmitted infections: cervical dysplasia; genital herpes; genital warts; chlamydia; gonorrhea; trichomonas; and other STIs | All STIs except chlamydia were associated with PTSD. Cervical dysplasia AOR = 1.86 (CI 1.61–2.16), Genital herpes AOR = 1.69 (CI 1.36–2.08), Genital warts AOR = 1.83 (CI 1.45–2.31), Chlamydia AOR = 1.66 (CI 0.93–2.96), Gonorrhea AOR = 3.12 (CI 1.51–6.44), Trichomonas AOR = 1.60 (CI 1.08–2.39), Other STIs AOR = 1.83 (CI 1.52–2.21) All STIs were associated with depression. Cervical dysplasia AOR = 2.35 (CI 2.12–2.59), Genital herpes AOR = 2.51 (CI 2.20–2.87), Genital warts AOR = 2.44 (CI 2.09–2.86), Chlamydia AOR = 2.21 (CI 1.49–3.27), Gonorrhea AOR = 3.99 (CI 2.38–6.71), Trichomonas AOR = 2.38 (CI 1.85–3.06), Other STIs AOR = 2.21 (CI 1.95–2.53) All STIs were most strongly associated with comorbid PTSD and depression. Cervical dysplasia AOR = 2.65 (CI 2.41–2.91), Genital herpes AOR = 2.55 (CI 2.24–2.91), Genital warts AOR = 2.97 (CI 2.56–3.43), Chlamydia AOR = 2.58 (CI 1.80–3.70), Gonorrhea AOR = 4.74 (CI 2.91–7.71), Trichomonas AOR = 3.75 (CI 3.01–4.66), Other STIs AOR = 2.92 (CI 2.59–3.28) |
Sexual violence and mental health outcomes | ||||
Amone-P’olak et al., 2013 Uganda | Depression and anxiety | Acholi Psychosocial Assessment Instrument (APAI) | Sexual abuse measured by one item in the War Trauma Screening scale | Sexual abuse (β = 0.32, SE = 0.16, p < 0.001) predicted symptoms of depression and anxiety for female but not male youths in multivariate analysis. |
Roberts et al., 2008 Uganda | PTSD | HTQ | Rape or sexual abuse | Those who reported rape or sexual abuse had greater odds of PTSD symptoms (AOR = 1.76, CI 1.01, 2.75) but not depression symptoms (NR) |
Nakimuli-Mpungu et al., 2013 Uganda | Depression PTSD | Self- reporting questionnaire (SRQ-20) HTQ | Experienced sexual violence
HIV serostatus
| Experiencing sexual violence was significantly related to PTSD symptom scores (β = 3.75, SE = 1.01, p < 0.05) but not depression symptom scores (β = 0.54, SE = 0.45). Being HIV-positive was not significantly related to depression (β = 0.51, SE = 0.43) or PTSD (β = −1.41, SE = 0.94) scores. |
Okello et al., 2007 Uganda | Depression Anxiety PTSD | MINI-KID | Sexual torture (undefined) Being forced to marry | Quantitative results not presented in a table, but the stated that no trauma event (including sexual torture and being forced to marry) showed any significant relationship with any diagnosis of PTSD, major depression and generalized anxiety disorder.a |
Betancourt, Agnew-Blais, et al., 2010 Sierra Leone | Depression and anxiety | A measure developed by the Oxford Refugee Studies Program for use among former child soldiers includes a subscale for anxiety, depression, and hostility | Rape as part of Child War Trauma Questionnaire | Surviving rape predicted an increase in depression over time (b = 2.58, p = 0.01) after controlling for demographic and war-related experiences. When perceived discrimination was included, the strength of the relationship between rape and depression is reduced, (b = 1.65, p = 0.08). When protective factors were added, there was no longer a relationship between rape and depression. Surviving rape was significantly associated with higher levels of anxiety (b = 5.35, p < 0.001) even after perceived discrimination and protective factors were controlled for. |
Betancourt et al., 2011 Sierra Leone | Depression and anxiety | HSCL-25 | Rape as part of Child War Trauma Questionnaire | No significant relationship between rape and depression after controlling for multiple variables b = 2.42 (CI -0.99, 5.84). Rape was significantly related to anxiety b = 2.85 (CI 0.45, 5.26, p = 0.05). A smaller percentage of boys experienced rape (5%) compared to girls (44%), but the effect of rape on anxiety was significant among male child soldiers and not for females (b = −6.42, p = 0.05). |
Betancourt, Borisova, et al., 2010 Sierra Leone | Depression and anxiety | Oxford Refugee Studies Program measure for use among former child soldiers | Rape as part of Child War Trauma Questionnaire | Rape was correlated to depression symptoms (r = 0.24, p ≤ 0.01) and anxiety symptoms (r = 0.38, p ≤ 0.001). Rape was not predictive of depression at T2, adjusting for all covariates (b = 1.74, CI -0.53, 4.00). Rape was the strongest predictor of anxiety at T2 controlling for anxiety levels at T1 (b = 4.06, CI 1.49, 6.62, p < 0.05) and adjusting for all other covariates. |
Betancourt, Brennan et al., 2010 Sierra Leone | Depression and anxiety | Oxford Refugee Studies Program measure for use among former child soldiers | Rape as part of Child War Trauma Questionnaire | Rape was associated with higher baseline levels of internalizing problems (depression/anxiety) (b = 4.60, p < 0.05). After adjusting for all hardship and protective factors, among time-invariant predictors, only being raped remained significantly related to depression/ anxiety (b = 4.34, p = 0.039). |
Johnson et al., 2008 Liberia | Depression PTSD | Patient Health Questionnaire 9 PTSD Symptom Scale Interview (1 month recall) | Sexual violence defined as any violence, physical or psychological, carried out through sexual means or by targeting sexuality and included rape and attempted rape, molestation, sexual slavery, being forced to undress or being stripped of clothing, forced marriage, and insertion of foreign objects into the genital opening or anus, forcing 2 individuals to perform sexual acts on one another or harm one another in a sexual manner, or mutilating a person’s genitals. | Adults who experienced sexual violence were more likely to meet criteria for PTSD (69% vs. 38%, p < 0.001) and MDD (57% vs. 37%, p = 0.002) compared to adults who did not experience sexual violence. The weighted prevalence of PTSD (81% vs. 46%, p < 0.001) and MDD (64% vs.42%, p = 0.003) was higher among male former combatants who had experienced sexual violence compared to those who had not. The weighted prevalence of PTSD (74% vs. 44%, p = 0.005) was higher but not MDD (63% vs.55%, p = 0.51) among female former combatants who experienced sexual violence compared to those who had not. Noncombatant sexual violence was not related to MDD (32% vs. 29%, p = 0.73) nor PTSD (39% vs. 36%, p = 0.74) for men nor MDD (48% vs. 36%, p = 0.15) nor PTSD (56% vs.36%, p = 0.09) for women. Those who experienced lifetime sexual violence had 1.39 (p = 0.04) the odds of MDD and 2.67 (p < 0.001) the odds of PTSD compared to those who did not experience sexual violence. |
Johnson et al., 2010 Democratic Republic of Congo | Depression PTSD | Patient Health Questionnaire–9 PTSD Symptom Scale Interview (PSS-I) | Sexual violence – defined above | The prevalence of MDD was significantly higher for those who experienced sexual violence (60.4%) compared to those who did not experience sexual violence (30.7%, p < 0.001); The prevalence of PTSD was significantly higher for those who experienced sexual violence (70.2%) than those who did not experience sexual violence (40.3%, p < 0.001) . The prevalence of MDD for females who experienced conflict-related sexual violence was significantly higher (67.7%) than for those who did not experience conflict-related sexual violence (30.3, p < 0.001). The prevalence of PTSD for females who experienced conflict-related sexual violence was significantly higher (75.9%) than for those who did not experience conflict-related sexual violence (44.4%, p < 0.001). There were no differences in the prevalence of MDD (47.5% vs. 36.3%, p = 0.18) or PTSD (56% vs. 41.7%, p = 0.17) for men who did and did not experience conflict-related sexual violence. There were no differences in the prevalence of MDD (50.7% vs. 38.4%, p = 0.38) or PTSD (61.5% vs. 44.1%, p = 0.34) for men nor of MDD (72.9% vs. 40.1%, p = 0.07) or PTSD (83.6% vs. 52.4%, p = 0.06) for women who experienced community based sexual violence. |
Johnson et al., 2014 Kenya | Depression PTSD | Patient Health Questionnaire–9 PSS-I | Sexual violence – defined above | 31% of those who experienced sexual violence had anxiety and depression before the 2007 election, 45% who experienced sexual violence had anxiety and depression during the election, and 33.7% who experienced sexual violence had anxiety and depression after the 2007 election. The weighted prevalence of MDD (41.0%, CI 27, 55 vs. 35.0%, CI 29.2, 40.8) and PTSD (40.1%, CI 28.6, 51.6 vs. 30.9%, CI 25, 36.8) were not significantly different between those who reported sexual violence and those who did not report sexual violence. |
Cardozo et al., 2000 Kosovo | PTSD | HTQ | Rape | Rape was not related to PTSD symptoms: 21.6% or women who reported rape had symptoms of PTSD vs. 16.92% of women who did not report rape, p = 0.49; AOR = 1.68, CI 0.69, 4.08 |
Sabin et al., 2003 Guatemalan refugees living in Mexico | Depression Anxiety PTSD | HSCL-25 HTQ | Sexual abuse or rape reported as traumatic event | Sexual abuse or rape was independently associated with anxiety (p = 0.02) but sexual abuse did not remain significant in the full model. All rape survivors (N = 6, 100%) experienced anxiety. Sexual abuse or rape was not related to PTSD or depression.a |
Wolfe et al., 1998 USA | PTSD | Mississippi Scale for Combat-related PTSD | Sexual assault defined as a sexual experience that was unwanted and involved the use or threat of force (attempted or completed rape) either by strangers or people you knew | Women who were sexually assaulted experienced a significant 18.9 point increase in PTSD scores (M = 91.83, SD = 22.69) compared to women with no sexual harassment (M = 71.36, SD = 17.53). Women who were sexually assaulted had increased risk for PTSD compared to women who were only physically (12.5 point difference) or verbally (15.9 point difference) harassed. |
Washington et al., 2013 USA | PTSD | 7-item screen for DSM IV PTSD | History of military sexual assault | Women with PTSD were significantly more likely to have had experienced sexual assault in military (43% vs. 5.1%, p < 0.001). |
Kang et al., 2005 USA | PTSD | PCL | Sexual assault | Among female (AOR = 5.41; 95% CI 3.19, 9.17) and male (AOR = 6.21 CI 2.26, 17.04) veterans, sexual assault was significantly associated with PTSD even while controlling for other covariates. |
HIV acquisition/disease progression and mental health outcomes | ||||
Epino et al., 2012 Rwanda | Depression | HSCL-15 | CD4 count | There was not a significant difference in depression for those with <=200 CD4 cell count (25.5) and > 200 CD4 count (26) (p = 0.58). |
Mugisha, Muyinda, Wandiembe et al., 2015 Uganda | PTSD | Mini-International Neuropsychiatric Interview (MINI) | HIV status
Sexual trauma events
| Those reporting HIV+ status had greater odds of having PTSD (UOR = 2.09, CI 1.48, 2.95) Those who experienced 1–2 sexual trauma events had greater odds of having PTSD in the unadjusted (UOR = 2.6, CI = 1.63, 4.15) but not the adjusted (AOR = 1.23, CI 0.73, 2.07) model Those who experienced 3+ sexual trauma events had greater odds of having PTSD (UOR = 5.65, CI 3.33, 9.61; AOR = 2.02, CI 1.08, 3.76) |
Mugisha, Muyinda, Malamba et al., 2015 Uganda | Depression | MINI | HIV status High risk sexual behaviors Receiving HIV treatment | HIV+ status was related to MDD (UOR = 2.85, CI 2.04, 3.96), after adjusting for sex and age (AOR = 2.63, CI 1.87, 3.70), and in the multivariate model (OR = 1.83, CI 1.22, 2.74) High risk sexual behavior was not related to MDD in the unadjusted (UOR = 1.13, CI 0.77, 1.67) or adjusted model (AOR = 1.37, CI 0.91, 2.09) Receiving HIV treatment was related to MDD in the adjusted model (AOR = 3.22, CI 1.08, 9.57) but not the unadjusted model (UOR = 2.03, CI 0.85, 4.85) |
Muldoon et al., 2014 Uganda | Depression and anxiety | APAI | All participants had exchanged sex for money or resources in the previous 30 days | For all participants the mean score for the depression sub-scale was 12.84 (SD = 4.79) and the mean score for the anxiety sub-scale was 8.76 (SD = 5.14). No cut off score is defined for symptomatic for either subscale. |
M.H. Cohen et al., 2009 Rwanda | Depression PTSD | CES-D HTQ | About 50% of participants in each group of HIV-positive and HIV-negative experienced genocidal rape CD4 cell counts | Women with HIV infection were more likely than HIV-negative women to have clinically significant depression (81% vs. 65%, p < 0.0001) and MDD (31% vs. 23%, p < 0.047). Women with more advanced HIV, indicated by CD4 cell counts < 200 = mL (OR 4.97, CI 2.93, 8.45), were the most likely to have depressive symptoms. Women who had experienced genocidal rape were more likely to have PTSD in unadjusted analyses (OR = 1.63, CI 1.23, 2.15). Depressive symptoms were higher in women who had a history of genocidal rape (OR = 1.56, CI 1.12, 2.16). |
M.H. Cohen et al., 2011 Rwanda | Depression PTSD | CES-D HTQ | About 50% of participants in each group of HIV-positive and HIV-negative experienced genocidal rape | HIV-positive status was related to increased symptoms of depression (81.5% vs. 63.8%, p < 0.0001), marginally related to symptoms of PTSD (59.6 vs. 67.5%, p = 0.081), and not related to MDD (29.2% vs. 22.7%, p = 0.11) compared to HIV-negative status at baseline. There was a continued reduction in PTSD at each follow-up visit for both HIV-positive and HIV-negative groups (6 month change = −0.78, p < 0.0001; 12 month change = − 0.9, p < 0.0001; 18 month change = − 0.84, p < 0.0001). HIV-positive status (b = 0.03, p = 0.38) was not related to PTSD improvement from baseline to 18-month follow up. All participants had fewer depressive symptoms at 18 months follow up compared to baseline (77% vs. 57%). In changes from baseline to visit 4, experiencing genocidal rape was significantly associated with reduced PTSD.a |
Other associations between mental health and HIV acquisition and disease progression | ||||
Gard et al., 2013 Rwanda | Depression PTSD | CES-D HTQ | About 50% of participants in each group of HIV-positive and HIV-negative experienced genocidal rape | HIV-positive women had higher depression scores than HIV-negative participants (23.67, SD = 9.19 vs. 20.79, SD = 9.60, p < 0.001). More HIV-positive women met criteria for depression than HIV-negative women (81.46% vs.64.58%, p < 0.001). There was no difference in PTSD scores between HIV-positive and HIV-negative women (2.31, SD = 0.69 vs. 2.4 SD = 0.67, p = 0.09). A greater percentage of HIV-negative compared to HIV-positive women experienced elevated PTSD scores (65.63% vs. 57.8%, p = 0.05). |
Kohli et al., 2014 Democratic Republic of Congo | Depression PTSD | HSCL-15 HTQ | Rape | Rape or sexual assault in the past 10 years was related to increased symptoms of PTSD (β = 0.35, p < 0.001) and depression (β = 0.29, p < 0.001) in multivariate regression. |
Sinayobye et al., 2015 Rwanda | Depression PTSD | CES-D HTQ | CD4 count | Depression scores were associated with CD4 count (p < 0.001) with: CD4 counts > 350 having a mean depression score of 22.4 ± 9.3; CD4 count 200–350 having a mean depression score of 23.0 ± 8.2; CD4 count < 200 having a mean depression score of 25.8 ± 9.1 PTSD scores were not associated with CD4 count (p = 0.60) with: CD4 counts > 350 having a median (IQR) PTSD score of 2.1 (1.7–2.7) CD4 count 200–350 having a median (IQR) PTSD score of 2.1 (1.8–2.8) CD4 count < 200 having a median (IQR) PTSD score of 2.2 (1.8–2.8) |